Resection rate and effect of postoperative chemotherapy on survival after surgery for colorectal liver metastases.

BACKGROUND: The purpose of this study was to investigate whether adjuvant therapy can improve survival after curative resection of colorectal liver metastases. METHODS: Some 235 patients had 256 liver resections for metastatic colorectal cancer. There were no predefined criteria for resectability with regard either to the number or size of the tumours or to locoregional invasion, except that resection had potentially to be complete and macroscopically curative. All patients who had curative hepatic resection were advised to start postoperative adjuvant chemotherapy. RESULTS: The resectability rate in screened patients was 91 per cent (235 of 259 patients); the postoperative mortality rate was 4 per cent. In 35 patients resection of the primary tumour was performed simultaneously with partial liver resection. Forty-four patients (19 per cent) developed intra-abdominal recurrence; 14 (6 per cent) underwent reoperation and the recurrent tumour was resected. Adjuvant chemotherapy was given to 99 patients (55 per cent), most treatments being based on 5-fluorouracil with folinic acid. The overall actuarial survival rates at 1, 3 and 5 years were 87, 60 and 36 per cent respectively. In a multivariate analysis, four or more metastases, preoperative carcinoembryonic antigen level higher than 5 ng/ml and a positive resection margin were independent predictors of poor outcome. Adjuvant chemotherapy improved the 5-year survival rate to 53 per cent. CONCLUSION: This study provides some evidence that postoperative chemotherapy is beneficial; however, prospective randomized studies are necessary to define its exact role.     

Treatment strategy for patients with colorectal cancer and synchronous irresectable liver metastases

BACKGROUND: The aim of this case-matched study was to determine the best treatment strategy for patients with asymptomatic colorectal cancer and irresectable synchronous liver metastases. METHODS: Between 1997 and 2002, 27 patients with asymptomatic colorectal cancer and irresectable synchronous liver metastases were treated by chemotherapy without initial primary resection (chemotherapy group). These 27 patients were compared with 32 patients matched for age, sex, performance status, primary tumour location, number of liver metastases, nature of irresectable disease and type of chemotherapy, but who were treated initially by resection of primary tumour (resection group). RESULTS: The 2-year actuarial survival rate was 41 per cent in the chemotherapy group and 44 per cent in the resection group (P = 0.753). In the latter group, the mortality and morbidity rates for primary resection were 0 and 19 per cent (six of 32 patients) respectively. In the chemotherapy group, intestinal obstruction related to the primary tumour occurred in four of 27 patients. The mean overall hospital stay was 11 days in the chemotherapy group and 22 days in the resection group (P = 0.003). CONCLUSION: Systemic chemotherapy without resection of the bowel cancer is the option of choice because, for most patients, it is associated with a shorter hospital stay and avoids surgery without a detrimental effect on survival.     

Role of neoadjuvant chemotherapy in the treatment of multiple colorectal metastases to the liver

BACKGROUND: The role of neoadjuvant chemotherapy for patients with multiple (five or more) bilobar hepatic metastases irrespective of initial resectability is still under scrutiny. The purpose of this study was to compare the outcome of hepatectomy alone with that of hepatectomy after neoadjuvant chemotherapy for multiple bilobar hepatic metastases from colorectal cancer. METHODS: Retrospective data were collected from 71 patients after hepatectomy for five or more bilobar liver tumours. The outcome of 48 patients treated by neoadjuvant chemotherapy followed by hepatectomy was compared with that of 23 patients treated by hepatectomy alone. RESULTS: Patients who received neoadjuvant chemotherapy had better 3- and 5-year survival rates from the time of diagnosis than those who did not (67.0 and 38.9 versus 51.8 and 20.7 per cent respectively; P = 0.039), and required fewer extended hepatectomies (four segments or more) (39 of 48 versus 23 of 23; P = 0.027). Multivariate analysis showed neoadjuvant chemotherapy to be an independent predictor of survival. CONCLUSION: In patients with bilateral multiple colorectal liver metastases, neoadjuvant chemotherapy before hepatectomy was associated with improved survival and enabled complete resection with fewer extended hepatectomies.     

