Preoperative imaging for hepatic resection of colorectal cancer metastasis

Despite recent advances in chemotherapeutic agents, the prognosis for metastatic colon cancer remains poor. Over the past two decades, hepatic metastasectomy has emerged as a promising technique for improving survival in patients with metastatic colon cancer and in some cases providing long-term cure. To maximize safety and efficacy of metastasectomy, appropriate pre-operative imaging is needed. Advancements in computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) have led to improved detection of occult lesions and better definition of surgical anatomy. While CT, PET and MRI have a comparable sensitivity for detection of large liver metastases, MRI excels at detection of subcentimeter liver metastases compared to CT and FDG-PET, especially with the combination of diffusion weighted imaging (DWI) and hepatocyte-specific contrast agents. CT may be useful as a screening modality or in preoperative planning such as volumetric estimation of the remnant liver size or in defining preoperative arterial anatomy for hepatic artery infusion pump placement. While technologic advancements have led to unprecedented image quality and clarity, this does not replace the need for a dedicated, competent radiologist with experience in hepatic imaging.Key Words: Colorectal metastases, preoperative imaging, hepatic artery infusion pump, volumetrics, hepatic resection     

The impact of primary tumour location in patients undergoing hepatic resection for colorectal liver metastasis

Background

Primary tumour location has long been debated as a prognostic factor in colorectal cancer patients with liver metastases (CRLM) undergoing liver resection. This retrospective study was conducted to clarify the prognostic value of tumour location after radical hepatectomy for CRLM and its underlying causes.

Adjuvant hepatic arterial infusion after resection of hepatic metastasis from colorectal cancer

We examined retrospectively the efficacy of hepatic arterial infusion (HAI) chemotherapy comparing systemic treatment as adjuvant therapy after the curative resection of hepatic metastasis from colorectal cancer. Seventeen cases of HAI and 8 of the systemic treatment were enrolled in this study. We compared the pattern of recurrent sites and the overall survival rate between the two groups. There was no difference in a patients' background. Intrahepatic recurrence rate was lower and extrahepatic recurrence rate was higher in the HAI group, but not significant. The 1-, 3-, and 5-year overall survival rate was 94, 72, and 49% in the HAI group and 100, 100, and 50% in the systemic treatment group (p = 0.29), respectively. HAI chemotherapy did not contribute to the elongation of survival time in comparison with systemic treatment. This study indicates that there is no efficacy of HAI alone after the resection of hepatic metastasis from colorectal cancer and that there is need to use systemic chemotherapy together with HAI to prevent an extrahepatic recurrence.     

Predictors of survival after hepatic resection among patients with colorectal liver metastasis

Studies suggest improved survival following resection of colorectal cancer liver metastases (CLMs). We investigated predictors of survival among patients with CLM who underwent hepatic resection using the SEER-Medicare database to identify patients >/=65 years diagnosed with CLM, 1991-2003, who underwent hepatectomy. Cox proportional hazards models were used to identify factors associated with survival after hepatectomy. Of 923 patients with CLM who underwent hepatectomy, 514 were stages I-III and developed CLM>6 months after diagnosis (metachronous), and 409 were stage IV with CLM at diagnosis (synchronous). From the date of hepatectomy, 5 year survival was 22%; younger age, being married, female gender, surgery in an NCI-designated cancer centre, fewer comorbidities, fewer positive lymph nodes, and lower grade were associated with improved survival. Both 5-fluorouracil (5FU)-based chemotherapy and hepatic arterial infusion (HAI) of floxuridine-based chemotherapy following hepatectomy improved survival (HR=0.62, 95% CI: 0.50-0.78; HR=0.51, 95% CI: 0.28-0.97, respectively) in the synchronous, but not metachronous, group. The HR for overall mortality was higher in hospitals with a high vs low procedure volume (0.75, 95% CI: 0.58-0.94). A substantial subgroup of patients with CLM who undergo hepatectomy experiences long-term survival. High hospital procedure volume and use of 5FU-based or HAI-based chemotherapy after resection were associated with improved prognosis.     

