Treatment of colorectal cancer with synchronous bilobar liver metastases with simultaneous bowel and liver resection plus radiofrequency ablation

Patients with synchronous bilobar colorectal liver metastases usually have an extent or distribution of the metastases that precludes curative resection. Recently radiofrequency ablation has been proved to safely control liver metastases but a combination of radiofrequency ablation with more than liver resection is rarely performed. We report two patients with colorectal primary and synchronous classically unresectable bilobar liver metastases treated with a combination of bowel and liver resection plus radiofrequency ablation. In the first patient we performed left colectomy, left hepatic lobectomy and radiofrequency ablation of lesions in segments I and VII. In the second patient we performed low anterior resection, wedge resections for three superficially placed lesions in segments V and VIII, and radiofrequency ablation of five more deeply located lesions in segments III, IV, VI and VII. Both patients recovered uneventfully. At the eighth month, the first patient developed three new liver metastases that were treated with subsequent radiofrequency ablation and at the tenth and seventh months of follow-up respectively, both patients are disease free. In conclusion, combination of bowel and liver resection plus radiofrequency ablation expands the possibilities to treat more patients with colorectal cancer having synchronous bilobar unresectable liver metastases.     

Complete resection of unresectable liver metastases from colorectal cancer without deterioration of liver function after cetuximab and irinotecan: two case reports

Complete resection for colorectal metastases is the only treatment that can provide long-term survival and may lead to cure. Recent reports have shown that liver resection following systemic chemotherapy in patients with initially unresectable metastases from colorectal cancer may also result in a good long-term survival, and rescue surgery after chemotherapy has become a strategy of choice. A 29-year-old male and a 35-year-old female with unresectable liver metastases from colorectal cancer underwent complete resection after administration of third-line combination therapy of cetuximab and irinotecan. Although systemic chemotherapy may decrease liver function, which may make liver resection unfeasible, in the two cases reported, liver function did not deteriorate after cetuximab plus irinotecan. The indocyanine green retention rate at 15 minutes, which is useful in deciding the safe limit of hepatectomy, was optimal after the administration of cetuximab plus irinotecan in both patients. Cetuximab plus irinotecan may be beneficial as neoadjuvant chemotherapy for metastatic colorectal cancer, not only because of its oncological efficacy but also for preservation of liver function.     

Xelox (capecitabine plus oxaliplatin) as neoadjuvant chemotherapy of unresectable liver metastases in colorectal cancer patients

Complete resection of liver metastasis may provide long term survival in patients with colorectal cancer. Increased number of studies on successful resection after neoadjuvant chemotherapy with initially unresectable liver metastasis has been reported. We evaluated retrospectively the results of 35 patients with unresectable liver only metastases from colorectal cancer treated with capecitabine plus oxaliplatin combination (XELOX). Treatment consisted of IV oxaliplatin 130 mg/m2 day 1 and oral capecitabine 1000 mg/m2 day twice daily on days 1 to 14 followed by 7 days of rest repeated every 3 weeks. After chemotherapy, 13 (37, 2 %) patients showed partial clinical response. Among them, 7 patients were considered suitable for surgery but 2 patients refused the surgery. While one of 5 patients had unresectable disease at surgery, the remaining 4 patients (11, 4 %) had a complete resection. There was one postoperative mortality due to sepsis within 2 months after surgery. Our data suggests that XELOX regimen seems to be useful in unresectable liver only metastases from colorectal cancer because of its activity, feasibility and tolerability. Further studies of XELOX in combination with bevacizumab and/ or cetuximab are warranted in this setting.     