OncoSurge: a strategy for long‐term survival in metastatic colorectal cancer

OncoSurge is a combined modality strategy for the management of colorectal cancer with hepatic metastases. It has emerged as a result of new and expanded patient selection criteria for resectability of metastases, coupled with more effective neoadjuvant and postoperative chemotherapy. By bringing together these developments in surgery and medical oncology, the new approach promises to increase significantly the resectability rate and long‐term survival in colorectal cancer patients with liver metastases. Surgery for colorectal liver metastases should now be considered across a range of clinical circumstances that would historically have been contraindications to resection. These contraindications include multiple or bilobar metastases, large tumour size, a Dukes stage C or poorly differentiated primary tumour, synchronous detection of metastases with the primary tumour, disease in elderly patients, or a resection margin of less than 1 cm. None of these criteria should necessarily exclude a patient from resection, because although they may be associated with a less favourable prognosis they do not exclude the possibility of long‐term survival. Non‐resectable extrahepatic disease and portal lymph node involvement, however, remain contraindications to resection in most circumstances. Retrospective studies of neoadjuvant therapy have indicated that a regimen based on low dose oxaliplatin, 5‐fluorourucil (5‐FU) and leucovorin increased the overall resectability rate of patients presenting with hepatic colorectal metastases from 20% to 30%, with 13.6% of patients with unresectable metastases becoming eligible for curative resection. More recently, studies using more potent oxaliplatin‐based regimens have reported significantly higher resectability rates of at least 40%, with 5‐year survival of 50% reported in one large study among patients whose liver metastases were resected after initial neoadjuvant therapy for unresectable tumours. Following resection, postoperative therapy based on a combination of hepatic artery infusion (HAI) and systemic chemotherapy reduces hepatic recurrence and increases survival, but more potent systemic therapy is required to reduce the rate of extrahepatic recurrence. Studies are now in progress combining HAI with oxaliplatin‐based systemic therapy to address this issue. By combining a more inclusive approach to surgery with more effective neoadjuvant and postoperative chemotherapy, the OncoSurge treatment model is likely to increase significantly the number of patients with hepatic colorectal metastases who can be treated with curative intent, and thus has the potential to improve overall patient survival.     

Treatment of colorectal liver metastases

BACKGROUND: Surgical resection is the only potentially curative treatment for colorectal liver metastases, with 5-year survival rates approaching 40 per cent. However, at present only 20-25 per cent of such lesions are deemed resectable. This review examines developments in neoadjuvant and adjuvant treatments of colorectal liver metastases that aim to improve the results of surgical management of this disease. METHODS: A literature review was undertaken based on a Medline search from 1970 to May 1998. RESULTS: Further evolution in surgical technique is unlikely to lead to a dramatic increase in the resectability rate of colorectal liver metastases. Recent developments in neoadjuvant and adjuvant chemotherapy schedules, together with a range of interventional radiological procedures and interstitial lytic techniques, show promise in terms of extending the limits of resectability and decreasing recurrence rates associated with these lesions. Using multimodality regimens 5-year survival rates of 40 per cent are now being reported for lesions that were initially considered irresectable. CONCLUSION: Patients with colorectal liver metastases should be assessed in units that can offer all the specialist techniques necessary to deliver optimum care. Incorporation of newer neoadjuvant and adjuvant treatments into management strategies should occur in the setting of randomized trials.     

