Diagnosis and treatment of colorectal liver metastases - workflow

In this review, standards of diagnosis and treatment of colorectal liver metastases are described on the basis of a workshop discussion. Algorithms of care for patients with synchronous / metachronous colorectal liver metastases or locoregional recurrent tumour are presented. Surgical resection is the procedure of choice in the curative treatment of liver metastases. The decision about the resection of liver metastases should consider the following parameters: 1. General operability of the patient (comorbidity); 2. Achievability of an R 0 situation: i. if necessary, in combination with ablative methods, ii. if necessary, neoadjuvant chemotherapy, iii. the ability to eradicate extrahepatic tumour manifestations; 3. Sufficient volume of the liver remaining after resection ("future liver remnant = FLR): i. if necessary, in combination with portal vein embolisation or two-stage hepatectomy; 4. The feasibility to preserve two contiguous hepatic segments with adequate vascular inflow and outflow as well as biliary drainage; 5. Tumour biological aspects ("prognostic variables"); 6. Experience of the surgeon and centre! Extrahepatic disease does not contraindicate hepatectomy for colorectal liver metastases provided a complete resection of both intra- and extrahepatic disease is feasible. Even in bilobar colorectal metastases and 5 or more tumours in the liver, a complete tumour resection has been described. The type of resection (hepatic wedge resection or anatomic resection) does not influence the recurrence rate. Preoperative volumetry is indicated when major hepatic resection is planned. The FLR should be 25 % in patients with normal liver, 40 % in patients who have received intensive chemotherapy or in cases of fatty liver, liver fibrosis or diabetes, and 50-60 % in patients with cirrhosis. In patients with initially unresectable colorectal liver metastases, preoperative chemotherapy enables complete resection in 15-30 % of the cases, whereas the value of neoadjuvant chemotherapy in patients with resectable liver metastases has not been sufficiently supported. In situ ablative procedures (radiofrequency ablation = RFA and laser-induced interstitial thermotherapy = LITT) are local therapy options in selected patients who are not candidates for resection (central recurrent liver metastases, bilobar multiple metastases and high-risk resection or restricted patient operability). Patients with tumours larger than 3 cm have a high local recurrence rate after percutaneous RFA and are not optimal candidates for this procedure. The physician's experience influences the results significantly, both after hepatectomy and after in situ ablation. Therefore, patients with colorectal liver metastases should be treated in centres with experience in liver surgery.     

Neoadjuvant chemotherapy as a treatment strategy for multiple bilobar liver metastases from colorectal carcinoma

Hepatic resection remains the only potentially curative therapy for patients with colorectal liver metastases. Because most have multiple bilobar liver metastases, surgical resection is possible in only 25-58% of patients with colorectal liver metastases. Currently, attention is focused on the potential for neoadjuvant chemotherapy to render formerly unresectable patients resectable. The availability of more efficacious chemotherapy agents and an inventive approach to delivery schedules have resulted in an increase in the number of candidates for hepatic resection after neoadjuvant chemotherapy. Although tumor response varies with regimen and/or route of chemotherapy for colorectal liver metastases, with 16-63% tumor response rates, hepatic resection for responders after neoadjuvant chemotherapy gives survival benefits, with 20-48% 5-year survival rates after surgery. Provided that neoadjuvant chemotherapy controls multiple bilobar liver metastases well, aggressive hepatic resection should be considered for patients with those lesions. As a treatment strategy for multiple bilobar liver metastases, neoadjuvant chemotherapy is a useful to increase resection rates and may contribute to the improvement of prognosis in patients with such 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. Received: February 7, 2000 / Accepted: April 26, 2000     

Oncologic aspects of the decision-making process for surgical approach for colorectal liver metastases progressing during chemotherapy

Colorectal cancer represents the third most diagnosed malignancy in the world. The liver is the main site of metastatic disease, affected in 30% of patients with newly diagnosed disease. Complete resection is considered the only potentially curative treatment for colorectal liver metastasis (CRLM), with a 5-year survival rate ranging from 35% to 58%. However, up to 80% of patients have initially unresectable disease, due to extrahepatic disease or bilobar multiple liver nodules. The availability of increasingly effective systemic chemotherapy has contributed to converting patients with initially unresectable liver metastases to resectable disease, improving long-term outcomes, and accessing tumor biology. In recent years, response to preoperative systemic chemotherapy before liver resection has been established as a major prognostic factor. Some studies have demonstrated that patients with regression of hepatic metastases while on chemotherapy have improved outcomes when compared to patients with stabilization or progression of the disease. Even if disease progression during chemotherapy represents an independent negative prognostic factor, some patients may still benefit from surgery, given the role of this modality as the main treatment with curative intent for patients with CRLM. In selected cases, based on size, the number of lesions, and tumor markers, surgery may be offered despite the less favorable prognosis and as an option for non-chemo responders.     