Improvement of surgical margin with a coupled saline-radio-frequency device for multiple colorectal liver metastases

Complete resection of colorectal liver metastases (LM) has been the only curative treatment. However, when LM are multiple and bilobar, only a few patients are candidates for curative surgery. We report on a 53-year-old woman with synchronous multiple and bilobar LM from sigmoidal cancer who became resectable after a multimodal strategy including preoperative systemic chemotherapy and two-step surgery. The spectacular decrease in tumor size after systemic chemotherapy led us to perform two-step surgery, including right portal-vein ligation and left liver metastasectomies, with a coupled saline-radiofrequency device, in order to improve the surgical margin. An extended right hepatectomy was performed later to remove the remaining right liver lesions. The patient was discharged after 28 days without major complication and was recurrence-free 14 months later. We conclude that improving the surgical margin with a coupled saline-radiofrequency device is feasible and effective, avoiding small remnant liver even after multiple tumorectomies. The multimodal strategy, including preoperative chemotherapy, two-step surgery, and tumorectomies, using a coupled saline-radiofrequency device, could increase the number of patients with diffuse bilobar liver metastases who can benefit from liver resection.     

Neoadjuvant and adjuvant therapy in relation to surgery for colorectal liver metastases

Liver resection is associated with prolonged survival in patients with colorectal liver metastases. At diagnosis, 15-20% of patients have resectable colorectal liver metastases whereas other patients have too advanced disease to enable surgical treatment and receive chemotherapy. In patients undergoing resection of colorectal liver metastases, disease relapse occurs in up to 70%. Therefore, a combined approach including preoperative or postoperative chemotherapy or both has been tested to improve outcome after surgery. In patients with unresectable colorectal liver metastases, chemotherapy is initially the sole treatment option. The considerable improvement of the efficacy of anticancer agents has contributed to increase the response rate in patients with advanced colorectal cancer. In case of major response to chemotherapy, surgery with curative intent can be offered to patients with initially unresectable liver metastases.     

Computer planned,image-guided combined resection and ablation for bilobar colorectal liver metastases

For patients with extensive bilobar colorectal liver metastases (CRLM), initial surgery may not be feasible and a multimodal approach including microwave ablation (MWA) provides the only chance for prolonged survival. Intraoperative navigation systems may improve the accuracy of ablation and surgical resection of so-called “vanishing lesions”, ultimately improving patient outcome. Clinical application of intraoperative navigated liver surgery is illustrated in a patient undergoing combined resection/MWA for multiple, synchronous, bilobar CRLM. Regular follow-up with computed tomography (CT) allowed for temporal development of the ablation zones. Of the ten lesions detected in a preoperative CT scan, the largest lesion was resected and the others were ablated using an intraoperative navigation system. Twelve months post-surgery a new lesion (Seg IVa) was detected and treated by trans-arterial embolization. Nineteen months post-surgery new liver and lung metastases were detected and a palliative chemotherapy started. The patient passed away four years after initial diagnosis. For patients with extensive CRLM not treatable by standard surgery, navigated MWA/resection may provide excellent tumor control, improving longer-term survival. Intraoperative navigation systems provide precise, real-time information to the surgeon, aiding the decision-making process and substantially improving the accuracy of both ablation and resection. Regular follow-ups including 3D modeling allow for early discrimination between ablation zones and recurrent tumor lesions.     

Hepatic resections for bilobar liver metastases from colorectal cancer

The present study was performed to assess survival benefits in patients who underwent a hepatic resection for isolated bilobar liver metastases from colorectal cancer. Thirty-eight patients underwent a curative hepatic resection for isolated colorectal liver metastasis. Among them, 11 patients had bilobar liver metastases and 19 had a solitary metastasis. The remaining 8 patients had unilobar multiple lesions. We investigated survival in two groups those with bilobar and those with solitary metastatic tumors. Survival and disease-free survival were 36% and 18% at 5 years, respectively, in the patients with bilobar liver metastases, while these survivals were 43% and 34% in the patients with solitary liver metastasis. In the 38 patients, repeated hepatic resections were performed in 15 patients with recurrent liver disease. The 5-year survival and disease-free survival rates for these patients were 38% and 27%, respectively, after the second hepatic resections. Of the 11 patients with bilobar liver metastases, 5 underwent a repeated hepatic resection, and they all survived for over 42 months. Based on our observations, a hepatic resection was thus found to be effective even in selected patients with either bilobar nodules or recurrence in the remnant liver.     