Non-operative management of the primary tumour in patients with incurable stage IV colorectal cancer

BACKGROUND: Excision of primary colorectal cancer associated with irresectable synchronous metastases confers high morbidity and mortality with uncertain benefit. METHODS: For patients with incurable stage IV colorectal cancer, minimally symptomatic primary tumours were left in situ and 5-fluorouracil-based chemotherapy was administered systemically. Primary tumour-specific complications and survival were monitored. RESULTS: There were 13 men and 11 women with primary tumours in the right colon (eight), transverse colon (one), sigmoid colon (eight) or rectum (seven). Eleven patients had metastases limited to the liver (liver replacement less than 25 per cent in one, 25-50 per cent in four and more than 50 per cent in six) and 13 patients had extrahepatic disease (lung or peritoneum). Four patients with sigmoid colon tumours developed bowel obstruction, which required an uncomplicated operation in two and deployment of colonic stents in two patients, at 1, 3, 12 and 20 months from diagnosis. Three further patients underwent right hemicolectomy for abdominal pain of uncertain aetiology, with poor symptomatic relief, and another had a potentially curative operation following disease downstaging. The overall median survival was 10.3 months with a 1-year actuarial survival rate of 44 per cent. CONCLUSION: A policy to defer resection of minimally symptomatic primary colorectal cancer is associated with a low risk of complications before death from progressive systemic disease.     

Simultaneous resection of colorectal primary tumour and synchronous liver metastases

BACKGROUND: The surgical strategy for treatment of synchronous colorectal liver metastases remains controversial. The outcome and overall survival of patients presenting with such metastases, treated either by simultaneous resection or by delayed resection, were evaluated. METHODS: From 1987 to 2000, 97 patients presented with synchronous colorectal liver metastases, of whom 35 (36 per cent) underwent a simultaneous resection and 62 patients (64 per cent) a delayed resection. Simultaneous resection was considered prospectively for patients with fewer than four unilobar metastases. RESULTS: Age, blood transfusion requirements, operating time, duration of inflow occlusion, hospital stay and mortality rate were similar in the two groups. The morbidity rate did not differ significantly (23 per cent after simultaneous resection and 32 per cent after delayed resection). The location of the primary tumour and extent of liver resection did not influence the morbidity rate significantly in the simultaneous resection group. The overall survival rate was 94, 45 and 21 per cent at 1, 3 and 5 years respectively after simultaneous resection, and 92, 45 and 22 per cent after delayed resection. CONCLUSION: In selected patients, simultaneous resection of the colorectal primary tumour and liver metastases does not increase mortality or morbidity rates compared with delayed resection, even if a left colectomy and/or a major hepatectomy are required.     

Quelle stratégie thérapeutique devant un cancer du rectum avec métastases hépatiques synchrones ?

Rectal cancer with synchronous liver metastases includes a wide variety of clinical presentations. In patients with rectal cancer and synchronous liver metastases, treatment strategy depends on the site and the extent of rectal cancer, the extent of liver metastases and the presence of extra-hepatic disease. In the majority of patients, liver metastases are unresectable and in this setting, the primary goal of treatment strategy is to prolong survival and to preserve quality of life. Most of these patients are treated with systemic chemotherapy and local treatment including radiotherapy or surgical resection is indicated in patients presenting with symptoms or complications related to the primary tumor. In patients with resectable liver metastases, a curative approach to the disease including resection of rectal cancer and liver metastases should be proposed. In this setting, a large number of treatment options can be discussed especially regarding the use of preoperative treatments (radiotherapy, radiochemotherapy or chemotherapy) and the design of surgical strategy (simultaneous resection of rectal cancer and liver metastases or staged resection). Treatment strategy should aim at conciliating optimal treatment for all tumor sites. Accurate pretreatment workup contributes to identify the most advanced tumor site that should be treated first without compromising optimal treatment of the other site. None standard treatment approach can be define for all patients presenting with rectal cancer and synchronous liver metastases because this entity includes a wide variety of clinical presentation and a large number of treatment options are available. Treatment strategy should be discussed during multidisciplinary meeting at diagnosis.     

