Hepatic Resection for Colorectal Metastasis: Impact of Tumour Size

Background Many colorectal liver metastasis patients are denied surgical resection on the basis of tumour size. The aim of this study was to explore the impact of metastasis size on modern liver resection.Methods Using a prospectively collected database, this was a retrospective analysis of 484 consecutive patients who underwent liver resection for colorectal liver metastases between 1993 and 2003. The cohort was divided into two groups: smaller metastases (<8 cm) and larger metastases (≥ 8 cm). Those with larger metastases were then further stratified into big metastases (8–12 cm) and giant metastases (>12 cm). Demographic, pathological, surgical technique and outcome data were compared between the groups.Results There were 88 (18%) patients with metastases measuring 8 cm or larger. There was an association between higher carcinoembryonic antigen (CEA) and cancer antigen (CA) 19-9 levels and larger metastases. The actuarial 5-year survival for patients with larger metastases was 38% compared with 42% for smaller metastases (not statistically significant). Patients with giant metastases had poorer overall and disease-free survival (both nonsignificant) compared with those with big metastases: 29% and 28% at 5 years, respectively.Conclusion Patients with colorectal liver metastasis greater than 8 cm and up to 12 cm in size should not be treated differently from those with smaller lesions.     

Surgical treatment of colorectal liver metastases

Recent advances not only in diagnostic imaging examinations but also in surgical techniques of liver resection have extended the indication of liver resection for colorectal metastases, and accumulated experience has improved surgical outcome. Liver metastases develop in a quarter of patients with colorectal cancer, and of these 30 % are candidates for liver resection under the criteria that liver resection is indicated when all tumors can be removed technically with adequate normal parenchyma left, no extrahepatic metastases are detectable, and the patients is considered fit for surgery. As the 5 year survival rate ranges from 30 % and 40 %, liver resection benefits 9 % to 12 % of patients with liver metastases. Recurrence in the liver remnant after liver resection develops in 40% to 50 %, and repeat liver resection benefits those patients.     

Second liver resections are safe and effective treatment for recurrent hepatic metastases from colorectal cancer: a bi-institutional analysis

OBJECTIVE: To determine the value of repeat liver resection for recurrent colorectal metastases to the liver. SUMMARY BACKGROUND DATA: Liver resection represents the best and a potentially curative treatment for metastatic colorectal cancer to the liver. After resection, however, most patients develop recurrent disease, often isolated to the liver. METHODS: This study reports the combined experience of repeat liver resection for recurrent liver metastases at an American and a European surgical oncology center. Patients were identified from prospective databases and records were retrospectively reviewed. A total of 126 patients (American n = 96, 1986-2001; European n = 30, 1985-1999) underwent repeat liver resection. Patient characteristics were similar in the two institutions. Median follow-up from first liver resection was 88 and 105 months, respectively. RESULTS: Operations performed included 90 minor resections and 36 resections of a lobe or more. The 1-, 3-, and 5-year survival rates were 86%, 51%, and 34%. There were 19 actual 5-year survivors to date. By multivariate regression analysis (proportional hazard model), more than one lesion and tumor size larger than 5 cm were independent prognostic indicators of reduced survival. The interval between the first and second liver resection was not predictive of outcome. CONCLUSIONS: Repeat liver resection for colorectal liver metastases is safe. Patients with a low tumor load are the best candidates for a repeat resection. In well-selected patients, further resection of the liver can provide prolonged survival after recurrence of colorectal liver metastases.     

Resection of liver metastases from breast cancer: towards a management guideline

In selected patients with colorectal and neuroendocrine liver metastases, the outcome of liver resection is well established with 5-year survival rates ranging from 25% to 60%. However, the role of liver resection for non-colorectal non-neuroendocrine (NCRCE) liver metastases has not been fully established. Liver metastases in breast cancer are common and a small number of those patients may be suitable for surgical resection. There have been some case series with low mortality and morbidity and prolonged survival after liver resection. We performed this review to evaluate the overall and disease free survival after liver resections for breast metastases. Extensive search of Pubmed, Medline, Cochrane database was performed and data was analysed. Although mostly case series with smaller number of patients, outcome has been comparable to colorectal liver metastases in selected group of patients with 5 years survival rate at the range of 20%-60% with main prognostic factors of being the absence of extrahepatic disease (in exception of isolated pulmonary and bony metastasis) and to achieve an R0 resection.     