Challenges in everyday surgical practice: synchronous bilobar hepatic colorectal metastases--newer multimodality approach

BACKGROUND/AIMS: This study was designed to assess the efficacy of two-stage liver surgery and hepatic directed chemo-biological therapy in treatment of synchronous bilobar hepatic metastases of colorectal origin. METHODOLOGY: A total of thirty-two patients were included in this study that were diagnosed to have colorectal carcinoma with synchronous bilobar hepatic metastases. During stage one surgery along with excision of primary colorectal carcinoma; ligation and transection of main portal branch on side of bulky metastases disease (right branch in 28 and left in 4 patients) was performed. The metastatic nodules in the opposite lobe were ablated by microwave therapy and a hepatic arterial jet port catheter was introduced via the gastroduodenal artery for liver directed chemo-biological therapy. The catheter was connected to a subcutaneously placed port. Three cycles of chemotherapeutic drugs and Avastin (Bevacizumab) were given via hepatic arterial infusion (HAI) at intervals of twenty-five days. During the second stage surgery hepatic resection was carried out followed by continuation of hepatic arterial infusion of chemobiological drugs as adjuvant therapy. RESULTS: In the follow-up period of 31 months, 1-year survival of 100% and 2-year survival of 80% with a mean 28 months survival was noted. CONCLUSIONS: Combined approach of ligating the portal branch, microwave ablation, hepatic regional chemo-biological therapy and staged liver surgery (a multimodality approach) in the treatment of advanced liver metastatic disease synchronous with colorectal cancer is an effective method of treatment which improves the overall survival and quality of life of the patient with hepatic bilobar metastases synchronous with colorectal carcinoma. Avastin, a monoclonal antibody against vascular endothelial growth factor; used for inhibition of tumor growth has shown its efficacy in early results and holds good promise for the future.     

The role of surgery in the treatment of liver metastases for colorectal cancer patients.

BACKGROUND/AIMS: Liver metastases deriving from colorectal cancer can be treated with curative intention in a select number of patients. Controversy does, however, persist pertaining to the impact of adjuvant treatment strategies. The aim of this study is to elucidate upon the various treatment modalities for patients suffering from liver metastases of colorectal primary tumor as well as to provide a rationale for surgical and adjuvant treatment. METHODOLOGY: From November 1987 to September 1998, a total of 449 consecutive patients suffering from liver metastases deriving from a colorectal cancer were documented at our institution in a prolective study. Prognostic factors providing the most beneficial outcome (whether with surgical and/or adjuvant treatment modalities) were analyzed by univariate and multivariate analysis. RESULTS: Whenever possible, curative (R0) surgical resection of colorectal liver metastases provides the most benefit to the patient. Multivariate analysis revealed tumor infiltration of the lymph nodes of the hepatoduodenal ligament and metachronous occurrence of liver metastases as most independent factors related to survival. CONCLUSIONS: Adjuvant post-operative chemotherapy fails to significantly improve survival following resection of liver metastases when compared to the liver resection only group. In patients with unresectable metastases, regional arterial chemotherapy did not improve survival significantly when compared with systemic chemotherapy.     

Kurativer Ansatz für metastasierte kolorektale Karzinome

Synchronous or metachronous metastases of colorectal cancer (CRC), although being the expression of systemic disease, allow a curative approach for a selected group of patients. Mainly patients presenting with colorectal liver metastases (CLM) should be evaluated for multimodal management with curative intent. Preoperative and/or postoperative systemic chemotherapy show beneficial impact on progression-free and overall survival, without significantly increasing postoperative complication rates. Concerning the complex definition of resectability and the number of patients with ?borderline“ resectable CLM, preoperative chemotherapy plays an important role in both improvement of prognosis and ?conversion“ to a resectable status. Advances in hepatic surgery and the addition of either locally ablative procedures, such as radiofrequency and SIRT are extending resectability to a larger group of patients and have joined the armamentarium for cases of positive resection margins or technically unresectable disease or add to surgery with a large loss of liver parenchyma. Moreover, multimodal approaches should be considered in pulmonary and peritoneal metastases of CRC.     