Determinants of survival in liver resection for colorectal secondaries

All 72 resections for colorectal liver secondaries during the period 1971-1984 were analysed retrospectively. Liver tumours were single in 35 (49 per cent), unilateral in 55 (76 per cent) and associated with extrahepatic disease in 12 (18 per cent) patients. Operative mortality was 5.6 per cent. With respect to the disease in the liver, the presence or absence of four or more metastases was the predominant prognostic determinant with a 5 year survival rate of 20 per cent in patients with less than four liver tumours, and no 3 year survivor among patients with four or more tumours. When the number of liver tumours was less than four, the prognosis in patients with unilateral disease was not significantly better than in patients with bilateral disease (P = 0.19). No other liver disease variable seemed to play any role in the prognosis. Extrahepatic disease was associated with a poor prognosis and no 5 year survivor. The length of the tumour-free resection margin was the only treatment variable that varied with the outcome: a resection margin of less than 10 mm was followed by a poor survival. Variables that did not influence survival included uni- or bilateral disease, liver tumour volume, tumour size, type of liver resection, Dukes' classification, differentiation of the primary tumour and synchronous or metachronous disease. It is concluded that resection for liver colorectal secondaries is indicated when there are less than four liver tumours, even if bilateral, no extrahepatic disease is present, and a resection margin of at least 10 mm can be obtained. It should not be performed unless all of these requirements are met.     

Influence of postoperative morbidity on long-term survival following liver resection for colorectal metastases

BACKGROUND: Survival after resection of colorectal liver metastases may be influenced by the patient, the primary tumour and the liver metastases. Postoperative morbidity is associated with poor survival in several cancers. The aim of this retrospective study was to evaluate prognostic factors of survival after resection of colorectal liver metastases, including postoperative morbidity. METHODS: From 1985 to 2000, 311 consecutive patients with liver metastases from colorectal cancer underwent resection with curative intent. Univariate and multivariate analyses were performed to assess the influence of age, sex, site and stage of the colorectal tumour, disease-free interval, number, size and distribution of metastases, type of hepatectomy, pedicular clamping, resection margin, blood transfusion, postoperative morbidity and adjuvant chemotherapy on overall and disease-free survival. RESULTS: The postoperative mortality and morbidity rates were 3 and 30 per cent respectively. The 3- and 5-year overall survival rates were 53 and 36 per cent respectively. Both overall and disease-free survival rates were independently associated with nodal status of the colorectal tumour, number of metastases and postoperative morbidity. Patients with postoperative morbidity had an overall and disease-free 5-year survival rate half that of patients with no morbidity: 21 versus 42 per cent for overall survival (P < 0.001) and 12 versus 28 per cent for disease-free survival (P = 0.001) respectively. CONCLUSION: Long-term survival can be altered by postoperative morbidity after resection of colorectal liver metastases by increasing the risk of tumour recurrence. This justifies optimizing the surgical treatment of colorectal liver metastases to decrease postoperative morbidity and the use of efficient adjuvant treatments in patients with postoperative morbidity.     

Neo-adjuvant therapy improves resectability rates for colorectal liver metastases

PURPOSE: Liver resection improves survival in selected patients with colorectal liver metastases. However, the majority of patients with colorectal liver metastases have inoperable disease at presentation. Neo-adjuvant therapy (systemic or regional chemotherapy and interstitial laser therapy) used singly or in combination may convert a selected group of patients with irresectable liver metastases into an operable state. PATIENTS AND METHODS: We report a series of patients with initially inoperable multiple colorectal liver metastases who became operable after neo-adjuvant therapy. Operability was defined as unilateral disease limited to the liver. Twelve patients (7 female, 5 male, median age 57 years, range 38-69 years) with multiple inoperable colorectal liver metastases (8 synchronous, 4 metachronous) were initially treated with systemic chemotherapy (n = 7), hepatic arterial chemotherapy (n = 2) and chemotherapy plus interstitial laser therapy (n = 3). RESULTS: In all cases, a significant response was achieved which enabled subsequent liver resection to be undertaken. There was only one postoperative complication (8%) and no peri-operative deaths. 3 patients were operated on within the last 12 months and are still alive. Of the remainder, 1 died within 1 year with recurrent disease. The remaining patients have a median survival of 2.5 years, range 1.39-4 years. CONCLUSIONS: These results are similar to those reported for patients undergoing resection for operable metastases without neo-adjuvant therapy. Aggressive multimodality treatment of colorectal liver metastases in specialised centres may improve the resectability rates and survival in a selected group of patients.     