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??Liver metastases of colorectal cancer: a survival analysis ZHU De-xiang*??REN Li??WEI Ye??et al. *Institute of General Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
Corresponding author??XU Jian-min??E-mail??xujmin@yahoo.com.cn
Abstract Objective To investigate survival in patients with liver metastases of colorectal cancer and identify risk factors associated with survival. Methods Clinical, pathologic, treatment and complete follow-up data of the consecutive cases of colorectal liver metastasis admitted between 2000 and 2010 in Zhongshan Hospital of Fudan University were analyzed retrospectively. The prognostic value of different factors was studied through univariate and multivariate analyses. Results The median survival was 22.0 months and 5-year survival rate was 16%. Survival of synchronous liver metastases (21.2 months and 16%) was lower than that of metachronous liver metastases (30.1 months and 23%, P<0.01). Survival after resection of liver metastases was 49.8 months and 37%, which was higher than that after chemotherapy ??22.2 months and 0??, that after intervention??19.0 months and 11%??, that after chemotherapy combined with intervention??22.8 months and 10%??and that after local regional treatment (28.5 months and 0). Five factors were found to be significant and independent predictors of poor survival by multivariate analysis: simultaneous liver metastases (P=0.005), poorly differentiated primary (P=0.005), number of liver metastases ≥ 4 (P=0.008), largest liver metastases ≥ 5 cm (P=0.007), and no surgical treatment of liver metastases (P<0.001). Conclusion Survival of synchronous liver metastases is lower than that of metachronous liver metastases. Resection of liver metastases provides good long-term survival benifit for patients with resectable and initially irresectable liver metastases. Expansion of the indications for liver resection is acceptable. Long-term survival outcome can be predicted from a risk factor scoring system.     

Surgical treatment of liver metastases from colorectal cancer

We analyze our experience over a 10-year period in the surgical treatment of liver metastases from colorectal cancer. Between 01.01.1995 and 08.31.2005 189 liver resections were performed in 171 patients with liver metastases from colorectal cancer (16 re-resections - 2 in the same patient and a "two-stage" liver resection in 2 patients). In our series there were 83 patients with synchronous liver metastases (69 simultaneous resections, 12 delayed resections and 2 "two-stage" liver resection were performed) and 88 metachronous liver metastases. Almost all types of liver resections have been performed. The morbidity and mortality rates were 17.4% and 4.7%, respectively. Median survival was 28.5 months and actuarial survival at 1-, 3- and 5-year was 78.7%, 40.4% and 32.7%, respectively. Between January 2002 and August 2005 hyperthermic ablation of colorectal cancer liver metastases has been performed in 6 patients; in other 5 patients with multiple bilobar liver metastases liver resection was associated with radiofrequency ablation and one patient underwent only radiofrequency ablation for recurrent liver metastasis. In conclusion, although the treatment of colorectal cancer liver metastases is multimodal (resection, ablation, chemotherapy and radiation therapy), liver resection is the only potential curative treatment. The quality and volume of remnant liver parenchyma is the only limitation of liver resection. The morbidity, mortality and survival rates after simultaneous liver and colorectal resection are similar with those achieved by delayed resection. Postoperative outcome of patients with major hepatic resection is correlated with the surgical team experience. The long-term survival was increased using the new multimodal treatment schemes.     