Arterial, portal, or systemic chemotherapy for patients with hepatic metastasis of colorectal carcinoma

Hepatic metastases from colorectal carcinoma are common and may be resected for cure. The response of liver metastases to systemic chemotherapy is low. In contrast, hepatic arterial chemotherapy produces higher response rates than systemic chemotherapy, but randomized trials have not definitely proved a survival advantage because they allowed cross over. Most adjuvant portal vein chemotherapy studies have shown a survival advantage over the control group, but it is not clear whether this benefit is from the portal vein therapy or from immediate postoperative chemotherapy, since there is rarely a reduction in liver metastases. We describe the results of systemic, hepatic artery infusion, and portal therapy for patients with liver metastases of colorectal carcinoma.     

结直肠癌肝转移的综合治疗策略

结直肠癌(colorectal cancer,CRC)是世界上常见的消化道肿瘤之一,约有50%的患者最终出现肝转移。对于发生肝转移的患者,若不经治疗,中位生存期仅为6.9个月,5年生存率为0。若肝脏转移灶行根治性手术,则中位生存期为35个月,5年生存率为30～50%,因此手术切除仍是结直肠癌肝转移治疗的首选。对于同时性肝转移的患者,若无肠道梗阻、穿孔、出血等症状,笔者倾向于同时性切除原发灶和转移灶,术中联合应用B超探查、微波、射频等新技术来提高切除率,降低复发率。而临床上只有少部分患者(10%～15%)可以行手术治疗。对于不可切除的肝转移灶,需通过多学科讨论,针对疾病某一时期,制定出详细的个体化综合性治疗方案,如术前新辅助化疗、联合靶向药物治疗、门静脉栓塞术的应用、局部治疗、放疗等,使得一些不可切除的病灶转化为可切除病灶。因此癌肿作为一项全身性疾病,单纯依靠一种治疗手段很难取得理想的效果,需要多学科的合作,通过对疾病的不同时期进行认识、讨论,以便找到针对某一时间段疾病的最佳治疗方法。同时术后需要定期复查及时发现复发和转移以及制定进一步治疗计划,从而提高患者的长期生存率及生活质量。     

Chemotherapy for the conversion of unresectable colorectal cancer liver metastases to resection

Resection of colorectal liver metastases (CLM) is the ultimate aim of treatment strategies in most patients with liver-confined metastatic colorectal cancer. Long-term survival is possible in selected patients with initially resectable or unresectable CLM. As a majority of patients have unresectable liver disease at the outset, there is a clear role for chemotherapy to downstage liver disease making resection possible. Studies of systemic chemotherapy with or without biologic therapy in patients with unresectable CLM have resulted in increased response rates, liver resection rates and survival. A sound physiologic rationale exists for the use of hepatic arterial infusion (HAI) therapy. Studies have shown that HAI with floxuridine combined with systemic chemotherapy increases response rates and liver resection rates in those patients with initially unresectable CLM. Toxicity from preoperative chemotherapy, biologic therapy and HAI therapy may adversely affect hepatic resection but can be kept minimal with appropriate monitoring. All conversion strategies should be decided by a multidisciplinary team.     

