Major hepatic resection for colorectal liver metastases

A 6 1/2 year experience in the management of hepatic colorectal metastases in a specialist unit is reviewed. During the period studied, 48 patients were referred of whom only 24 actually came to resection. There were two in-hospital deaths, at 20 and 60 days, and six patients had non-fatal complications. Although the extent of resection was greater than in most reported series (13 right hepatectomies and 6 extended right hepatectomies), the results of resection were broadly the same as those of others, with a median survival of 30 months and 2 and 3 year survivals of 50 and 44 per cent respectively. A number of factors which others have considered to be of prognostic significance were examined. Tumour clearance was the only important prognostic indicator, where a 5 mm clear margin between the tumour and cut surface produced a significant difference in survival. It is suggested that a much larger number of patients in the UK with hepatic colorectal metastases might be considered for resection.     

Parenchyma-preserving hepatic resection for colorectal liver metastases

Background  

Hepatic resection of colorectal liver metastases is the only curative treatment option. As clinical and experimental data indicate that the extent of liver resection correlates with growth of residual metastases, the present study analyzes the potential benefit of a parenchyma-preserving liver surgery approach.     

Diagnostic laparoscopy and ultrasonography for colorectal liver metastases.

BACKGROUND AND AIMS: To evaluate diagnostic laparoscopy (DL) and laparoscopic ultrasonography (LUS) in the diagnostic workout of patients with colorectal liver metastases, who were considered to have resectable disease after multi detector computed tomography (MDCT). MATERIAL AND METHODS: The medical records of 45 patients, 22M/23F, mean age 62.0 (+/-10.6), who were considered to have resectable liver metastases after CT-scan, were analysed. RESULTS: DL and LUS could not be performed in 7 patients (16%) because of adhesions. Unresectable disease was detected by DL in 3 patients (7%), in all cases due to carcinosis. Additional lesions in the liver were detected by DL in 2 cases (4%), none of these making the patient unresectable. LUS showed additional lesions in 3 patients (7%), which in one case (2%) made the patient unresectable. None of the patients in the present study experienced adverse effects to DL or LUS. CONCLUSION: DL and LUS, due to the low efficacy with regard to avoid unnecessary laparotomies and the relative high failure rate because of adhesions, should not be a routine part of the diagnostic work out in patients with colo-rectal liver metastases.     

Comparison between hepatic wedge resection and anatomic resection for colorectal liver metastases

Some investigators have suggested that wedge resection (WR) confers a higher incidence of positive margins and an inferior survival compared with anatomic resection (AR) of colorectal liver metastases (CLM). We sought to investigate the margin status, pattern of recurrence, and overall survival of patients with CLM treated with WR or AR. We identified 253 consecutive patients, in a multi-institutional database from 1991 to 2004, who underwent either WR or AR. WR was defined as a nonanatomic resection of the CLM, and AR was defined as single or multiple resections of one or two contiguous Couinaud segments. Clinicopathologic factors were analyzed with regard to pattern of recurrence and survival. One hundred six WRs were performed in 72 patients and 194 ARs in 181 patients. There was no difference in the rate of positive surgical margin (8.3%), overall recurrence rates, or patterns of recurrence between patients treated with WR vs. AR. Patients who had a positive surgical resection margin were more likely to recur at the surgical margin regardless of whether they underwent WR or AR. The median survival was 76.6 months for WR and 80.8 months for AR, with 5-year actuarial survival rates of 61% and 60%, respectively. AR is not superior to WR in terms of tumor clearance, pattern of recurrence, or survival. WR should remain an integral component of the surgical treatment of CLM. Presented at the 2005 American Hepato-Pancreato-Biliary Association Congress, Hollywood, Florida, April 14–17, 2005.     

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.     

Benefits and safety of hepatic resection for colorectal metastases.

BACKGROUND: Metastatic colorectal carcinoma to the liver is a potentially curable disease. The purpose of this study was to determine the safety and efficacy of hepatic resection for metastatic colorectal carcinoma. METHODS: One hundred twenty-one consecutive hepatic resections in 110 patients with metastatic colorectal cancer between January 1978 and September 1998 performed by a single surgeon were reviewed. RESULTS: The actuarial 5-year survival for all patients in the series was 46%. Of the patients operated on before 1993, the actual 5-year survival was 43% and actual disease-free 5-year survival was 28%. The actual 10-year survival was 27%, and of all patients operated on in the last 20 years, 48% are alive today. When comparing initial regional lymph node status, the 5-year survival was 54% for the patients with negative lymph nodes and 40% for patients with positive nodes. Only 18% of patients required a perioperative blood transfusion, and the median length of stay was 7 days. There were complications in 34% of cases, and the operative mortality was 4%. CONCLUSIONS: Hepatic resection for metastatic colon cancer is safe, and significant longevity and cure can be obtained after resection.     

