Prognostic factors in resection of pulmonary metastasis from colorectal cancer

BACKGROUND: The aim of this retrospective study was to evaluate characteristics of primary colorectal cancer and pulmonary metastases in order to identify prognostic factors for overall survival and risk factors for further intrapulmonary recurrence after resection of pulmonary metastases from colorectal cancer. METHODS: Forty-nine patients who underwent resection of pulmonary metastases from colorectal cancer were reviewed. The factors assessed were age, sex, pathological findings of the original colorectal cancer (depth, lymphatic invasion, venous invasion, lymph node metastasis, differentiation, Dukes' stage) and pulmonary metastasis (maximum tumour size, number of tumours, completeness of resection), serum carcinoembryonic antigen level, previous hepatectomy for liver metastases, and surgical procedure for resection of pulmonary metastasis. Overall survival and intrapulmonary recurrence were also reviewed. RESULTS: Survival rates after resection of pulmonary metastases were 78 per cent at 3 years and 56 per cent at 5 years. Solitary pulmonary metastases were significantly correlated with survival (P = 0.049). The pathological features of the primary colorectal cancer had no impact on survival. Histologically incomplete resection of pulmonary metastasis significantly correlated with pulmonary re-recurrence (P = 0.034). CONCLUSION: Long-term survival can be expected after complete resection of pulmonary metastases arising from colorectal cancer, especially in patients with a solitary pulmonary metastasis.     

Aggressive repeat liver resection for hepatic metastases of colorectal carcinoma

Although hepatectomy for liver metastases from colorectal carcinoma is an effective treatment, recurrence in the liver is still the most common site after hepatectomy. Thirty patients underwent hepatectomy for hepatic metastases and 17 of them had recurrence in the remnant liver during the following 12-year period. Six of the 17 patients underwent a removal of isolated hepatic recurrences. Two of the six patients underwent a third hepatectomy, and three patients underwent partial lung resection on a total of five occasions. There were no operative deaths while complications after a third hepatectomy contributed to a high morbidity rate of 40 per cent. The mean length of survival of the six patients was 28.5 months from the second hepatectomy. The prognosis of the six patients who underwent a repeat hepatectomy was significantly better than that of patients with unresectable recurrence after an initial hepatectomy (p<0.01). The overall 5-year survival of 29 patients excluding one inhospital death was 44.7 per cent. Our results reveal that aggressive removal of isolated and resectable recurrent disease has the potential to improve the prognosis of selected patients with metastatic cancer.     

Management of intrahepatic recurrence after curative treatment of colorectal liver metastases

BACKGROUND: Management of intrahepatic recurrence after complete surgical treatment for colorectal liver metastases is not well defined. The aim of this study was to analyse the survival results of patients who had repeat liver resection for intrahepatic recurrence and to evaluate prognostic indicators for survival. METHODS: Between 1991 and 2005, 55 patients had repeat liver resection for isolated intrahepatic recurrence. The long-term survival results were assessed. Univariable and multivariable analyses were used to identify prognostic indicators for survival after repeat hepatectomy. RESULTS: The median survival was 53 (range 2-97) months and the 5-year survival rate was 49 per cent. In univariable analysis, size of largest initial liver metastasis, margin of initial liver surgery, carcinoembryonic antigen (CEA) level before and after initial liver surgery, liver disease-free survival, margin of repeat liver surgery, operation type of repeat surgery and CEA level before and after repeat surgery were significant prognostic factors. In multivariable analysis, largest initial liver metastasis 4 cm or less and CEA level 5 ng/ml or less after repeat liver surgery were independently associated with improved survival. CONCLUSION: Repeat hepatectomy can achieve an acceptable survival in selected patients with isolated intrahepatic recurrence.     

Results of extensive surgery for liver metastases in colorectal carcinoma.

Hepatic resections were performed during the past 13 years on 31 patients with hepatic metastases from colorectal carcinoma. Of the 31 patients, 22 underwent lymph node dissection of the hepatic hilus. Ten patients underwent removal of recurrent lesions in the liver, lung, adrenal gland and brain after initial hepatic resection. The overall 5-year survival rate was 45 per cent. The outcome for six patients who underwent repeat hepatectomy after an initial hepatectomy was significantly better than for nine patients with unresectable recurrence (P less than 0.01). Six of the 22 patients who underwent lymph node dissection had nodes positive for tumour. Two of the six patients underwent repeat hepatectomy and are alive after 49 and 66 months. Three- and 4-year survival rates of patients with positive lymph nodes were both 40 per cent. Repeat hepatectomy and dissection of hilar lymph nodes improves prognosis in selected patients with hepatic metastases of colorectal cancer.     

