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??Long-term survival after hepatectomy for metastatic colorectal cancer: A retrospective analysis of 317 consecutive cases at a single-institution YAN Xiao-luan, WANG Kun, BAO Quan, et al. Hepatobiliary and Pancreatic Surgery Unit I, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China
Corresponding author: XING Bao-cai??E-mail: xingbaocai88@ sina.com
Abstract Objective To identify risk factors associated with overall survival(OS) for patients performed hepatic resection for metastatic colorectal cancer. Methods The clinical, pathologic, and complete follow-up data were prospectively collected from 317 consecutive patients performed primary hepatic resection for colorectal liver metastases at Beijing Cancer Hospital from January 2005 to January 2015. Parametric survival analysis was used to identify predictors of cancer-specific survival. Results The 1-, 3- and 5-year overall survival were 90.5%, 54.5% and 45.0%, respectively. The median survival time was 43 months. Univariate analysis found 6 risk factors including gender, lymph node dissemination of the primary tumor, diameter of metastases>3 cm, synchronous metastases, carcinoembyonic antigen level >30 μg/L, and extra-hepatic disease??P<0.05??. On multivariate analysis, 3 risk factors were found to be independent predictors of poor survival, which included lymph node dissemination of the primary tumor, synchronous metastases, CEA>30 μg/L. Conclusion Resection of liver metastases provides long-term cancer-specific survival benefit. Clinicopathological characteristics including lymph node dissemination of the primary tumor, synchronous metastases, CEA>30 μg/L were predictors of adverse outcome.     

Five-year survival after resection of hepatic metastases from colorectal cancer in patients screened by positron emission tomography with F-18 fluorodeoxyglucose (FDG-PET)

OBJECTIVE: To report the first 5-year overall survival results in patients with colorectal carcinoma metastatic to the liver who have undergone hepatic resection after staging with [18F] fluoro-2-deoxy-D-glucose-positron emission tomography (FDG-PET). SUMMARY BACKGROUND DATA: The 5-year overall survival after hepatic resection for colorectal cancer metastases without preoperative FDG-PET has been established in 19 studies (6070 patients). The median 5-year overall survival rate in these studies is 30% and has not improved over time. FDG-PET detects unsuspected tumor in 25% of patients considered to have resectable hepatic metastasis by conventional staging. METHODS: From March 1995 to June 2002, all patients having hepatic resection for colorectal cancer metastases had preoperative FDG-PET. A prospective database was maintained. RESULTS: One hundred patients (56 men, 44 women) were studied. Metastases were synchronous in 52, single in 63, unilateral in 78, and <5 cm in diameter in 60. Resections were major (>3 segments) in 75 and resection margins were > or = 1 cm in 52. Median follow up was 31 months, with 12 actual greater than 5-year survivors. There was 1 postoperative death. The actuarial 5-year overall survival was 58% (95% confidence interval, 46-72%). Primary tumor grade was the only prognostic variable significantly correlated with overall survival. CONCLUSIONS: Screening by FDG-PET is associated with excellent postresection 5-year overall survival for patients undergoing resection of hepatic metastases from colorectal cancer. FDG-PET appears to define a new cohort of patients in whom tumor grade is a very important prognostic variable.     

Hepatic Resection for Metastatic Tumors From Gastric Cancer

OBJECTIVE: To assess the surgical results and clinicopathologic features of hepatic metastases from gastric adenocarcinoma to identify patients with a better probability of survival. SUMMARY BACKGROUND DATA: Many studies have reported the benefit of hepatic resection for metastatic tumors from colorectal cancer. However, indications for a surgical approach for gastric adenocarcinoma involving the liver have not been clearly defined. METHODS: Ninety (11%) of 807 patients with primary gastric cancer were diagnosed with synchronous (n = 78) or metachronous (n = 12) hepatic metastases. Of these, 19 underwent 20 resections intended to cure the metastatic lesion in the liver. The clinicopathologic features of the hepatic metastases in, and the surgical results for, the 19 patients were analyzed. RESULTS: The actuarial 1-year, 3-year, and 5-year survival rates after hepatic resection were, respectively, 77%, 34%, and 34%, and three patients survived for more than 5 years after surgery. Solitary and metachronous metastases were significant determinants for a favorable prognosis after hepatic resection. Pathologically, a fibrous pseudocapsule between the tumor and surrounding hepatic parenchyma was found in 13 of the 19 patients (68%). The presence of a peritumoral fibrous pseudocapsule and a well-differentiated histologic type of metastatic nodule were significant prognostic factors. Factors associated with the primary lesion were not significant prognostic determinants in patients who underwent curative resection of the primary cancer. CONCLUSIONS: Solitary and metachronous metastases from gastric cancer should be treated by a surgical approach and confer a better prognosis. A new prognostic factor, the presence of a pseudocapsule, may be helpful in defining indications for postoperative adjuvant treatment.     