Clinicians' attitudes towards management of metastatic colorectal adenocarcinoma

Background: Despite being a common problem, the optimal management of in situ primary colorectal carcinomas in patients presenting with unresectable synchronous metastases remains unknown. To date, no prospective randomized studies have been conducted to evaluate the outcomes of different approaches to management. We studied the attitudes of clinicians involved in the management of this group of patients with a view to determine their treatment preferences and assess the feasibility of conducting a randomized study addressing the role of resection of primary colorectal carcinomas in patients presenting with unresectable synchronous metastases. Methods: A survey of Australian colorectal surgeons, Australian medical oncologists and Victorian rural general surgeons was conducted. Results: The results indicated that with regard to preferred treatment (i) for patients with asymptomatic sigmoid or caecal primary tumours, surgeons preferred surgery followed by chemotherapy, whereas oncologists preferred chemotherapy alone; (ii) for patients with symptomatic sigmoid or caecal primary tumours, both surgeons and oncologists preferred surgery followed by chemotherapy; and (iii) for patients with metastatic rectal carcinoma, whether asymptomatic or symptomatic, both surgeons and oncologists preferred a multimodality approach to treatment. Clinicians were accepting a broad range of treatment options for patients with both asymptomatic and symptomatic primary colorectal tumours. Conclusion: There is a high level of acceptability among Australian clinicians for both surgical and non‐surgical approaches to management of the in situ primary colorectal tumour in patients with unresectable synchronous metastases. Further research is warranted to determine the management strategy that will yield the best outcome for these patients.     

Comparison of resection and radiofrequency ablation for treatment of solitary colorectal liver metastases

BACKGROUND: Liver resection is the treatment of choice for patients with solitary colorectal liver metastases. In recent years, however, radiofrequency ablation has been used increasingly in the treatment of colorectal liver metastases. In the absence of randomized clinical trials, this study aimed to compare outcome in patients with solitary colorectal liver metastases treated by surgery or by radiofrequency ablation. METHODS: Solitary colorectal liver metastases were treated by radiofrequency destruction in 25 patients. The indications were extrahepatic disease in seven, vessel contiguity in nine and co-morbidity in nine patients. Outcome was compared with that of 20 patients who were treated by liver resection for solitary metastases and had no evidence of extrahepatic disease. Most patients in both groups also received systemic chemotherapy. RESULTS: Median survival after liver resection was 41 (range 0-97) months with a 3-year survival rate of 55.4 per cent. There was one postoperative death and morbidity was minimal. Median survival after radiofrequency ablation was 37 (range 9-67) months with a 3-year survival rate of 52.6 per cent. CONCLUSION: Survival after resection and radiofrequency ablation of solitary colorectal liver metastases was comparable. The latter is less invasive and requires either an overnight stay or day-case facilities only.     

新辅助化疗结合三维适形放疗在晚期不可手术切除直肠癌转化治疗中的应用

目的:探讨新辅助化疗结合三维适形放疗在晚期不可手术切除直肠癌转化治疗中的应用效果。方法:选取2008年1月—2013年6月收治的56例不可切除的直肠癌患者(伴肝转移12例),30例作为观察组,使用新辅助化疗加三维适形放疗;26例作为对照组,采用新辅助化疗加常规放疗。比较两组患者治疗后可切除转化率、术后生存状态、不良反应和近期并发症情况。结果:在治疗16周时观察组可切除转化率明显高于对照组(60.0%vs.26.9%,P=0.013);与对照组比较,观察组无疾病进展生存期及总生存期均明显延长(P=0.046,P=0.029);两组不良反应及近期并发症发生情况差异无统计学意义(均P0.05)。结论:新辅助化疗结合三维适形放疗可明显提高不可手术切除直肠癌的可切除转化率,延长患者的生存期且不增加不良反应和与并发症的发生率。     