Influence of Preoperative Chemotherapy on the Intraoperative and Postoperative Course of Liver Resection for Colorectal Cancer Metastases

Background  

Liver resection is a possibly curative treatment for colorectal cancer (CRC) liver metastases. Preoperative chemotherapy may make initially irresectable tumors resectable. The aim of this study was to compare perioperative course and short-term mortality after liver resection for CRC metastases between patients who were and were not treated with preoperative chemotherapy.     

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.     

Staging laparoscopy for potentially resectable noncolorectal,nonneuroendocrine liver metastases

Background Carefully selected patients with noncolorectal, nonneuroendocrine (NCNN) liver metastases may benefit from hepatic resection. The incidence of occult unresectable disease and the possible benefits of staging laparoscopy in these patients are not known. Methods From December 1997 to July 2000, staging laparoscopy was performed in 30 consecutive patients with NCNN metastases before planned open exploration and resection. Demographies, extent of preoperative imaging, operative and postoperative findings, and factors associated with laparoscopic identification of unresectable disease were analyzed. Results Twenty-four patients (80%) had a complete laparoscopic examination, and 23 had laparoscopic ultrasonography. All patients underwent preoperative computed tomography or magnetic resonance imaging, and 21 (70%) patients had 2 or more preoperative radiological studies. Overall, nine patients had unresectable disease, six of whom were identified by laparoscopy. Of the remaining 24 patients believed to have resectable disease at laparoscopy, 21 went on to a potentially curative procedure. Laparoscopy did not identify irresectability because of vascular involvement in three patients. Laparoscopy added a median of 30 minutes of operative time to those patients going on to laparotomy. Conclusions Laparoscopy identified the majority of patients with occult unresectable disease, improved resectability, and should be routine in patients being considered for potentially curative hepatic resection. Presented in part at the 54th Annual Meeting of the Society of Surgical Oncology, Washington, DC, March 15–18, 2001.     

Resection of the liver for colorectal carcinoma metastases: a multi-institutional study of patterns of recurrence

The Registry of Hepatic Metastases has collected data on consecutive patients from 24 institutions who have undergone hepatic resection for colorectal carcinoma metastases. Patterns of recurrence were examined in a subgroup of 607 patients who had undergone curative resection of isolated hepatic metastases. Forty-three percent of these patient have had recurrences in the liver and 31% have had recurrences in the lung (either alone or in combination with other organs). A multivariate analysis showed that patients with positive pathologic margins or bilobar metastases were at an increased risk of having a recurrence in the liver (68% and 64%, respectively). We conclude that: hepatic resection effectively controls hepatic tumor in a substantial number of patients, adjuvant therapy after hepatic resection should be directed at both the lung and liver to significantly increase survival, and patients with positive pathologic margins or bilobar metastases are at an increased risk for hepatic recurrence.     

Incidence of Unsuspected and Treatable Metastatic Disease Associated With Operable Colorectal Liver Metastases Discovered Only at Laparotomy (and Not Treated When Performing Percutaneous Radiofrequency Ablation)

Background When patients with resectable colorectal liver metastases (LM) are treated with percutaneous radiofrequency (RF), some unsuspected intrahepatic and extrahepatic metastases, detectable only at laparotomy, might be ignored and left untreated. This would result in a reduced cure rate. Our purpose was to discover the incidence of unsuspected and surgically treatable intrahepatic and extrahepatic metastases discovered at laparotomy.Methods The data of 506 patients who underwent a laparotomy and then a hepatectomy for colorectal LM were prospectively collected and retrospectively analyzed. All patients had undergone at least two types of preoperative liver imaging (but no fluorodeoxyglucose-positron emission tomography).Results Unsuspected metastases were discovered at laparotomy in 209 patients (41.3%). There were extrahepatic metastases in 82 patients (16.2%), additional LM in 152 patients (30%), and both in 25 patients (4.9%). Liver palpation and intraoperative ultrasound allowed for detecting additional LM in 125 (24.7%) and 48 (9.4%) patients, respectively. All of them were resected. When only the 124 patients who presented with 1 to 3 LM measuring <3 cm in diameter (candidates for percutaneous RF) were considered, the results were similar. Moreover, the incidence of unsuspected metastases was similar when the periods of surgery (before and after January 1996) were considered.Conclusions Laparotomy permits discovery of and treatment with a curative intent of unsuspected intrahepatic or extrahepatic metastases in at least one third of patients with classically resectable colorectal LM. This does not support the use of percutaneous RF ablation instead of hepatic resection for this population, because it will result in an important survival decrease.     