Liver resection and transplantation — Therapeutic concepts in surgical treatment of hepatic metastases

Summary Background: Surgical procedures such as liver resection or liver transplantation are the only treatment modalities that provide a chance of cure for patients with liver metastases. Methods: This report reviews results of liver resection and liver transplantation for liver metastases from colorectal cancer and neuroendocrine tumors as compared to the natural course. Results: Overall 5 year survival after curative liver resection for colorectal metastases ranges between 25 and 48%. The operative mortality is between 0 and 5%. Risk factors for tumor recurrence are more or less defined. Reresections of metastases can be performed with comparable mortality rates and results. Liver transplantation for unresectable colorectal metastases offers a median survival of 28 months, but the chance of cure only for individual patients. Exclusion of patients with positive lymph nodes of the primary tumor improves median survival. As there are alternative treatment options for neuroendocrine metastases, indication for liver resection or transplantation is not clearly defined, but the chance of cure by means of surgical treatment should not be missed. Curative resections of neuroendocrine liver metastases can achieve 5-year survival rates of more than 80%. Conclusions: Radical surgical removal of liver metastases from colorectal and neuroendocrine cancer can improve the prognosis for selected patients. Further improval is expected from a multimodal approach.      

Survival After Hepatic Resection for Colorectal Metastases: A 10-Year Experience

Background Metastatic colorectal cancer is a major cause of cancer death in North America. Hepatic resection offers the potential for cure in selected patients. We report the long-term outcomes of patients who underwent hepatic resection for colorectal metastases over a 10-year period at a single hepatobiliary surgical oncology center. Methods All patients who underwent liver resection for metastatic colorectal cancer between 1992 and 2002 were identified. Data were retrospectively obtained through chart review. Major outcome variables were disease-free survival and overall survival. Risk factors for disease recurrence and mortality were identified by multivariate analysis by using the Cox proportional hazard method. Results A total of 423 hepatectomies were performed for metastatic colorectal cancer. Most operations (n = 276; 65%) were major (four or more segments) hepatectomies. Perioperative morbidity occurred in 74 (17%) patients. There were seven (1.6%) perioperative deaths. The disease-free survival at 1, 5, and 10 years was 64%, 27%, and 22%, respectively. The overall survival at 1, 5, and 10 years was 93%, 47%, and 28%, respectively. Multivariate analysis identified four negative predictive factors for overall survival (hazard ratio; 95% confidence interval): a positive surgical margin (2.9; 1.5–5.3), large metastases (>5 cm; 1.5; 1.1–2.0), multiple metastases (1.4; 1.1–1.9), and age >60 years (1.4; 1.1–1.9). Conclusions Hepatic resection for metastatic colorectal cancer is safe and provides good long-term overall survival rates of 47% at 5 years and 28% at 10 years. An aggressive approach is justified by the low operative mortality rate and good long-term survival, even in individuals with multiple bilobar metastases.     

Liver resection for multiple colorectal metastases: influence of parenchymal involvement and total tumor volume,vs number or location,on long-term survival

HYPOTHESIS: Multiple and/or bilateral liver metastases are not absolute contraindications to surgical resection. DESIGN: Retrospective analysis. SETTING: University department of surgery and transplantation. PATIENTS AND INTERVENTION: A total of 245 curative liver resections for colorectal metastases were divided into 3 groups: M1, single lesions; M2, multiple unilobar; and M3, multiple bilobar. MAIN OUTCOME MEASURES: Univariate and multivariate analysis using several prognostic factors was performed to distinguish variables affecting long-term survival. RESULTS: Overall operative mortality was 0.8%. Overall 5-year survival was 34%. On multivariate analysis, only the percentage of hepatic involvement by the tumor significantly affected prognosis. By replacing this variable with the total tumor volume, this latter variable was the only independent predictor of survival. Patients with multiple metastases and total tumor volume less than 125 cm(3) had a significantly better outcome than patients with single nodules and total tumor volume more than 380 cm( 3). Operative mortality and morbidity were comparable among groups M1, M2, and M3. The 5-year survival was 41%, 17%, and 34%, respectively (group M1 vs M2, P =.05; group M1 vs M3 and group M2 vs M3, not significant). The 5-year survival was 41% and 23% in patients with single and multiple lesions, respectively and was 35% and 32% in patients with unilobar and bilobar lesions, respectively. CONCLUSIONS: A better outcome in patients with small single lesions was shown. In patients with multiple and/or bilateral metastases, an acceptable 5-year survival superior to 20% was obtained by surgical approach. The total volume of metastases, not number and location, seems to be the strongest predictor of survival.     