Importance of response to neoadjuvant chemotherapy in patients undergoing resection of synchronous colorectal liver metastases

The purpose of this study was to compare the treatment and outcome in patients referred for staged re section of synchronous colorectal liver metastases. The records of patients who had undergone colon or rectal resection and were then referred for evaluation of clinically resectable synchronous liver metastases between January 1995 and January 2000 were reviewed. Comparisons were made between patients who did not receive neoadjuvant chemotherapy and had exploratory operations after recovery from colon re section and patients who did receive chemotherapy before liver resection. A total of 106 patients were treated during the 5-year period. Neoadjuvant chemotherapy was given to 52 of the patients; in 29 of them the disease did not progress, but in 17 patients the disease progressed while they were receiving treatment. Median follow-up was 30 months. Patient- and tumor-related variables were similar between groups. Five-year survival was statistically similar between patients who did and those who did not receive neoadjuvant chemotherapy (43% vs. 35%, P = 0.49). Patients within the neoadjuvant group whose dis ease did not progress while they were receiving chemotherapy experienced significantly improved sur vival as compared to patients who did not receive chemotherapy (85% vs. 35%, P = 0.03). In the setting of synchronous colorectal liver metastases, the response to neoadjuvant chemotherapy may be a prognos tic indicator of survival and may assist in the selection of patients for conventional or experimental adju vant therapies. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation).     

Liver resection after downstaging with neoadjuvant chemotherapy for "unresectable" colorectal metastases

Hepatic resection is the only treatment that offers a chance of long-term survival in patients with metastases from colorectal cancer. Nevertheless, a curative resection can be performed in only 10-20 per cent of patients: multiple bilobar metastases or "unresectable" disease are the greatest obstacles to surgical radicality. Techniques such as preoperative portal embolisation, preoperative portal ligation, two-stage hepatectomy, and neoadjuvant chemotherapy, have extended the possibility of liver surgery to patients with advanced metastatic colorectal cancer. The outcomes of two patients treated successfully with neoadjuvant chemotherapy (one case with FOL-F-OX, and one with FOL-F-IRI) followed by liver resection were analyzed. In both patients neoadjuvant chemotherapy enabled a curative liver resection to be performed without significant complications. In some patients, neoadjuvant chemotherapy permits the "downsizing" of metastatic disease to such an extent that a surgical approach proves feasible. This advance can dramatically improve the prognosis of patients with multiple or unresectable liver metastases from colorectal cancer.     

A population-based study of the incidence, management and prognosis of hepatic metastases from colorectal cancer

BACKGROUND: The aim of this population-based study was to evaluate the incidence, management and prognosis of patients with hepatic metastases related to colorectal cancer using data from the Digestive Cancer Registry of Calvados, France. METHODS: Of 1325 patients with colorectal cancer registered between January 1994 and December 1999, 358 developed hepatic metastases. Logistic regression was used to analyse prognostic factors. Survival analysis was carried out with Cox's proportional hazards model. RESULTS: Some 18.8 per cent of patients had synchronous metastases, while 29.3 per cent developed metastases at 3 years. Of patients with hepatic metastases, 17.3 per cent had a surgical resection, 40.2 per cent were treated with palliative chemotherapy and 42.5 per cent had symptomatic treatment. Factors associated with receiving symptomatic treatment only were age over 75 years and more than one metastasis, but not place of treatment. Median survival after a diagnosis of hepatic metastases was 10.7 (range 4.6-23.1) months. Significant adverse prognostic factors were: age over 75 years (P = 0.001), lymph node invasion of primary tumour (P = 0.024), bilateral distribution of metastases (P = 0.001), other metastases (P = 0.004) and symptomatic treatment only (P = 0.041). CONCLUSION: Despite improvement in treatment for hepatic metastases, age and extent of disease remain limiting factors for surgical resection and palliative chemotherapy.     