Use of OncoScint scan to assess resectability of hepatic metastases from colorectal cancer.

Patients with limited hepatic metastases from colorectal cancer can potentially be cured by resection. A number of patients deemed resectable by standard imaging procedures are found to have extrahepatic disease at laparotomy and are thus unresectable. A test capable of identifying these patients would assist in better patient selection. OncoScint (Cytogen Corp, Princeton, NJ) scan targets colorectal cancer by interacting with a tumor-associated glycoprotein. Can OncoScint scan be used to reliably identify patients with extrahepatic disease preoperatively? Between February 1996 and August 1998 eight patients with colorectal metastases to the liver were enrolled prospectively. All patients received preoperative OncoScint scan (indium-111) and underwent laparotomy. The laparotomy findings were correlated with the results of OncoScint scan. In four of eight patients (50%) OncoScint scan showed no extrahepatic disease. This was confirmed at laparotomy. All of these patients underwent hepatic resection. One of eight patients (12.5%) had OncoScint findings suggestive of extrahepatic disease pathologically confirmed during laparotomy. Three of eight patients (37.5%) had OncoScint findings of extrahepatic disease not confirmed by laparotomy. All three patients underwent hepatic resection. One of the three patients is still disease free for more than 48 months after hepatic resection. If OncoScint scan had been used to determine resectability this patient with false positive scan would have been denied a potentially curative operation. Because of the unacceptably high false positive rate the study was terminated after eight patients. Because of its high false positive rate (37.5%) OncoScint scan is not a reliable test for the assessment of extrahepatic disease. Other tests need to be developed to accurately stage extrahepatic disease with an acceptably low false positive rate to prevent exclusion of patients who can potentially be cured.     

Treatment strategy for multiple hepatic metastases of colorectal carcinoma

We describe the treatment strategy for multiple hepatic metastases of colorectal carcinoma based on a review of the literature and our own results. Although a number of studies have suggested that multiplicity or bilobar distribution of metastases is associated with poor outcome, liver resection is thought to be the only potentially curative treatment. The only contraindications to surgery are the presence of extrahepatic metastases (with the exception of resectable lung metastases) and if radical removal of all detectable tumors is not possible. Hepatectomy should be performed with the aim of maintaining a delicate balance between radical removal of tumors and the preservation of as much residual hepatic mass as possible with minimal blood loss. Surgeons should be familiar with the use of intraoperative ultrasonography, a standard adjunct to liver resection. Preoperative portal vein embolization may be indicated in selected patients as a means of inducing hypertrophy in the remaining hepatic parenchyma. Received for publication on Aug. 30, 1998; accepted on Nov. 2, 1998     

Five-Year Survival Following Hepatic Resection After Neoadjuvant Therapy for Nonresectable Colorectal [Liver] Metastases

Background: Surgical resection is the most effective treatment for colorectal liver metastases but only a minority of patients are candidates for a potentially curative resection. Our experience with neoadjuvant chemotherapy followed by resection and five years survival analysis of the patients treated is presented.Methods: Between February of 1988 and September of 1996, 701 patients with unresectable colorectal liver metastases were treated with neoadjuvant chemotherapy. Four categories of nonresectable disease were defined: large size, ill location, multinodularity, and extrahepatic disease. Liver resection was performed in those patients whose disease became resectable. After resection, the patients were followed up every 3 months. A 5-year survival analysis by the different categories described was performed.Results: Ninety-five patients (13.5%) were found to be resectable on reevaluation and underwent a potentially curative resection. There was no perioperative mortality, and the complication rate was 23%. As of December of 1999, 87 patients have completed 5 years of follow-up. The overall 5-year survival is 35% from the time of resection and 39% from the onset of chemotherapy. Respective 5-year survival rates are 60% for large tumors, 49% for ill-located lesions, 34% for multinodular disease, and 18% for liver metastases with extrahepatic disease. In this latter category, however, a 35% 5-year survival was found when all the patients with extrahepatic disease were analyzed rather than only those for whom extrahepatic disease was the main cause of nonresectability.Conclusions: Neoadjuvant chemotherapy enables liver resection in some patients with initially unresectable colorectal metastases. Long-term survival is similar to that reported for a priori surgical candidates.     