Extrahepatic disease does not contraindicate hepatectomy for colorectal liver metastases

BACKGROUND: Extrahepatic disease has always been considered an absolute contraindication to hepatectomy for liver metastases. The present study reports the long-term outcome and prognostic factors of patients undergoing resection of extrahepatic disease simultaneously with hepatectomy for liver metastases. METHODS: From January 1987 to January 2001, 111 (30 per cent) of 376 patients who had hepatectomy for colorectal liver metastases underwent simultaneous resection of extrahepatic disease with curative intent. RESULTS: Surgery was considered R0 in 77 patients (69 per cent) and palliative (R1 or R2) in 34 patients (31 per cent). The mortality rate was 4 per cent and the morbidity rate 28 per cent. After a median follow-up of 4.9 years, the overall 3- and 5-year survival rates were 38 and 20 per cent respectively. The 5-year overall survival rate of patients with R0 resection only (n = 75) was 29 per cent. The difference in survival between patients with and without extrahepatic disease discovered incidentally at operation was significant, as was the number of liver metastases. CONCLUSION: Extrahepatic disease in patients with colorectal cancer who also have liver metastases should no longer be considered an absolute contraindication to hepatectomy. However, the presence of more than five liver metastases and the incidental intraoperative discovery of extrahepatic disease remain contraindications to hepatic resection.     

Surgical management of recurrence after resection of colorectal liver metastases

The optimal treatment for recurrent lesions after hepatectomy for colorectal liver metastases is controversial. We report the outcome of aggressive surgery for recurrent disease after the initial hepatectomy and the influence on quality of life of such treatment. Forty-five (70%) of the 64 surviving patients developed recurrence after the initial hepatectomy for liver metastases. The determinants of hepatic recurrence were the distribution and the number of liver metastases. Twenty-eight (62%) of patients with recurrence underwent resection. A second hepatectomy was performed in 20 patients, and a third hepatectomy was done in 5 patients. Ten patients with pulmonary metastasis underwent partial lung resection on 14 occasions, while resection of brain metastases was performed in 3 patients on 5 occasions. There were no operative deaths after resection of recurrent disease. The morbidity rate was 28% after repeat hepatectomy, 21% after pulmonary resection, and 0% after resection of brain metastasis. The Karnofsky performance status (PS) after the last surgery was not significantly different from that after the initial hepatectomy. The 3- and 5-year survival rates after the second hepatectomy were 54% and 14%, respectively. The 3-and 5-year survival rates of the patients undergoing resection of extrahepatic recurrence were both 17%. The survival rate after resection of recurrent disease (n=28) was significantly better than that of patients (n=17) with unresectable recurrence (P < 0.05). For the 66 patients with colorectal liver metastases, the 5-year survival rate after initial hepatectomy was 50%. The distribution and the number of liver metastases and the presence of extrahepatic disease, as single factors, significantly affected prognosis after the initial hepatectomy. Multivariate analysis revealed that only the presence of extrahepatic metastasis and a disease-free interval of less than 6 months were independent predictors of survival after the initial and second hepatectomy, respectively. It is concluded that aggressive surgery is an effective strategy for selected patients with recurrence after initial hepatectomy. Careful selection of candidates for repeat surgery will yield increased clinical benefit, including long-term survival.     

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.     

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.     

Biopsy of resectable colorectal liver metastases causes tumour dissemination and adversely affects survival after liver resection

BACKGROUND: Liver resection is increasingly being performed for metastatic colorectal cancer. This study assessed the need for preoperative biopsy of suspected metastases and whether biopsy has any effect on long-term survival. METHODS: Prospectively collected data on patients who underwent liver resection for colorectal metastases between 1986 and 2003 were reviewed retrospectively. The endpoints of morbidity, operative mortality and long-term survival were compared between patients who had biopsy before referral (group 1) and those who did not (group 2). RESULTS: Patient demographics and disease distribution were similar for 90 patients in group 1 and 508 in group 2. Seventeen patients (19 per cent) who had undergone biopsy either at the time of colorectal resection or radiologically had evidence of needle-track deposits. Operative mortality and morbidity rates in the two groups were similar. The 4-year survival rate after liver resection was 32.5 (s.e. 5.5) per cent in group 1, compared with 46.7 (2.8) per cent in group 2 (P = 0.008). CONCLUSION: Needle-track deposits are common after biopsy of suspected colorectal liver metastases. Biopsy of metastases confers poorer long-term survival on patients after liver resection and cannot be justified in patients with potentially resectable disease.     