Survival of gastric cancer with concomitant liver metastases

BACKGROUND/AIMS: Prognosis of gastric cancer with concomitant liver metastasis is poor. Gastrectomy and chemotherapy had been reported to be beneficial to this group of patients. Whether all the patients can benefit from that treatment modality and whether the clinical characteristics can give some information about survival have not been evaluated. METHODOLOGY: Eighty-three gastric cancer patients with concomitant liver metastases who had received treatment in the past 10 years were retrospectively studied with special reference to different extent of liver metastases. Clinical characteristics (peritoneal tumor dissemination, tumor markers, clinicopathological factors), treatment modalities (gastrectomy or chemotherapy) and survival were analyzed for their possible relationship with the extent of liver metastases. RESULTS: There were 33 patients with liver metastases limited to one lobe and 50 patients had metastases in both lobes. The clinicopathological characteristics show no difference between uni- and bilobar liver metastases except higher percentage of concomitant peritoneal dissemination in patients with bilobar disease. More unilobar involvement patients underwent gastrectomy (70% vs. 48%, p=0.018). Higher frequency of abnormal CEA level in bilobar metastases (38% vs. 60%, p=0.045). Median survival of unilobar metastasis is 7.8 months and 4.3 months for the bilobar involvement (p=0.001). Gastrectomy might prolong the survival in patients with unilobar metastasis (p=0.005), but not in patients with bilobar diseases (p=0.074). Chemotherapy could prolong the survival in patients without gastrectomy, but not the survival after gastrectomy. CONCLUSIONS: The clinicopathological characteristics and tumor markers have no role in predicting the survival among patients with liver metastases. Both gastrectomy and chemotherapy for the patients without gastrectomy could prolong survival, but chemotherapy could not prolong the survival after gastrectomy, the benefit of resection and chemotherapy are probably caused by selection bias.     

Long-term complete response of unresectable liver metastases from colorectal cancer

Recent advances in chemotherapy for metastatic colorectal cancer, such as fluorouracil -leucovorin, irinotecan, oxliplatin, and bevacizumab, have been demonstrated to achieve a high response rate. For most patients with unresectable liver metastases, however, chemotherapy is still not considered to provide a sufficient long-term disease-free survival without a surgical resection. We herein report two cases of a complete response for more than 8 years after having received treatment consisting of hepatic arterial infusion of fluorouracil and oral chemotherapy for unresectable liver metastases. The clinicopathological characteristics of these two cases were as follows: the number of liver metastases, 20, 11; the maximum size, 1.2 cm, 2.8 cm; the serum carcinoembryonic antigen level, 1.2 ng/ ml, 2.4 ng/ml. The following computed tomography scan revealed the liver metastases to have completely disappeared 7 months and 22 months after the treatment, respectively. It is speculated that a small size and a low level carcinoembryonic antigen may predict a good response to chemotherapy for unresectable liver metastases from colorectal cancer.     

Current preventive treatment for recurrence after curative hepatectomy for liver metastases of colorectal carcinoma： A literature review of randomized control trials

To review the preventive approaches for recurrence after curative resection of hepatic metastases from colorectal carcinoma, we have summarized all available publications reporting randomized control trials (RCTs) covered in PubMed. The treatment approaches presented above include adjuvant intrahepatic arterial infusion chemotherapy, systemic chemotherapy, neoadjuvant chemotherapy, and immunotherapy. Although no standard treatment has been established, several approaches present promising results, which are both effective and tolerable in post-hepatectomy patients. Intrahepatic arterial infusion chemotherapy should be regarded as effective and tolerable and it increases overall survival (OS) and disease free survival (DFS) of patients, while 5-fluorouracil-based systemic chemotherapy has not shown any significant survival benefit. Fortunately chemotherapy combined with hepatic arterial infusion and intravenous infusion has shown OS and DFS benefit in many researches. Few neoadjuvant RCT studies have been conducted to evaluate its effect on prolonging survivals although many retrospective studies and case reports are published in which unresectable colorectal liver metastases are downstaged and made resectable with neoadjuvant chemotherapy. Liver resection supplemented with immunotherapy is associated with optimal results; however, it is also questioned by others. In conclusion, several adjuvant approaches have been studied for their efficacy on recurrence after hepatectomy for liver metastases from colorectal cancer (CRC), but multi-centric RCT is still needed for further evaluation on their efficacy and systemic or local toxicities. In addition, new adjuvant treatment should be investigated to provide more effective and tolerable methods for the patients with resectable hepatic metastases from CRC.     