Positron Emission Tomography Affects Surgical Management in Recurrent Colorectal Cancer Patients

Background: We determined the effect of positron emission tomography (PET) on surgical decision-making in patients with metastatic or recurrent colorectal cancer.Methods: A total of 114 patients with advanced colorectal cancer were imaged with computed tomography (CT) and PET scans. The PET and CT scans were independently interpreted before surgery and recorded.Results: Forty-two of the 114 patients had resectable disease on the basis of CT. PET altered therapy in 17 (40%) of these 42 patients on the basis of the following results: extrahepatic disease (n = 9), bilobar involvement (n = 3), thoracic involvement (n = 5), retroperitoneal lymphadenopathy (n = 2), bone involvement (n = 1), and supraclavicular disease (n = 1). In 25 patients with liver metastases only, PET found additional disease in 18 (72%), extrahepatic disease in 11, chest disease in 13, retroperitoneal lymphadenopathy in 4, and bone disease in 3. In five patients, both scans underestimated small-volume peritoneal metastases discovered at laparotomy.Conclusions: PET altered therapy in 40% of patients. In patients with isolated liver involvement, 72% had more extensive disease that precluded surgical resection. PET scans should be used in the management of patients with recurrent colorectal cancer who are being considered for potentially curative surgery.     

Treatment for multiple bilobar liver metastases of colorectal cancer

Background Recent advances have extended indications for hepatectomy to include multiple bilobar colorectal liver metastases (CLM). Staging systems based on the biological malignancy of primary and metastatic tumors provide appropriate indications for hepatectomy in CLM. However, suitability for resection in patients with complex and extensive hepatic metastases is controversial. Methods A medline search was performed to identify papers reporting the resection for CLM. Techniques, indication, and results were reviewed. Results If the anticipated remnant liver volume is small (25–40% of total), suggesting a high risk of postoperative liver failure, portal vein embolization (PVE) is recommended prior to hepatectomy. However, curative resections are not always possible. Specifically in synchronous multiple bilobar CLM, two-stage hepatectomy, comprising bilateral hepatectomy and primary resection with or without PVE, can prevent growth of ipsilateral metastatic nodules in the remnant liver and reduce surgical risk. Several local ablation techniques can complement surgery if hepatic resection alone increases the risk of postoperative liver failure or is not curative. Chemotherapy combined with targeted treatment can suppress recurrence and extend indications for hepatectomy by reducing the size and number of primary irresectable tumors. Conclusion PVE or staged procedure combining with local ablation or neoadjuvant, downstaging or adjuvant therapies extends indications for hepatectomy to include multiple bilobar CLM. The 5-year survival rate for multiple bilobar CLM treated with alternating hepatectomy and chemotherapy is comparable to the values reported for single and hemilateral CLM.     

Risk of Occult Irresectable Disease at Liver Resection for Hepatic Colorectal Cancer Metastases: A Contemporary Analysis

Introduction

Traditionally, rates of irresectable disease at laparotomy for colorectal liver metastases (CRLM) have ranged from 15 to 70%. Diagnostic laparoscopy has been shown to be effective at preventing nontherapeutic laparotomy in selected patients. The purpose of this study was to analyze the resectability rate and role of diagnostic laparoscopy in a contemporary cohort.

Methods

Using a prospectively maintained database, we identified patients who were explored for presumed resectable CRLM. Clinical and pathologic data associated with the finding of irresectable disease were analyzed.

Results

From 2008–2010, 455 patients were explored. Of these, 35 (7.7%) did not undergo a resection and/or ablation. Of the 35 patients with irresectable disease, 15 (43%) had disease limited to the liver, 17 (49%) had extrahepatic disease (EHD), and 3 (9%) had other reasons precluding resection. Of the whole cohort, 45 patients (9.9%) were found to have EHD, and 27 of these (60%) underwent complete resection or ablation. The only factor associated with irresectable disease was a prior history of EHD, which was present in 29% of those found irresectable versus 13% of those resected (p = 0.022). Diagnostic laparoscopy was performed in 55 patients. Four of these patients had irresectable disease, and three were spared unnecessary laparotomy. Therefore, the yield was 5% and the sensitivity 75%.