Short time to recurrence after hepatic resection correlates with poor prognosis in colorectal hepatic metastasis

BACKGROUND: Early recurrence is a major problem after hepatic resection of colorectal hepatic metastasis (CHM). Our aim was to investigate the relationship between time to recurrence after CHM resection and overall survival. METHODS: A retrospective analysis was performed for 101 consecutive patients who underwent hepatic resection for CHM and have been followed more than 5 years. RESULTS: Among 101 patients, 82 (81%) had a recurrence. Overall survival of patients with recurrence within 6 months after CHM resection was significantly worse than that of patients with recurrence after more than 6 months (P < 0.01). Overall survival was poorer when time to recurrence was shorter. One of the reasons for poor prognosis of patients with recurrence within 6 months was that only a few patients could undergo a second resection for recurrence after CHM resection. Histological type, including poorly differentiated signet ring cell or mucinous adenocarcinoma in the primary tumor, bilobar metastases, microscopic positive surgical margin and carcinoembryonic antigen (CEA) above 15 ng/ml had predictive value for decreased recurrence-free survival after CHM resection. CONCLUSION: Short time to recurrence after CHM resection correlates with a poor prognosis. Histological type of poorly differentiated signet ring cell or mucinous adenocarcinoma in the primary tumor might be a predictor for early recurrence after CHM resection.     

Predictors of early disease recurrence following hepatic resection for colorectal cancer metastasis.

BACKGROUND: With the broadening indications of hepatic resection for colorectal liver metastases (CRLM), the exact group of patients who would benefit from surgery is still debatable. The aim of this study was to identify predictors for early recurrence, defined as recurrence within 6 months of CRLM resection, in order to identify those patients who may require further pre-operative radiological staging of the disease prior to surgery. METHODS: Prospectively collected dataset of patients undergoing curative resection for CRLM during the 10-year period (January 1993-May 2003) were analyzed. Patients who received neo-adjuvant chemotherapy and patients who underwent repeat hepatic resections whose primary resection was not performed during the study period were excluded. RESULTS: Four hundred and thirty patients (89%) were included in the analysis. Eighty-six (20%) patients developed early recurrence. Early recurrence was associated with poorer outcome when compared to late recurrences (p<0.001). The predictor of early recurrence on multivariable analysis was the presence of eight or more metastases (p=0.036). CONCLUSION: We have identified a group of patients with multiple metastases who recur early following resection of CRLM. We suggest that these patients should be considered for additional pre-operative radiological workup in the form of PET scanning to identify those patients who would be deemed suitable for resection.     

大肠同时多原发癌

目的探讨大肠同时多原发癌的临床特点及诊断治疗.方法回顾性分析1990～1997年收治的9例同时多原发大肠癌.结果本组病例占同期收治大肠癌2.9%(9/315).病灶分布以左半结肠癌为主占65%.腺瘤合并率66%.结论应提高对同时多原发大肠癌的认识,避免漏诊.     

Cooperative study of intraarterial preventive chemotherapy after resection of hepatic metastasis from colorectal cancer

This is a compilation of the results of preventive intraarterial infusion following resection of hepatic metastasis from colorectal cancer at four surgical centers. The cases studied included two groups: A) 76 patients who underwent normal liver resection only, and B) 78 patients who underwent resection with adjuvant chemotherapy. Methods included: 1) WHF, 50 cases; 2) other methods using 5-FU, 18 cases; and 3) intraarterial infusions other than 5-FU, 10 (2 cases, outcome unknown). Survival rates for groups A and B for 1 and 5 years were 71.2, 18.9% and 91.5, 56.2%, respectively, with the rates for the intraarterial infusion group showing far better results. The 1- and 5-year survival rates in terms of infusion methods were: 1) 90.7% and 64.6%; 2) 94.4% and 39.3%; and 3) 90% and 60%, respectively, showing no remarkable differences between methods. Total doses of 5-FU were (a) less than 5 g, 7 patients (b) 5-15 g, 16 patients (c) 15-30 g, 22 patients (d) greater than 30 g, 23 patients. A comparison of 1- and 5-year survival rates shows (a) 85.7% and 17.1%; (b) 66.5% and 44.3%; (c) 100% and 62.7%; (d) 100% and 66.5%, respectively, with doses (c) and (d) showing markedly better results than the (a) dosage. From this we conclude that the group undergoing intraarterial hepatic infusion had a markedly improved prognosis compared to the group not undergoing any type of adjuvant therapy. Also, groups receiving a dosage of 15 g or greater of 5-FU showed prolonged survival rates.     