Perioperative chemotherapy and hepatic resection for resectable colorectal liver metastases

The role of perioperative chemotherapy in the management of initially resectable colorectal liver metastases (CRLM) is still unclear. The EPOC trial [the European Organization for Research and Treatment of Cancer (EORTC) 40983] is an important study that declares perioperative chemotherapy as the standard of care for patients with resectable CRLM, and the strategy is widely accepted in western countries. Compared with surgery alone, perioperative FOLFOX therapy significantly increased progression-free survival (PFS) in eligible patients or those with resected CRLM. Overall survival (OS) data from the EPOC trial were recently published in The Lancet Oncology, 2013. Here, we discussed the findings and recommendations from the EORTC 40983 trial.     

combined hepatic and inferior vena cava resection for colorectal metastases

Surgical resection continues to offer the only hope for cure of colorectal cancer metastatic to the liver. Tumor involvement of the vena cava is often viewed as a contraindication to surgical resection. Whereas proven technically feasible, the survival advantages of en bloc liver and vena cava resection remain unclear. We reviewed all patients at a tertiary care center who had resection of colorectal liver metastases, including those with vena cava resections. Eleven patients had en bloc liver and vena cava resection between 1988 and 2002; during the same time period, 97 patients underwent isolated liver resection. There were no perioperative deaths in the 11 patients. All resections had negative histological margins. Mean follow-up was 33 months from the date of surgery. Median disease-free survival of the group having caval resections was 9 months, whereas median survival was 34 months. When compared to the cohort of isolated hepatic resections, the group undergoing caval resections experienced a significantly reduced diseasefree survival of 18.6 vs. 9.1 months, respectively (P = 0.03); however, there was no difference in overall survival between the two groups at 55.2 vs. 34.3 months, respectively (P = 0.20). Colorectal liver metastases involving the vena cava should be considered for surgical resection. Presented at the 2005 American Hepato-Pancreato-Biliary Association Congress, Hollywood, Florida, April 14–17, 2005.     

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.     

Outcome after simultaneous colorectal and hepatic resection for colorectal cancer with synchronous metastases

BACKGROUND: Consensus has not been reached concerning the timing of hepatectomy in patients with synchronous colorectal liver metastases, specifically with respect to patient selection criteria for simultaneous resection of the colorectal primary and the liver metastasis. METHODS: Retrospectively obtained clinicopathologic data for 39 consecutive patients with synchronous colorectal cancer metastases to the liver, who underwent curative simultaneous "1-stage" hepatectomy and resection of the colorectal primary at 1 institution, were subjected to univariate and multivariate analysis concerning the safety and success of the combined procedure. RESULTS: Only the volume of the resected liver was selected as a risk factor for postoperative complications (350 g mean resected liver volume in patients with postoperative complications vs 150 g in those without complications; P <.05). Patient age of 70 years or older (P <.05) and poorly differentiated or mucinous adenocarcinoma as the primary lesion (P <.01) predicted decreased overall survival by univariate analysis. Multivariate analysis retained histologic differentiation of the colorectal primary as an independent survival predictor (P <.05). CONCLUSIONS: A 1-stage procedure appears desirable for synchronous colorectal hepatic metastases except for patients requiring resection of more than 1 hepatic section, patients aged 70 years or older, and those with poorly differentiated or mucinous adenocarcinomas as primary lesions.     

Repeat hepatic resection as effective treatment for recurrent colorectal liver metastases

Background: Approximately 20–40% of patients who undergo liver resection for colorectal metastases develop recurrent disease confined to the liver. The goals of this study were to determine whether the survival benefit of repeat hepatic resection justified the potential morbidity and mortality. Methods: A retrospective review was performed on all patients who underwent liver resection for colorectal cancer metastases between 1983 and 1995 (N=202). Repeat liver resections were performed on 23 patients for recurrent metastases. Results: There were no operative deaths in the 23 patients, and the postoperative morbidity rate was 22%. The 5-year actuarial survival rate after repeat resection was 32%, with a median length of survival of 39.9 months. There were three patients who survived for >5 years after repeat resection. Sixteen patients (70%) developed recurrent disease at a median interval of 11 months after the second resection; 10 of these 16 patients (62%) had new hepatic metastases. No clinical or pathological factors were significant in predicting long-term survival. Conclusions: Repeat liver resection for recurrent colorectal metastases (a) can be performed safely with acceptable mortality and morbidity rates and (b) may result in long-term survival in some patients.Presented at the 49th Annual Cancer Symposium of The Society of Surgical Oncology, Atlanta, Georgia, March 21–24, 1996.     