Conclusions

The finding of irresectable disease is a rare event with modern radiologic assessment and the expansion of indications for resection. Diagnostic laparoscopy has a low yield and should be considered if there is a history of EHD or suspicious findings on preoperative imaging.     

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.     

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.     

Carcinoma of the proximal extrahepatic biliary tree radiologic assessment and therapeutic alternatives.

Preoperative cholangiography and angiography have been used in a series of 37 patients with hilar cholangiocarcinoma investigated over a 17-month period in a single specialist unit. Twelve lesions were judged to be irresectable on the basis of the cholangiographic findings: this was confirmed at laparotomy in nine patients and at autopsy in one. Angiography was performed in 21 patients, and suggested irresectability in eight: this was confirmed by laparotomy in seven. The eighth patient had compression of the left portal vein which had been interpreted as tumor invasion on angiography, and it was possible to perform a curative extended right hepatic lobectomy. Of the 13 potentially resectable patients, three were unfit for major resectional surgery. Five were found to be irresectable at laparotomy because of vena cava involvement in two and distant metastases in three. Five patients underwent resection with histologically clear margins. The combined use of cholangiography and angiography is recommended as a means of selecting appropriate therapy for patients with hilar cholangiocarcinoma.     

A prospective evaluation of hepatic resection for colorectal carcinoma metastases to the liver: Follow-up report

Single institution studies of hepatic resection have implied that some subsets of patients with metastases from colon and rectum adenocarcinoma can be cured by surgery. However, it is unknown how such patients can be selected and what, in fact, the ultimate cure rate is. The objective of this multi-institutional study was to define in a prospective manner how many patients predicted to have resectable liver metastases actually could undergo curative resection and what the disease-free and overall survival were. A prospective 15-institution treatment plan included all patients who were predicted to have resectable metastases from colon and rectum cancer primaries. Results were compared among patients who underwent successful resection, patients who underwent resection with pathologically defined inadequate margins, and patients who underwent exploration but were found at surgery not to have resectable liver metastases. Fourteen institutions throughout North America and one in Milan who were members of the Gastrointestinal Tumor Study Group at the inception of this protocol in July of 1984 participated in the study. The patient population consisted of all those with metachronous or synchronous metastases from colon or rectum adenocarcinoma seen during a consecutive 3 1/2 year period with protocol registry at the time liver metastases were predicted to be isolated and resectable. Intervention consisted of the application of standard preoperative screening tests, abdominal exploration, and resection of all patients who had liver-only surgically resectable disease. The main outcome measures were: Accuracy of preoperative staging, acute and chronic operative morbidity, and disease-free, as well as overall, survival among the three treatment groups. The minimum follow up on all surviving patiens after curative resection was 2.2 years, with a median follow up of 3.2 years. Median survival times for patients receiving curative and noncurative resections and for those receiving no resection were estimated to be 35.7, 21.2, and 16.5 months, respectively. No statistically significant difference in the survival distribution of the noncuratively resected or the non-resected patients was observed. The survival distribution of curatively resected patients remains statistically superior to the distribution of noncuratively resected patients and those receiving no resection (P=0.01). These results confirmed that, although liver resection for hepatic metastases from colorectal car cinoma is safe to do and presently constitutes the only standard curative treatment for potentially resectable disease, it ultimately cures few patients.     

Surgery in hepatic and extrahepatic colorectal metastases

Extrahepatic disease (EHD) has been considered a contraindication to hepatectomy. Over the last few years, some series reported interesting 5-year survival rates after resection with hepatic colorectal metastases and EHD free margins. Between August 1989 and October 2005, 116 patients underwent liver resection for colorectal metastases at Surgical Department of the University of Udine, Italy. Among these, we reviewed the data of 5 patients affected by EHD. In 3 patients there were also an anastomotic recurrence of the primary tumor, in 3 patients diaphragm was infiltrated by contiguous liver metastases. We performed in all the patients minor liver resections. We have associated the radiofrequence ablation of a lesion not surgically resectable with liver resection in one case. The surgical procedure was always considered as curative. We observed no case of operative mortality. The mean survival of the entire cohort is 23.2 months (range 4-42 months). Our study, even if based upon a limited number of patients, supports the thesis that extrahepatic disease in patients affected by colorectal cancer with hepatic metastases should not be considered as an absolute contraindication to liver resection especially for the cases in with local radical cure exeresis is achievable.