Repetitive chemoembolization with melphalan plus intra-arterial immuno-chemotherapy within 5-fluorouracil and granulocyte-macrophage colony-stimulating factor (GM-CSF) as effective first- and second-line treatment of disseminated colorectal liver metastases

BACKGROUND/AIMS: In order to improve local and systemic efficacy of chemotherapeutic interventions we have used a combination of high concentrated plus low continuous regional chemotherapy modulated by GM-CSF cytokine in the treatment of inoperable colorectal liver metastases. METHODOLOGY: Sixty-six patients with disseminated inoperable colorectal liver metastases received continuous intra-arterial chemotherapy with 5-FU plus GM-CSF short time application plus chemoembolization Melphalan via an angiographically positioned hepatic artery catheter. The regimen consisted of the following steps: On day 1 + 2 1400 mg/m2 5-FU administered intra-arterially in a continuous circadian mode, 60 mg/m2 Rescuvolin given i.v. as a 2-hour infusion, 80 micrograms/m2 GM-CSF given i.a. as a 1-hour infusion, day 3 chemoembolization with 25 mg/m2 Melphalan plus Lipiodol and Gelfoam. RESULTS: 66 patients (38 male/28 female) with a median age of 60.4 years and a median Karnofsky index of 87.3 were treated with 299 cycles of immunochemoembolization. Fifty-four percent of these patients had received prior systemic chemotherapy. Side effects were manifested in all patients, mainly upper abdominal pain lasting one to four days and grade 1 or 2 vomiting. Systemic side effects were mild and transient with a very low rate of leukopenia. Using World Health Organization response criteria, the following responses could be demonstrated CR 1.0%, PR 42.4%, MR 24.2%, SD 18.2%, NR 12.1%. Time to progression was 8 months. Median survival has not been reached after an observation time of 28 months. Two-year survival was 66%. There was no statistically significant difference between chemonaive patients and patients pretreated by any kind of systemic therapy. CONCLUSIONS: Repetitive high concentrated regional chemotherapy by use of chemoembolization combined with continuous administered 5-FU and supplemented with GM-CSF is an effective tool in the therapy of disseminated colorectal liver metastases as front line as well as a second-line treatment.     

Outcome of Metastatic Colorectal Cancer: Analysis of a Consecutive Series of 229 Patients. The Impact of a Multidisciplinary Approach

Purpose New chemotherapy agents and integrated treatments have improved the prognosis of patients with metastatic colorectal cancer. Methods From January 2000 to December 2002, 229 consecutive metastatic patients were prospectively followed and their outcomes were analyzed. They were divided initially into four treatment groups: A, palliative chemotherapy for extensive extrahepatic disease with or without hepatic disease (97 patients); B, palliative chemotherapy as in Group A for extensive hepatic disease unlikely to become resectable (36 patients); C, neoadjuvant chemotherapy for potentially resectable liver metastases if responsive to therapy (33 patients); D, immediate surgery for liver metastases (63 patients). Results The series was analyzed after a median follow-up of 22.6 months. The median progression-free survival was 9, 7.3, 11.5, and 26 months in Groups A, B, C, and D, respectively. The median overall survival was 20.1, 17.2, 24.8, and >48 months in Groups A, B, C, and D, respectively. The outcome was considered for the 69 patients with metastases confined to the liver (Groups B and C), who were treated initially with chemotherapy. Surgery was performed in 21 patients (5 from Group B, and 16 from Group C) and was R0 in 16. In resected patients, the median progression-free survival was 14.7 months and the median overall survival was 40.5 months. In unresected patients, the median progression-free survival was 7.6 months and the median overall survival was 17.5 months. Conclusions Neoadjuvant therapy may prolong overall survival in a subset of patients with multiple hepatic metastases. The global impact on progression-free survival is low; less than one-half of the patients resected after chemotherapy are disease-free at three years. However, patients resected after chemotherapy obtained overall survival similar to that of primary surgery, suggesting a positive role for integrated approaches. Supported by grants from Associazione per la Ricerca e la Cura sul Cancro (AIRC, Milano, Italy), Consiglio Nazionale della Ricerche (CNR, Progetto Strategico Oncologia), and Ministero dell’Istruzione, dell’Università e della Ricerca (MIUR, Ricerca Finalizzata 2001, sottoprogetto B55.4.2). Reprints are not available.     