Trends in long-term survival following liver resection for hepatic colorectal metastases

OBJECTIVE: To examine trends in outcomes of patients undergoing resection at a single tertiary care referral center over a 16-year period. SUMMARY BACKGROUND DATA: Hepatic resection is considered the treatment of choice in selected patients with colorectal metastasis confined to the liver. Although a variety of retrospective studies have demonstrated improvements in short-term outcomes in recent years, changes in long-term survival over time are less well-established. METHODS: Data from 226 consecutive patients undergoing potentially curative liver resection for colorectal metastases between 1984 and 1999 were analyzed. Actuarial survival rates related to prognostic determinants were analyzed using the log-rank test. RESULTS: The median survival for the entire cohort was 46 months, with 5- and 10-year survival rates of 40% and 26% respectively. Ninety-three patients operated on between 1984 and 1992 were found to have an overall survival of 31% at 5 years, compared to 58% for the 133 patients operated on during the more recent period (1993-1999). Both overall and disease-free survival were significantly better in the recent time period compared with the earlier period on both univariate and multivariate analyses. Other independent factors associated with improved survival included number of metastatic tumors < or = 3, negative resection margin, and CEA < 100. Comparisons were made between time periods for a variety of patient, tumor and treatment-related factors. Among all parameters studied, only resection type (anatomical versus nonanatomical), use of intraoperative ultrasonography, and perioperative chemotherapy administration differed between the early and recent time periods. CONCLUSIONS: Long-term survival following liver resection for colorectal metastases has improved significantly in recent years at our institution. Although the reasons for this survival trend are not clear, contributing factors may include the use of newer preoperative and intraoperative imaging, increased use of chemotherapy, and salvage surgical therapy.     

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.     

Anatomie segmental hepatic resection is superior to wedge resection as an oncologic operation for colorectal liver metastases

Hepatic wedge resection tor colorectal liver metastasis has been reported to have a high incidence of positive surgical margins. Anatomic segmental resection is now widely practiced, although there are few data comparing segmental and wedge resection in terms of tumor clearance or long-term outcome. There were 267 patients who underwent liver resection for metastatic colorectal cancer between July 1985 and October 1998 at our institution who had either a wedge (n = 119) or segmental (n = 148) resection. Patient, tumor, and treatment data were compared, actuarial survival was determined, and prognostic factors were analyzed. Anatomic segmental resection was associated with similar blood loss, operative time, and complications as wedge resection. Segmental resection had a signilicantly lower rate of positive margins (2% vs. 16%) compared to wedge hepatcctomy (P <0.001). On univariatc analysis, segnicntcctoiuy resulted in longer survival with a median of 53 months vs. 38 months for wedge hepatectomy (P = 0.015). Preoperative carcinoembryomc antigen level, positive margin of resection, and the presence of extra-hepatic disease independently predicted survival on multivjriate analysis. Anatomic segmental resection is a safe procedure and is superior to wedge resection as an oncologic operation for colorectal liver metastasis because it results in better tumor clearance and improved survival. Supported in part by grants ROICA76416, RO1CA72632, and RO1CA61524 (Dr. Fong) from the National Institutes of Health. Presented at the Fortieth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Fla., May 16–19, 1999.     

Liver resection for colorectal metastases

BACKGROUND: Colorectal cancer is the second commonest malignancy in the UK. Metastases to the liver occur in greater than 50% of patients and remain the biggest determinant of outcome in these patients. Liver resection is a safe procedure that achieves good long-term survival, but surgery has traditionally been limited to select groups of patients. The improved outcome suggests that more patients could benefit from resection if more was known of what criteria are predictive of a good outcome. PATIENTS AND METHODS: A retrospective analysis was performed on all patients undergoing surgical resection of the liver for colorectal metastases between March 1989 and March 2001 in the Birmingham Liver Unit. RESULTS: During this period, 212 liver resections for colorectal cancer metastases were performed in 82 females and 130 males. The median follow-up was 16 months with an overall actuarial survival of 86% at 1 year, 54% at 3 years, and 28% at 5 years. The peri-operative mortality was 2.8%. The number and timing (metachronous or synchronous) of metastatic lesions, the gender of the patient, pathological staging of the primary lesion or surgical resection margins had no significant influence on survival. Patients with lesions less than 5 cm in size had a significantly prolonged survival compared with patients with lesions greater than 5 cm in size (P < 0.004). CONCLUSIONS: Liver resection is the only curative treatment for patients with colorectal metastases. The long-term survival reported in patients with resected colorectal metastases confined to the liver is comparable to primary surgery for solid gastrointestinal tumours. Every attempt must be made to increase the availability of liver resection to patients with hepatic metastases from colorectal cancer.