Lymphatic node dissection in liver resection for colorectal metastasis

European Surgery - The incidence of colorectal carcinoma is increasing, and it is now the third most common type of cancer worldwide. Liver resection for colorectal liver metastasis is the only...     

Postoperative complications following aggressive repeat hepatectomy for colorectal liver metastasis have adverse oncological outcomes

Purposes

Repeat hepatectomy remains the only curative treatment for recurrent colorectal liver metastasis (CLM) after primary hepatectomy. However, the repeat resection rate is still low, and there is insufficient data on the outcomes after repeat hepatectomy. The aim of this study was to investigate the feasibility and prognostic benefit of aggressive repeat hepatectomy for recurrent CLM.

Methods

Data were reviewed from 282 consecutive patients who underwent primary curative hepatectomy for CLM between January 1994 and March 2015. The short- and long-term outcomes were analyzed.

Results

One hundred ninety-three patients (68 %) developed recurrence, and repeat hepatectomy was conducted in 62 patients. Overall, 62 s, 11 third, 4 fourth, and 1 fifth hepatectomies were performed. The postoperative morbidity and mortality rates were low (11.5 and 1.3 %, respectively). The overall survival rates at 3 and 5 years after primary hepatectomy for CLM in the repeat hepatectomy group were 79.5 and 57.4 %, respectively. A multivariate analysis indicated that postoperative complications were independently associated with overall survival after repeat hepatectomy.

Conclusions

Repeat hepatectomy for CLM is feasible, with acceptable rates of perioperative morbidity and mortality, and the potential for long-term survival. However, postoperative complications following aggressive repeat hepatectomy for CLM are associated with adverse oncological outcomes.

     

Impact of repeat hepatectomy on recurrent colorectal liver metastases

BACKGROUND. Hepatic recurrence is seen in approximately 40% of patients undergoing hepatectomy for colorectal metastases. This study was designed to assess the risks and clinical benefits of repeat hepatectomy for those patients. METHODS. Twenty-six patients underwent repeat hepatectomy for hepatic recurrence, and their clinical data were retrospectively reviewed for operative morbidity and mortality, performance level, and survival. RESULTS. There was no operative mortality after repeat hepatectomy. Operative bleeding was significantly increased in the second hepatectomy; but operating time, duration of hospital stay, and performance status after the second hepatectomy were comparable with those of the initial hepatectomy. The median survival time from the second hepatectomy was 31 months, and the 3- and 5-year survival rates were 62% and 32%, respectively. A short disease-free interval (6 months or less) between the initial hepatectomy and diagnosis of hepatic recurrence in the remnant liver was significantly associated with poor survival after the second hepatectomy. CONCLUSIONS. Repeat resection contributed to clinical benefits for selected patients with hepatic recurrence after the initial hepatectomy for colorectal liver metastases. However, appearance of hepatic recurrence within 6 months or less after the initial hepatectomy is a poor prognostic factor for repeat hepatectomy.     

Obstructive jaundice caused by lymphatic remetastasis from the hepatic metastasis of rectosigmoid cancer

The significant benefit of performing hepatic resection for hepatic metastases from colorectal primary cancers is well established; however, the effectiveness of dissection of the lymph nodes draining the liver remains uncertain. Herein, we report the case of a 52-year-old man who was found to have obstructive jaundice caused by lymphatic remetastasis from the hepatic metastasis of primary rectosigmoid cancer. He had previously undergone a high anterior resection for the rectosigmoid cancer, in April 1990, and a hepatic resection for metastasis was done in March 1994. When the hepatic resection was carried out, dissection of the regional lymph nodes of the liver (i.e., the nodes in the hepatoduodenal ligament) was not performed because no obvious metastatic nodes were identified. Three years after the hepatic resection, enlarged lymph nodes compressing the extrahepatic bile duct from outside were identified by cholangiography and computed tomography (CT). Because radiological studies were unable to determine the lesion capable of metastasizing to these nodes, they were diagnosed as remetastasized lymph nodes from the hepatic metastasis that had been resected 3 years earlier. The lymphatic remetastases were intractable to treatment, and the patient finally died of hepatic failure and malignant cachexia. This case serves to demonstrate that lymphatic dissection of the regional lymph nodes may need to be taken into consideration when resection of hepatic metastases from colorectal cancers is performed. Received: October 30, 2000 / Accepted: March 12, 2001     

淋巴管生成及其内皮特异性标志物在结直肠癌肝转移中作用的研究进展

淋巴管内皮细胞特异性标志物的出现使淋巴管生成及淋巴管转移的分子机制成为肿瘤转移的研究热点。以往认为结肠癌肝转移的途径主要通过血道途径,而近期一些研究表明,淋巴管生成及淋巴结转移可能在结直肠癌肝转移的过程中同样发挥着至关重要的作用。笔者就淋巴管生成及其内皮特异性标志物在结直肠肝转移中的作用机制作一综述。     

Prognostic factors for poor survival after repeat hepatectomy in patients with colorectal liver metastases