Predictors of extrahepatic recurrence after resection of colorectal liver metastases

BACKGROUND: It is important to identify patients at high risk of extrahepatic recurrence after surgery for liver metastases, in order to maximize the survival benefit obtained by prophylactic regional chemotherapy. METHODS: Data from 68 patients who underwent resection of colorectal liver metastases but who did not receive hepatic arterial chemotherapy or intravenous systemic chemotherapy were collected. Twenty-two variables were examined by univariate and multivariate analyses to determine which factors were relevant to extrahepatic recurrence. A scoring system was developed that included the most relevant factors. RESULTS: The extrahepatic recurrence rate at 3 years after hepatectomy was 57.8 per cent. Three variables were independently associated with extrahepatic recurrence including raised serum level of carcinoembryonic antigen after hepatectomy (relative risk (RR) 5.4, P < 0.001), venous invasion of the primary tumour (RR 4.0, P = 0.001) and high-grade budding of the primary tumour (RR 3.1, P = 0.006). Patients with none of these risk factors had a 3-year extrahepatic recurrence rate of 7.1 per cent, compared with 61.6 per cent for those with one risk factor and 100 per cent for those with two or three risk factors. CONCLUSION: It was possible to identify patients at high risk of disease relapse at extrahepatic sites. This system might be used on an individual basis to select patients with colorectal liver metastases for regional chemotherapy or systemic chemotherapy after surgical intervention.     

Surgical treatment for colorectal liver metastases involving the paracaval portion of the caudate lobe

BACKGROUND: Hepatic neoplasms in the paracaval portion of the caudate lobe (S1r) are usually difficult to treat surgically because such neoplasms often invade the hepatic veins and/or inferior vena cava (IVC). We reevaluated resected cases of colorectal liver metastases involving S1r to confirm the significance of aggressive surgical treatments. METHODS: Between July 1977 and December 2002, 95 consecutive patients with colorectal liver metastases underwent hepatic resection. Seven patients with liver metastases involving the S1r underwent resection. RESULTS: The surgical procedures for liver metastases comprised 3 isolated caudate lobectomies, 2 right hepatectomies, and 2 right hepatic trisectionectomies with caudate lobectomy. Combined resections included partial resection of the hepatic vein in 2 patients, wedge resection of the IVC in 3, and segmental resection of the IVC in 1. Six of the 7 patients with S1r metastasis had recurrent disease in liver and/or lung. A second hepatectomy was carried out in 4 patients and a partial lung resection in 2 patients. Four of the 7 patients survived more than 5 years, but 2 of them died of recurrent disease at 61 and 95 months after initial hepatectomy. The remaining 2 patients are alive 72 and 118 months without any sign of recurrence. The median survival time of the 7 patients was 60 months. CONCLUSION: Liver metastases involving the S1r could be resected radically with en bloc resection of the major hepatic veins and/or the inferior vena cava. An aggressive surgical approach with combined resection of the adjacent major vessels may offer a better chance of long-term survival in selected patients with caudate lobe metastasis from colorectal cancer.     

Adjuvant regional chemotherapy after hepatic resection for colorectal metastases.

BACKGROUND: This study explored the possibility of achieving a better survival rate and reduced recurrence in the remaining liver in patients with colorectal hepatic metastases undergoing hepatic resection. Adjuvant postoperative regional chemotherapy was administered via the hepatic artery or the portal vein. METHODS: A retrospective study was performed on 174 patients after hepatic resection for colorectal metastases. These comprised 78 patients who had hepatic artery infusion (HAI) chemotherapy (HAI group), 30 who had portal vein infusion (PVI) chemotherapy (PVI group) and 66 who had no regional chemotherapy (resection alone group). The three groups were compared with one another in terms of complications, survival rate and patterns of recurrence. RESULTS: Severe complications did not occur at any point during adjuvant HAI or PVI chemotherapy. The 5-year disease-free survival rate of patients in the HAI, PVI and resection alone groups were 35, 13 and 9 per cent respectively, including six hospital deaths. Patients in the HAI group showed significantly improved recurrence rates in the remaining liver compared with the resection alone group (P = 0.03), and more prolonged disease-free and overall survival than those in the PVI (P = 0.01 and P = 0.02 respectively) and resection alone (P = 0.0001 and P = 0.0006 respectively) groups. CONCLUSION: This study suggests that adjuvant HAI chemotherapy after hepatic resection may have therapeutic potential for improved management of patients with colorectal metastases.     