Prognostic factors for long-term outcome of hepatic resection for colorectal liver metastases

The aim of the study was to analyse the prognostic factors for long-term outcome of liver resections for metastases from colorectal cancer. The retrospective analysis included 297 liver resections for colorectal carcinoma liver metastases. The following prognostic factors were considered: age, gender, stage and grade of differentiation of the primary tumour, node metastases, site of the primary colorectal cancer, number and diameter of the hepatic lesions, time interval from primary cancer to liver metastases, preoperative CEA level, adjuvant chemotherapy after hepatic resection, type of hepatic resection, use of intraoperative ultrasound and portal triad clamping, blood loss and transfusions, postoperative complications and hospital stay, tumour-free surgical margins, clinical risk score (as defined by the Memorial Sloan-Kettering Cancer Centre group, MSKCC-CRS). Overall survival rates were estimated according to the Kaplan-Meier method and were compared at univariate analysis using the log-rank test. Multivariate analysis was performed including significant variables at univariate analysis using the Cox regression model. Differences were considered significant at p < 0.05. The 1, 3, 5 and 10-year overall survival rates were 90.6%, 51%, 27.5%, and 16.9%, respectively. The univariate analysis revealed a statistically significant difference (p < 0.05) in overall survival in relation to: grade of differentiation of the primary cancer (5-year survival of grades G1-G2 vs grades G3-G4: 30.7% vs 14.4%, p = 0.0016), preoperative CEA level > 5 and > 200 ng/ml (5-year survival of CEA < 5 ng/ml vs CEA > 5 ng/ml: 51.1% vs 15.5%, p = 0.0016; 5-year survival of CEA < 200 ng/ml vs CEA > 200 ng/ml: 27.9% vs 17.4%, p = 0.0001), diameter of major lesions > 5 cm (5-year survival of diameter < or = 5 cm vs > 5 cm: 30.0% vs 18.8%, p = 0.0074), disease-free interval between primary tumour and liver metastases longer than 12 months (5-year survival of patients with disease-free interval < or = 12 months vs > 12 months: 23.0% vs 36.1%, p = 0.042), high MSKCC-CRS (5-year survival of MKSCC-CRS 0-1-2 vs 3-4-5: 36.4% vs 1 6.3%, p = 0.017). The multivariate analysis showed three independent negative prognostic factors: G3-G4 primary cancer, CEA level > 5 ng/ml, and high MSKCC-CRS class. No single prognostic factor turned out to be associated with such disappointing outcomes after hepatic surgery for colorectal liver metastases as to permit the identification of specific subgroups of patients to be excluded on principle from undergoing liver resection. However, in the presence of a number of specific prognostic factors (G3-G4 grade of differentiation of the primary tumour, preoperative CEA level > 5 ng/ml, high MSKCC-CRS) enrolment of the patient in trials exploring new diagnostic tools or new adjuvant treatments may be suggested to improve the preoperative staging of the disease and reduce the incidence of tumour recurrence after liver resection.     

Survival after resection of multiple bilobar hepatic metastases from colorectal carcinoma

OBJECTIVE: To define the long-term outcome and treatment complications for patients undergoing liver resection for multiple, bilobar hepatic metastases from colorectal cancer. METHODS: A retrospective analysis of 165 consecutive patients undergoing liver resection for metastatic colorectal cancer was performed. Patients were divided into a simple hepatic metastasis group, consisting of patients with three or fewer metastases in a unilobar distribution, and a complex hepatic metastases group, consisting of patients with four or more unilobar metastases or at least two bilobar metastases. RESULTS: The 5-year survival rate was 36% for the simple group and 37% for the complex group. Multivariate analysis revealed that the number of hepatic segments involved by tumor and the maximum diameter of the largest metastasis correlated significantly with the 5-year survival rate. The surgical death rate was 4.9% for the simple group and 9.1% for the complex group; this difference was not significant. Multivariate analysis revealed that extended lobar resection and concomitant colon and hepatic resection were significant and independent predictors of surgical death. The combination of extended lobar resection and concomitant colon resection was used significantly more frequently in the complex group than in the simple group. CONCLUSIONS: Resection of complex hepatic metastases, as defined in this study, results in a 5-year survival rate of 37% and confers the same survival benefit as does resection of limited hepatic metastases. The surgical death rate for this aggressive approach is significantly higher if extended lobar resections are necessary and if concomitant colorectal resection is performed. Patients who have complex hepatic metastases at the time of diagnosis of the primary colorectal cancer and who would require extended hepatic lobectomy should have hepatic resection delayed for at least 3 months after colon resection.     