Combining systemic chemotherapy with chemoembolization in the treatment of unresectable hepatic metastases from colorectal cancer

Treatment of liver metastases from colorectal cancer include surgical resection, radiation, hepatic chemoembolization, immunotherapy and intravenous chemotherapy. Complete surgical resection of liver metastases is feasible only for solitary or unilobar metastasis. Unresectable hepatic metastases of colorectal origin are resistant to radiation and immunotherapy, and the unsatisfactory results of systemic chemotherapy and chemoembolization have led to more aggressive treatment. A new method that combines systemic chemotherapy and chemoembolization is proposed. In this study, data from a total of 40 patients with unresectable hepatic metastasis from colorectal cancer were collected. All of these patients received combined chemoembolization and systemic chemotherapy. Embolization was performed by the selective cannulation of right and left hepatic artery. Equal amounts of a mixture of 10 ml lipiodol, 1,500 mg 5-fluorouracil (5-FU) and 15 mg leucovorin was deployed selectively in equal parts into the main right and left hepatic artery. Two weeks following chemoembolization, patients underwent systemic chemotherapy with 2,600 mg/m² 5-FU continuous infusion for 24 h and received 150 mg leucovorin intravenous bolus. The course of chemotherapy was repeated weekly for 24 weeks. The median follow-up period was 27 months (range 10–36 months). Following the intention-to-treat principle, the objective tumor response rate was 47.5%. The median disease-free interval was 12 months and the median survival time was 16 months. Most of the patients (73%) died of hepatic failure, while the second largest group died of abdominal carcinomatosis. In conclusion, the results of this study are of sufficient interest to justify future randomized trials.     

Prognostic factors of intrahepatic cholangiocarcinoma after hepatic resection: univariate and multivariate analysis

BACKGROUND/AIMS: Intrahepatic cholangiocarcinoma is clinicopathologically distinct from hepatocellular carcinoma and hilar cholangiocarcinoma, and the prognostic factors after hepatic resection of these rare tumors are not well documented. The aim of this study was to evaluate prognostic factors of intrahepatic cholangiocarcinoma after hepatic resection. METHODOLOGY: We retrospectively studied 20 consecutive patients with intrahepatic cholangiocarcinoma who underwent hepatectomy over a 15-year period from 1984 to 1998. Fifteen prognostic factors were evaluated for their association with overall and disease-free survivals in univariate and multivariate analysis (Cox's proportional hazards model). RESULTS: Eighty percent of the resected patients had major hepatectomy. Operative morbidity and mortality rates were 30% and 0%, respectively. Four patients (20%) survived more than 5 years without recurrence after hepatic resection. The 1-year, 3-year, and 5-year overall or disease-free survival rate after hepatic resection were 56.0% or 49.5%, 43.8% or 43.3%, and 43.8% or 37.3%, respectively. Univariate analysis showed young age and periductal invasion tumor or the presence of vascular invasion, lymphatic invasion, and lymph node metastasis as significant poor prognostic predictors contributing overall and disease-free survivals. Multivariate analysis revealed only lymph node metastasis as an independent prognostic factor affecting disease-free survival. During the same time, 17 unresectable patients were treated by intrahepatic arterial infusion chemotherapy (12), systemic chemotherapy (4), or radiation (1). Median overall survival time in resected patients (16 months) was significantly better than in unresectable patients (5 months) (P = 0.005). CONCLUSIONS: Hepatic resection remains to be the best current therapeutic option. The prognosis after hepatic resection for intrahepatic cholangiocarcinoma was determined by lymph node metastasis. New adjuvant chemotherapy after surgery is imperative for such patients.