BACKGROUND: The recurrence rate for colorectal liver metastases after repeat hepatic resection is high, and selection criteria for repeat hepatectomy are still controversial. METHODS: Clinical data of patients undergoing repeat hepatectomy for metastatic colon cancer were reviewed retrospectively and compared with those of initial hepatectomy and other treatments to determine criteria for repeat hepatectomy and to confirm its efficacy. RESULTS: For 22 patients who underwent repeat hepatectomy, no mortality and an 18% morbidity rate were observed. The 3-year survival rate after repeat hepatectomy was 49%. The only poor prognostic factor after repeat hepatectomy was a serum carcinoembryonic antigen level greater than 50 ng/mL before initial hepatectomy. The prognosis for patients who underwent repeat hepatectomy and had shown high carcinoembryonic antigen levels before initial hepatectomy was approximately equal to that for the patients who received systemic chemotherapy or hepatic arterial infusion for unresectable tumors in the remnant liver. CONCLUSION: Repeat hepatectomy for colorectal liver metastases can be performed safely and appears to be as effective as initial hepatectomy. However, for patients with a carcinoembryonic antigen level greater than 50 ng/mL before the initial hepatectomy, repeat hepatic resection alone may not be as effective, and a new strategy is needed.     

切缘宽度对结直肠癌肝转移同期肝切除患者术后生存的影响

目的探讨结直肠癌同期肝切除术合适的肝转移瘤切缘宽度。方法回顾性分析1994年8月至2004年12月行肝肠同期切除的39例同时性结直肠癌肝转移患者的临床资料,将患者根据肝转移瘤切缘宽度小于1cm和大于或等于1cm分为A、B两组,用Kaplan—Meier法进行生存分析,用Log-rank检验比较两组术后的生存期。结果A组患者14例,B组患者25例;两组患者性别、年龄、原发瘤浸润深度、淋巴结转移、肝转移瘤数目和分布及最大直径、手术时间和术中出血量比较．差异均无统计学意义（P〉0．05）。两组患者中位生存期分别为17和37个月（P〈0．01）,5年生存率分别为0和19．8％（P〈0．01）,差异有统计学意义。结论结直肠癌肝转移行同期肝切除术时应力争肝转移瘤切缘宽度大于或等于1cm。     

Repeat hepatectomy for colorectal liver metastases

This study includes 16 patients (9 men, 7 women; mean age 64 years) who underwent a total of 19 repeat hepatectomies for metastasis after colon (n=7) or rectal (n=9) carcinoma. All patients were reoperated for recurrent liver metastasis after the first resection (mean, 21 months; range, 7-40 months), and three had a third hepatectomy 13, 24, or 65 months after the second. Perioperative mortality was 0% and morbidity was 37%. The 3- and 5-year survival rates after the second resection were 56.8% and 28.4%, respectively, with a median survival of 42.3 months. Seven patients died (mean survival, 25.7 months; range, 9-58 months) before the end of the study. Six patients were alive with one or more recurrences, and three (24, 51, and 173 months of follow-up) were alive without known recurrence. Survival rates for repeat resections of colorectal liver metastases in selected patients were comparable with those obtained after resection of a first liver metastasis.     

淋巴管在肿瘤转移中的作用

恶性肿瘤的局部及远处转移是导致患者死亡的根本原因,淋巴管形成以及结构改变的作用与淋巴转移途径密不可分.本文主要针对淋巴管在肿瘤转移过程中发挥的作用进行讨论,并且主要从近几年国际上关于淋巴管上皮细胞分子水平上的机制研究进展作一综述.     

Clinicopathological analysis of recurrence patterns and prognostic factors for survival after hepatectomy for colorectal liver metastasis

Background

Hepatectomy is recommended as the most effective therapy for liver metastasis from colorectal cancer (CRCLM). It is crucial to elucidate the prognostic clinicopathological factors.

Methods

Eighty-three patients undergoing initial hepatectomy for CRCLM were retrospectively analyzed with respect to characteristics of primary colorectal and metastatic hepatic tumors, operation details and prognosis.

Results

The overall 5-year survival rate after initial hepatectomy for CRCLM was 57.5%, and the median survival time was 25 months. Univariate analysis clarified that the significant prognostic factors for poor survival were depth of primary colorectal cancer (≥ serosal invasion), hepatic resection margin (< 5 mm), presence of portal vein invasion of CRCLM, and the presence of intra- and extrahepatic recurrence. Multivariate analysis indicated the presence of intra- and extrahepatic recurrence as independent predictive factors for poor prognosis. Risk factors for intrahepatic recurrence were resection margin (< 5 mm) of CRCLM, while no risk factors for extrahepatic recurrence were noted. In the subgroup with synchronous CRCLM, the combination of surgery and adjuvant chemotherapy controlled intrahepatic recurrence and improved the prognosis significantly.

Conclusions

Optimal surgical strategies in conjunction with effective chemotherapeutic regimens need to be established in patients with risk factors for recurrence and poor outcomes as listed above.     