Hepatic resection for colorectal liver metastases. Influence on survival of preoperative factors and surgery for recurrences in 80 patients.

This report analyses an experience with 80 liver resections for metastatic colorectal carcinoma. Primary colorectal cancers had all been resected. Liver metastases were solitary in 44 patients, multiple in 36 patients, unilobar in 76 patients, and bilobar in 4 patients. Tumor size was less than 5 cm in 33 patients, 5-10 cm in 30 patients, and larger than 10 cm in 17 patients. There were 43 synchronous and 37 metachronous liver metastases with a delay of 2-70 months. The surgical procedures included more major liver resections (55 patients) than wedge resections (25 patients). Portal triad occlusion was used in most cases, and complete vascular exclusion of the liver was performed for resection of the larger tumors. In-hospital mortality rate was 5%. Three- and 5-year survival rates were 40.5% and 24.9%, respectively. None of the analysed criteria: size and number of liver metastases, delay after diagnosis of the primary cancer, Duke's stage, could differentiate long survivors from patients who did not benefit much from liver surgery due to early recurrence. Recurrences were observed in 51 patients during the study, two thirds occurring during the first year after liver surgery. Eight patients had resection of "secondary" metastases after a first liver resection: two patients for extrahepatic recurrences and six patients for liver recurrences. Encouraging results raise the question of how far agressive surgery for liver metastases should go.     

First and repeat resection of colorectal liver metastases in elderly patients

OBJECTIVE: The objective of this study was to evaluate the short- and long-term outcome after first and repeat resection in patients older than 70 years. SUMMARY BACKGROUND DATA: Liver resection is the best treatment for colorectal liver metastases and is currently increasingly performed in elderly patients. The benefit of resection for these patients needs to be evaluated. METHODS: Between 1990 and 2000, 56 first and 16 repeat liver resections were performed in 61 patients older than 70 years. Patients were identified from a prospective database and records were reviewed retrospectively. RESULTS: First and repeat liver resection resulted, respectively, in a 0% and 7% postoperative mortality rate and a 41% and 38% complication rate, respectively. Median survival after first resection of 53 patients with R0 resection was 33 months, and the 5-year survival rate was 22%. Factors associated with poor long-term survival in multivariate analysis were extrahepatic disease, high carcinoembryonic antigen level over 200 ng/mL, and the presence of 3 or more liver metastases. Patients without these risk factors showed a median survival of 42 months and a 5-year survival rate of 36%. Repeat liver resection resulted in a median survival of 17 months and in a 3-year survival rate of 25%. CONCLUSION: First and repeat liver resection for colorectal liver metastases can be performed safely in patients older than 70 years. A 5-year survival rate similar to those of younger patients can be expected after first liver resection for patients without the presence of risk factors.     

Liver resection: a regional hospital experience

Background: Liver resection is a significant operation usually limited to large metropolitan hospitals. Liver resections were first performed at the Launceston General Hospital (LGH), a regional centre (bed capacity 280), in May 2000. This is a summary of liver resection at LGH. Methods: Data of liver resections performed between May 2000 and March 2008 at LGH were collected retro‐prospectively and reviewed with attention to patient survival, post‐operative complications and mortality. Results: There were 102 consecutive liver resections during the study period. Metastatic colorectal adenocarcinoma was the most frequent pathology (n = 61). Six patients had metastases from primaries other than colorectal cancer. There were 13 resections for primary liver malignancy, 2 from invasion by gallbladder carcinoma, 1 for contiguous invasion by gastric cancer and 19 were for benign conditions. Thirteen patients had post‐operative wound infections and six had significant bile leaks. There were five deaths in‐hospital (surgical mortality 4.9%). At the end of the study period, 51 cancer patients were still alive (14 with disease recurrences) and 30 have died (23 from recurrent diseases). Patients operated for colorectal cancer metastases achieved a 44% 5‐year survival rate (median survival = 46 months). Patients with hepatocellular carcinoma had 3‐year survival rate of 15% (median survival = 24 months). Conclusion: Resection provides the best hope of cure for patients with primary or secondary hepatic malignancy. With adequate expertise, liver resections can be performed safely in a regional hospital.     