Surgical therapy of hepatic colorectal metastasis

This review summarizes data demonstrating the safety and efficacy of liver resection for colorectal metastases. Hepatic resection in appropriately selected patients remains the only potentially curative treatment for patients with such metastases. Recommendations for preoperative patient evaluation, patient selection, adjuvant therapy, and postoperative follow-up are presented. Other surgical modalities utilized in the treatment of unresectable or recurrent hepatic colorectal metastases, including ablative modalities and surgical delivery of regional chemotherapy, are described.     

Liver resection for colorectal liver metastasis

At some point in the natural course of colorectal cancer up to 50% of patients will develop metastasis to the liver. Historically only 20% of these patients would have to be deemed resectable, with an intent to cure, at the time of presentation. But with recent improvements in cross-sectional imaging, chemotherapeutic agents and advances in the techniques of surgical resection the emphasis of resection has now changed to 'who is not resectable' as opposed to 'who is resectable'. There are few contraindications to liver resection on the proviso that the patient is fit enough. As a result of this paradigm shift, 5 year survival rates are approaching 60%. Historically liver resection was perceived as a formidable operation but now liver resection for CRLM is safe and specialist centres are reporting mortality rates of less than 1%. This review briefly covers the standard techniques currently employed and some of the recent innovations being developed to improve resectability.     

A case report of primary liver cancer with cerebral metastasis after hepatic resection

A 67-year-old male, who had a left hepatectomy for hepatocellular carcinoma, was readmitted to our hospital because of a left hemiparesis. A brain computed tomography scan and an r-carotid angiogram revealed a large mass involving the right parietal area, and thus a brain tumor removal was performed. A histological diagnosis of the removed brain tumor found it to be a metastatic, hepatocellular carcinoma. The patient died of pulmonary congestion due to lung metastasis, approximately 2 years and seven months after hepatectomy, and 1 year and three months after the removal of this metastatic brain tumor. In selected cases, the removal of a metastatic brain tumor seems to bring about improvements in the quality and duration of life.     

Surgical therapy of hepatic colorectal metastasis.

The liver is a common site of metastases from colorectal cancer. The data are convincing that liver resection is a safe and effective therapy for such metastatic disease. Even extensive resections can be performed with a less than 5% mortality rate at major centers and a 5-year survival rate of 30% to 40%. This review examines factors important for patient selection for liver resection and proposes a prognostic scoring system that may help in patient selection. For unresectable disease, many methods for ablating tumors are now available that will likely prove to be useful adjuncts to current treatment.     

Four cases of multiple liver metastasis of colorectal cancer treated with hepatic resection after chemotherapy]

Four cases of multiple liver metastasis of colorectal cancer treated with hepatic resection after chemotherapy were investigated. The 4 patients consisted of 3 males and 1 female with a mean age of 67.8 years. Two patients underwent systemic chemotherapy, and the other 2 received hepatic arterial infusion chemotherapy. The effect was PR in all patients, and mean duration until resection was 8.5 months. One patient had lung metastasis and one had recurrence in a local lesion and residual liver after hepatic resection, but all patients remain alive. The longest survival periods in 4 patients who underwent hepatic resection and 13 who did not were 32 and 24 months, respectively. It is suggested that hepatic resection after chemotherapy for multiple liver metastasis of colorectal cancer may be useful for improvement of outcome.     

Second hepatic resection for metastatic colorectal cancer

We report a case where repeat hepatic resection was successfully performed 3 years after extended right hepatic lobectomy for metastatic colorectal cancer. The patient remains well and disease free 2.5 years after the second hepatic resection.     

Synchronous resection for colorectal liver metastases: The future

Colorectal Cancer is a common malignancy. Many patients have metastatic disease at presentation and a significant proportion subsequently go onto develop metastatic disease, following surgery for the primary disease.