Optimal lymph node dissection for colorectal cancer]

Previous studies on the distribution of positive lymph nodes have revealed that the colon should be resected 10 cm from the tumor on both sides and that the intermediate nodes along the main vessel should be dissected in patients with colon cancer. In rectal cancer, superior lymphatic spread along the inferior mesenteric artery (IMA) is the main metastatic route. The IMA should be dissected immediately after the bifurcation of the left colic artery, and the intermediate lymph nodes should be removed. The positive rate of the lateral lymph nodes is about 10%. The rate of local failure is high and the prognosis is poor in patients with positive lateral lymph nodes, even if the lateral lymph nodes have been dissected. However, it has been reported that lateral lymph node dissection combined with excision of the internal iliac vessels results in good disease-free survival in patients with positive lateral nodes. Therefore the indications for lateral node dissection remain controversial. Lymphatic spread into the mesorectum on the anal side has been shown to be an important factor in local failure. The mesorectum should be resected for up to 4 or 5 cm from the inferior tumor margin in middle rectal cancer, and the entire mesorectum should be removed in lower rectal cancer. Nerve tissue preserved in pelvic autonomic nerve-preserving surgery contains a small amount of lymphoid tissue and lymph nodes. Therefore the extent of lymph node dissection and the area of autonomic nerves to be preserved based on tumor site or tumor penetration remain controversial.     

Repeat hepatectomy for colorectal liver metastases.

OBJECTIVE: The authors assess the long-term results of repeat hepatectomies for recurrent metastases of colorectal cancer and determine the factors that can predict survival. SUMMARY BACKGROUND DATA: Safer techniques of hepatic resection have allowed surgeons to consider repeat hepatectomy for colorectal metastases in an increasing number of patients. However, higher operative bleeding and increased morbidity have been reported after repeat hepatectomies, and the long-term benefit of these procedures needs to be evaluated. STUDY POPULATION: Sixty-four patients from a group of 243 patients resected for colorectal liver metastases were submitted to 83 repeat hepatectomies (64 second, 15 third, and 4 fourth hepatectomies). Combined extrahepatic surgery was performed in 21 (25%) of these 83 repeat hepatectomies. RESULTS: There was no intraoperative or postoperative mortality. Operative bleeding was not significantly increased in repeat hepatectomies as compared to first resections. Morbidity and duration of hospital stay were comparable to first hepatectomies. Overall and disease-free survival after a second hepatectomy were 60% and 42%, respectively, at 3 years and 41% and 26%, respectively, at 5 years. Factors of prognostic value on univariate analysis included the curative nature of first and second hepatectomies (p = 0.04 and p = 0.002, respectively), an interval between the two procedures of more than 1 year (p = 0.003), the number of recurrent tumors (p = 0.002), serum carcinoembryonic antigen levels (p = 0.03), and the presence of extrahepatic disease (p = 0.03). Only the curative nature of the second hepatectomy and an interval of more than 1 year between the two procedures were independently related to survival on multivariate analysis. CONCLUSIONS: Repeat hepatectomies can provide long-term survival rates similar to those of first hepatectomies, with no mortality and comparable morbidity. Combined extrahepatic surgery can be required to achieve tumor eradication. Repeat hepatectomies appear worthwhile when potentially curative.     

Significance of hepatic lymph node metastasis in patients with unresectable synchronous liver metastasis of colorectal cancer

The frequency and significance of hepatic lymph node (HLN) metastasis were retrospectively evaluated in 43 patients with unresectable synchronous liver metastasis of colorectal cancer who underwent resection of the primary tumor and histopathologic evaluation of HLNs between March 1997 and August 2007. HLN metastasis was detected in 12 patients (27.9%). No significant correlations were observed between the presence of HLN metastasis and any of the 12 clinicopathologic factors examined. On multivariate analysis using the Cox proportional hazards model, the presence of HLN metastasis (P = 0.002), along with a large number (> or = 4) of regional lymph node metastases (P = 0.003), and nonuse of oxaliplatin-based chemotherapy (P = 0.005) were identified as independent risk factors for shorter survival. To establish a new therapeutic strategy for initially unresectable liver metastasis of colorectal cancer, HLNs should be examined histologically in patients undergoing resection of hepatic lesions when they are rendered resectable by effective chemotherapy.     

结直肠癌同时性肝转移的同期手术切除

目的探讨同时性结直肠癌肝转移行同期切除原发瘤和肝转移瘤的安全性和有效性。方法回顾性总结分析从1981年5月至2005年11月在我院住院治疗的43例结直肠癌同时性肝转移同期手术的临床病理资料及结果并结合文献复习。结果43例患者中男性21例,女性22例,中位年龄52岁,手术持续中位时间180min。共30例术中输血,中位输血量800ml。术后总住院时间10—50d,中位时间15d。并发症发生率18．6％（8／43）,手术死亡率2．3％（1／43）。全组总的中位生存期为25个月,5年生存率19．1％。R0切除组的中位生存期48个月,5年生存率33．8％;非R0切除组的中位生存期为20个月,5年生存率7．6％。两组的生存时间经LogRank检验差异明显,P=0．002。结论同时性结直肠癌肝转移同期手术的安全性和有效性可以保证。对可切除的同时性结直肠癌肝转移应争取同期手术,并争取R0切除。