Colorectal metastasis (liver and lung)

Distant metastases are the major cause of death for colorectal carcinoma patients. Depending on the primary tumor's stage, liver metastases occur in 20% to 70% of patients and lung metastases in 10% to 20%. Unlike many other cancers, the presence of distant metastases from colorectal cancer does not preclude curative treatment. Surgical resection remains the only treatment that can ensure long-term survival and cure in some patients, but only a minority of liver metastases are amenable to surgery. New treatment modalities including portal vein embolization, perioperative chemotherapy and local destruction with cryotherapy or radiofrequency ablation may make more patients suitable for surgical resection of hepatic metastases and may prolong survival in cases of nonresectabilitv. The availability of new active drugs has changed the treatment of liver metastases from colorectal cancer.     

Surgical treatment of liver metastases from colorectal cancer patient selection and oncological outcome

The indications for surgical resection of liver metastases from colorectal cancer remain controversial. Clinical, pathological, and outcome data for 418 consecutive patients undergoing hepatectomy between 1984 and 1998 were examined. The over-all 5-year survival rate was 42%, and the 10-year survival rate was 31%. The 5-year survival rate of patients with four or more nodules was 24%, with 20 patients surviving for more than 5 years. Five factors were found to be significant and independent predictors of poor long-term outcome by multivariate analysis. The preoperative scoring system reported by Fong et al was double-checked in our 418 patients and was found to be useful to predict long-term outcome after hepatectomy. It is clear that liver resection alone has limitations. Therefore clinical risk scoring (CRS) and effective intravenous systemic chemotherapy to prevent recurrence both in the remaining liver and lung should be established to improve survival outcome in patients with poor prognostic factors after liver resection.     

Liver resection for hepatic metastases: 15 years of experience

Background/Purpose: Liver metastases, especially those from primary colorectal cancers, are treatable and potentially curable. Imaging techniques such as computed tomography, magnetic resonance, and ultrasonography have advanced in recent years and led to increased sensitivity and specificity in the diagnosis of liver metastases. Liver surgery also has been revolutionized in the past two decades. Dissection along nonanatomical lines has permitted the resection of multiple lesions that previously might have been considered unresectable. Methods: From 1986 to 2000, 181 patients underwent liver resection for hepatic metastasis from colorectal cancer. Of these, 56 patients underwent systematic anatomical major hepatic resection and 125 underwent nonanatomical limited resection. Results: Operative morbidity and mortality rates were higher in patients in whom anatomical procedures were performed. The overall 5-year survival rate of the 181 patients was 39.8%. Conclusions: An aggressive surgical procedure in patients with hepatic colorectal metastases is safe, and may prolong overall survival, and therefore should be considered in all patients with metastases confined to the liver. Received: April 14, 2002 / Accepted: May 12, 2002 Offprint requests to: G. Belli Via Cimarosa 2/a, 80127 — Naples, Italy Accepted at fifth World Congress of the International Hepato-Pancreato-Biliary Association (IHPBA)     

Surgery for colorectal liver metastases with hepatic lymph node involvement: a systematic review

BACKGROUND: Liver resection for colorectal metastases is the only known treatment associated with long-term survival; extrahepatic disease is usually considered a contraindication to such treatment. However, some surgeons do not regard spread to the hepatic lymph nodes as a contraindication provided that these nodes can be excised adequately. A systematic review of the literature was undertaken to address this issue. METHODS: An electronic search using Medline, Cancerlit and Embase databases was performed for studies reporting liver resection for colorectal metastases from 1964 to 1999. Data were extracted from papers reporting outcome for patients with positive hepatic nodes and analysed according to predetermined criteria. RESULTS: Fifteen studies were identified that gave survival data on 145 node-positive patients. Five patients were reported to have survived 5 years after liver resection; one was disease free, two had recurrent disease and the disease status was not described in the remaining two. Five studies containing 83 patients specified a formal lymph node dissection as part of the surgical procedure and four of the five node-positive 5-year survivors were from these studies. CONCLUSION: There are few 5-year survivors after liver resection, with or without lymph node dissection, for colorectal hepatic metastases involving the hepatic lymph nodes.     