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.     

Indicators for treatment strategies of colorectal liver metastases

OBJECTIVE: To analyze the survival predictors of patients undergoing hepatectomy for colorectal liver metastasis to determine useful indicators for therapy selection. SUMMARY BACKGROUND DATA: Although recurrence develops in more than two thirds of patients undergoing hepatectomy for colorectal liver metastasis, preoperative characteristics that might predict such recurrence have yet to be clearly identified. METHODS: Clinicopathologic data of 85 consecutive patients with colorectal cancer who underwent a curative resection of primary lesions and metastatic liver diseases at one institute were analyzed using the multivariate method with respect to both the metastatic state and the primary lesion. RESULTS: Multivariate analysis indicated that the aggressiveness of the primary tumor, early liver metastasis, and a large number of liver metastases were the characteristics that could be detected before hepatectomy and that independently indicated a worse survival. A three-ranked classification based on these coefficients (H-staging) was significantly related to both the recurrence rate within 6 months (7% in H-stage A, 30% in B, and 44% in C) and the 5-year survival rates (55%, 14%, and 0% respectively). An additional scoring system (H'-staging) based on the aggressiveness of the primary tumor and the level of carcinoembryonic antigen 1 to 3 months after hepatectomy was found to be related to the mode of subsequent recurrence and surgical resectability of the recurrent foci. CONCLUSIONS: H-staging can provide useful prognostic information for the treatment of liver metastasis. H-staging could also help in predicting the possible mode of recurrence after hepatectomy and in determining the most suitable mode of additional therapy. Further multiinstitutional studies based on a large collective database will confirm the utility of these two staging systems.     

Treatment strategy for hepatic metastases of colorectal cancer

Over the past 25 years, 125 patients with colorectal liver metastases underwent 167 hepatectomies in our department. The 1-, 3-, and 5-year survival rates after the initial hepatectomy were 90%, 58%, and 51%, respectively, and those after repeated hepatectomy were 88%, 60%, and 42%, respectively. The predictive factors significantly associated with poor prognosis after initial hepatectomy were maximal diameter of metastasis (> or = 5 cm), distribution pattern in the liver (multiple bilobar), number of nodules (> or = four), and presence of extrahepatic metastases. A disease-free interval of > 6 months after initial hepatectomy was a significant factor for prolongation of survival after repeat hepatectomy. Patients with hilar node metastases at the initial hepatectomy did not receive a survival benefit from hepatectomy, while 5 patients underwent repeat hepatectomy with lymphadenectomy for remnant liver and hilar node metastases with a disease-free interval of > 8 months and 4 of them survived for > 5 years. Our treatment strategies for colorectal hepatic metastases are as follows: 1) hepatectomy is the first choice for < 4 liver metastases without extrahepatic disease; 2) a careful evaluation for liver resection is performed for patients with > or = 4 liver metastases receiving hepatic arterial infusion chemotherapy because of the high frequency of hepatic and/or extrahepatic recurrence after initial hepatectomy; 3) the presence of hilar node metastases at the initial hepatectomy should be excluded from surgical indications; 4) simultaneous single metastasis limited to the lung is an indication for lung resection; and 5) a suitable indication for repeat hepatectomy for hepatic recurrence is patients with a longer disease-free interval. Aggressive surgery based on the optimum patient selection can contribute to clinical benefit, including long-term survival in patients with colorectal liver metastases.     

Analysis of predictive factors for recurrence after hepatectomy for colorectal liver metastases

Hepatectomy for liver metastases from colorectal cancer has recently received general acceptance as a safe, potentially curative treatment. Most patients, however, die of recurrent disease after hepatectomy. The predictive factors for recurrence after first resection of liver metastases have not yet been clarified. The authors aimed to determine the factors that can predict recurrence, especially hepatic-only recurrence after hepatectomy for colorectal liver metastases. Seventy-six patients who underwent liver resection of colorectal metastases were studied retrospectively. Forty-seven (61.8%) of the patients had a recurrence. The patients' disease-free survival after first hepatectomy and the second recurrence sites were univariately and multivariately analyzed using 16 clinicopathologic variables. Wall invasion, lymph node metastases, lymphatic invasion, venous invasion of the primary tumor, 24 months or longer disease-free interval after resection of the primary colorectal cancer, and bilateral liver metastases significantly influenced the disease-free survival (log-rank test: p < 0.05). The multivariate analysis revealed that venous invasion of the primary tumor and bilateral hepatic metastases were independent risk factors for recurrence after hepatectomy. The liver was the only site of second recurrence in 23 patients. Patients with lymph node metastases and venous invasion of the primary tumor had a significant difference between hepatic-only and extrahepatic recurrence after first hepatectomy (chi-square test or Fishers' exact test: p < 0.05). Recurrence after hepatectomy was influenced more by factors associated with the primary colorectal cancer than factors surrounding the first liver metastases. Venous invasion of the primary colorectal cancer was the most important predictable factor for hepatic-only second recurrence.     