Colorectal cancer patterns of care in the Western Sydney and Wentworth Area Health Services

INTRODUCTION: Colorectal cancer is a leading cause of morbidity and mortality in Australia. Recent clinical trials show that the recurrence of colorectal cancer decreases with chemotherapy and/or radiotherapy in advanced disease. The present study aimed to document the patterns of care by the type of treatment, document the preoperative investigations and provide results to the Area Health Services. METHODS: A prospective data collection was initiated in May 1994 and ended in May 1996 in the Western Sydney and Wentworth Area Health Services of New South Wales. Deaths and recurrences were followed up until July 2002. RESULTS: There were 253 colon cancers, 107 rectal cancers and 10 patients with tumours in both the colon and rectum. Forty-one surgeons performed 299 curative procedures with 78% of them performing one to four procedures annually. One hundred and twenty-two patients had non-fatal complications and six (2%) died postoperatively. Twenty-eight per cent of rectal cancer patients underwent abdomino-perineal resection and 56% underwent low anterior resection. Forty-five per cent of rectal cancer patients and 51% of colon cancer patients who were potentially eligible received appropriate adjuvant therapy. Ninety-one per cent of patients who received chemotherapy had no or mild toxicity. By the end of follow-up period, 30% of rectal cancer patients and 24% of colon cancer patients had developed recurrence. At last follow up, 197 patients had died. Median overall survival from time of diagnosis was 73 months. Overall 5-year survival for colonic and rectal cancers was 50% and 57%, respectively. For the 299 patients who had curative procedures, the 5-year survival was 63% and 62% for colonic and rectal cancers, respectively. CONCLUSION: Colorectal cancer patients who were eligible for and received adjuvant therapy had significantly better survival. Rectal cancer patients whose tumours only required low anterior resection had a better survival than those who needed an abdomino-perineal resection. High-volume surgeons have less postoperative complications than low-volume surgeons. The high proportion of late presentations seen in colon cancer patients supports the need for screening to improve early detection.     

Clinicopathological Features and Prognosis in Resectable Synchronous and Metachronous Colorectal Liver Metastasis

Introduction Hepatic resection may offer long-term survival for patients with colorectal metastases. However, controversies exist regarding the prognostic factors. Herein, the impact of synchronicity of liver metastasis on patient clinicopathological features and prognosis was evaluated. Methods One hundred and fifty-five patients who underwent hepatectomy for colon cancer metastasis, from 1995 to 2004, were enrolled in this study. Patients were divided into two groups: synchronous and metachronous colorectal liver metastasis. Patient demographics, the nature of the primary and metastatic tumors, surgery-related complications, and long-term outcome were analyzed. Results Patients included in the synchronous group tended to be younger than those in the metachronous group. Compared to the metachronous group, patients in the synchronous group showed more metastases (P = 0.008) and bilobarly distributed metastases (P = 0.016). Bile leakage was the most common surgical complication. The estimated 5-year disease-free and overall survival rates were 16.8 and 41.1%, respectively. Univariate analysis indicated that synchronous metastases, advanced stage of the primary tumor, bilobar distribution of the metastases, more than three metastases, and colonic versus rectal location of the primary tumor were prognostic factors of shorter disease-free survival, but not overall survival. Multivariate analysis revealed that synchronous metastases and the advanced stage of the primary tumor were indicators for a worse disease-free survival. Conclusion The synchronous presence of primary colon cancer and liver metastasis may indicate a more disseminated disease status and is associated with a shorter disease-free survival than metachronous metastasis. These patients may need more careful monitoring and aggressive chemotherapy following curative resection.     

结直肠癌肝转移的外科治疗

外科手术是治疗结直肠癌肝转移的重要手段。手术切除的适应证已扩展至满足肝内肿瘤能全部切除、切缘阴性、肝脏储备功能足够即可;而手术切除联合局部治疗进一步扩大了手术适应证。转移癌及原发癌一期或二期手术的远期生存率比较,差异无统计学意义。腹腔镜手术治疗结直肠癌肝转移安全可行,疗效确切。围手术期辅助化疗疗效并不明确,新辅助化疗可能不会使所有患者都受益。