The Role of Preoperative Chemotherapy in Patients with Resectable Colorectal Liver Metastases

Background  Liver metastases develop in 40–50% of patients with colorectal cancer and represent the major cause of death in this disease. Surgical resection remains the only treatment procedure that can ensure long-term survival and provide cure when liver metastases can be totally resected with clear margins, when the primary cancer is controlled, and when there is no nonresectable extrahepatic disease. Five-year survival rate after surgical resection of colorectal metastases varies from 25% to 55%, but cancer relapse is observed in most patients. Aim  To review the potential benefits and disadvantages of neoadjuvant chemotherapy administered before surgery to patients with initially resectable metastases. Results  European Organization for Research and Treatment of Cancer (EORTC) study 40983 has shown that neoadjuvant chemotherapy could reduce the risk of relapse by one-quarter, and allows to test the chemosensitivity of the cancer, to help to determine the appropriateness of further treatments, and to observe progressive disease, which contraindicates immediate surgery. Neoadjuvant chemotherapy can induce damage to the remnant liver. Oxaliplatin-based combination regimen is associated with increased risk of vascular lesions, whereas irinotecan-containing regimens have been associated with increased risks of steatosis and steatohepatitis. Analysis of EORTC study 40983 showed that administration of six cycles of neoadjuvant systemic chemotherapy with 5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX) was associated with moderate increase of the risk of reversible complications after surgery, but mortality rate was below 1% and not increased. If patients are not overtreated, chemotherapy before surgery is well tolerated. The integration of novel targeted agents in combination with cytotoxic drugs is a promising way to improve outcome in patients with advanced colorectal cancer. Preliminary trials have shown that targeted agents combined with cytotoxic regimens can increase tumor response rates. Another impact of preoperative chemotherapy is that metastases that respond to treatment may no longer be visible on computed tomography (CT) scan or at surgery. Patients should be carefully monitored and receive surgery before metastases disappear. Conclusion  Treatment of most patients with liver metastases—those with resectable metastases as well as those with initially unresectable metastases—should start with chemotherapy. If drugs are well chosen and the duration of treatment is monitored with care during multidisciplinary meetings, benefits largely outweigh potential disadvantages.     

Simultaneous colorectal and hepatic resections for colorectal cancer: postoperative and longterm outcomes

BACKGROUND: Our goal was to analyze the results of resection of colorectal cancer and liver metastases in one procedure. STUDY DESIGN: Between June 1982 and July 1998, 522 patients underwent liver resection for colorectal metastases. Liver resection was performed simultaneously with colorectal resection in 71 cases, representing the population in this study. Morbidity, mortality, overall survival, and disease-free survival times were analyzed. Median followup time was 29 months (range 6 to 162 months). Prognostic factors and their influence on outcomes were analyzed. RESULTS: The median hospital stay was 8 days (range 5 to 23 days). Morbidity was 21% and included nine pleural effusions, seven wound abscesses, four instances of hepatic failure, three systemic infections, three intraabdominal abscesses, and one colonic anastomosis leakage. Operative mortality was 0%. Recurrence rate was 57.7% (41 or 71), and progression of disease was detected in 33.8%. Overall and disease-free survivals at 1, 3, and 5 years were 88%, 45%, and 38% and 67%, 17%, and 9%, respectively. Prognostic factors with notable influence on patient outcomes were nodal stage as per TNM classification, number of liver metastases, diameter (smaller or larger than 5 cm), liver resection specimen weight (lighter or heavier than 90 g), and liver resection margin (smaller or larger than 1 cm). CONCLUSIONS: Simultaneous resection of colorectal cancer and liver metastases can be performed with low morbidity and mortality rates, avoiding a second surgical procedure.