Long-term results of treating hepatic colorectal metastases with cryosurgery

BACKGROUND: The purpose of this study was to determine the long-term efficacy of cryosurgery as an adjunct to hepatic resection in patients with colorectal liver metastases not amenable to resection alone. METHODS: Thirty patients met the following inclusion criteria: metastases confined to the liver and judged irresectable, ten or fewer metastases, cryosurgery alone or in combination with hepatic resection allowed tumour clearance. RESULTS: Median follow-up was 26 (range 9--73) months. Overall 1- and 2-year survival rates were 76 and 61 per cent respectively. Median survival was 32 months. Disease-free survival at 1 year was 35 per cent, at 2 years 7 per cent. Six patients developed recurrence at the site of cryosurgery; given that the total number of cryosurgery-treated lesions was 69 the local recurrence rate was 9 per cent. CONCLUSION: In patients with colorectal liver metastases, local ablative techniques can be used as an effective adjunct to hepatic resection to obtain tumour clearance.     

Treatment strategy for patients with middle and lower third bile duct cancer

BACKGROUND: The prognosis for patients with middle and lower third bile duct carcinoma remains poor. This study was conducted to identify independent predictors for survival, as well as the patterns of recurrence after curative resection. METHODS: Sixty-seven patients with pathologically verified middle and/or lower third bile duct carcinoma were analysed retrospectively by Cox regression analysis for predictors of survival. RESULTS: The overall 5-year survival rate after resection was 39 per cent, and 0 per cent for patients who did not undergo resection. The 5-year survival rate was 63 per cent in 26 patients without microscopic residual disease (R0), 16 per cent in 25 patients with microscopic residual tumour (R1) and 0 per cent in six patients with macroscopic residual tumour (R2); ten patients did not undergo resection. Radiotherapy improved the 5-year survival rate in eight patients who had R1 resection compared with the rate in 17 patients who underwent resection alone (8 versus 0), but not significantly so (P = 0.137); however, median survival was significantly longer (P = 0.004) in six patients who had R2 resection compared with that in ten inoperable patients (11.4 versus 3.5 months). Multivariate analysis revealed that the primary tumour and tumour node metastasis (TNM) stage were independent predictors of survival; 13 clinicopathological factors were not independent prognostic factors. Of 26 patients having R0 resection, one had a locoregional relapse only, six had distant metastases only, and five had both types of recurrence. The liver was the most frequent site for metastasis, and microscopic venous invasion (MVI) in the primary tumour was a significant predictor of liver metastasis. CONCLUSION: Curative (R0) resection is only one step in curing cancer, and radiotherapy may play a beneficial role in controlling locoregional residual tumour. MVI could be a useful indicator of when systemic adjuvant therapy should be implemented to prevent liver metastasis after R0 resection, although no effective systemic treatment has yet been developed.     

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.     

Hepatectomy for Colorectal Liver Metastases with Macroscopic Intrabiliary Tumor Growth

Objectives We set out to clarify the clinicopathologic characteristics of colorectal liver metastases with macroscopic intrabiliary tumor growth and to determine optimal surgical management. Methods Over 15 years, 6 of 103 patients undergoing hepatectomy for colorectal liver metastases had macroscopic intrabiliary tumor growth and were analyzed retrospectively. Results We performed 11 operations for the 6 patients, consisting of 10 hepatectomies (including 1 hepatopancreatoduodenectomy) and 1 pancreatoduodenectomy. Three patients survived more than 5 years: 1 died of pulmonary emphysema with no sign of recurrence 101 months after initial hepatectomy; the 2 others were alive with no sign of recurrence at 74 and 145 months after initial hepatectomy. Median survival time of all 6 patients was 87.5 months. Histologically, intrabiliary tumor growth had two components: intraluminal and intraepithelial extension. In the proximal direction, distance between these two components ranged from 4–10 mm. Conclusion Aggressive surgical treatment can improve chances of long-term survival for patients with macroscopic intrabiliary growth of colorectal liver metastasis. Although nonanatomic limited resection is a common procedure for colorectal liver metastasis, anatomic hepatobiliary resection is recommended.