Partial hepatectomy for metastases from noncolorectal, nonneuroendocrine carcinoma

OBJECTIVE: To define perioperative and long-term outcome and prognostic factors in patients undergoing hepatectomy for liver metastases arising from noncolorectal and nonneuroendocrine (NCNN) carcinoma. SUMMARY BACKGROUND DATA: Hepatic resection is a well-established therapy for patients with liver metastases from colorectal or neuroendocrine carcinoma. However, for patients with liver metastases from other carcinomas, the value of resection is incompletely defined and still debated. METHODS: Between April 1981 and April 2002, 141 patients underwent hepatic resection for liver metastases from NCNN carcinoma. Patient demographics, tumor characteristics, treatment, and postoperative outcome were analyzed. RESULTS: Thirty-day postoperative mortality was 0% and 46 of 141 (33%) patients developed postoperative complications. The median follow up was 26 months (interquartile range [IQR]) 10-49 months); the median follow up for survivors was 35 months (IQR 11-68 months). There have been 24 actual 5-year survivors so far. The actuarial 3-year relapse-free survival rate was 30% (95% confidence interval [CI], 21-39%) with a median of 17 months. The actuarial 3-year cancer-specific survival rate was 57% (95% CI, 48-67%) with a median of 42 months. Primary tumor type and length of disease-free interval from the primary tumor were significant independent prognostic factors for relapse-free and cancer-specific survival. Margin status was significant for cancer-specific survival and showed a strong trend for relapse-free survival. CONCLUSIONS: Hepatic resection for metastases from NCNN carcinoma is safe and can offer long-term survival in selected patients. Hepatic resection should be considered if all gross disease can be removed, especially in patients with metastases from reproductive tract tumors or a disease-free interval greater than 2 years.     

结直肠癌肝转移综合治疗预后因素分析（附317例报告）

目的 探讨影响结直肠癌肝转移以外科手术为主的综合治疗疗效的预后风险因素。方法 回顾性分析北京大学肿瘤医院肝胆胰外一科2005年1月至2015年1月行肝切除手术治疗317例结直肠癌肝转移病人的临床资料及术后随访情况。结果 全组病人1、3、5年总存活率分别为90.5%、54.5%、45.0%。中位生存期43个月。单因素分析结果显示性别、原发灶淋巴结转移、肝转移灶最大径、肝转移灶出现时间、癌胚抗原（CEA）水平及是否存在肝外转移灶是影响预后的因素（P<0.05）;多因素分析结果显示原发灶淋巴结转移、同时性肝转移和CEA>30 μg/L是影响预后的独立危险因素。结论 以外科手术为主的综合治疗可显著改善结直肠癌肝转移病人的长期生存,多种临床风险因素影响病人预后。     

Resection of hepatic metastases from colorectal cancer

Summary Background: The aim of this paper is to analyze our experience with liver resection for metastatic colorectal cancer and to evaluate the prognostic significance of various parameters. Methods: 40 consecutive patients treated with potentially curative liver resection between 1984 and 1996 were included. The prognostic significance of various parameters was evaluated with respect to survival. Univariate and multivariate analyses were performed for following factors: age, gender, site and stage and grading of the primary tumor, size of metastases, number of metastases, lobar distribution of metastases, diagnostic interval, type of liver resection, resection margin, perioperative blood transfusion and preoperative carcinoembryonic antigen (CEA) level. Results: 3-year- and 5-year survival was 54% and 33%, median survival was 37 months. The 30 day mortality rate was 0%, postoperative complications occurred in 8 patients (20%). As single factors the following significantly affected the prognosis: number of metastases (p=0.0001), mesenteric lymphnode involvement of the primary tumor (p=0.002), lobar distribution (p=0.002) and intraoperative units of blood (p=0.05). Multivariate analysis revealed that age, gender, mesenteric lymphnode involvement, number of metastases and synchronous versus metachronous metastatic disease were independent predictors of survival. Conclusions: Liver resection is effective in selected patients with hepatic metastases from colorectal cancer. In resectable patients it is not possible to establish a clear prognosis based on the investigated factors. Therefore, patients with adverse prognostic factors should not be denied resection.      

Prognostic factors and survival after complete resection of pulmonary metastases from colorectal carcinoma: experiences in 167 patients

OBJECTIVE: Surgical resection is an important form of treatment for pulmonary metastases from colorectal carcinoma. We analyzed the clinical course, outcome, and prognostic factors after surgery. METHODS: Between 1985 and 2000, 167 patients (103 men, 64 women) underwent complete pulmonary resection of metastatic colorectal carcinoma. Only patients who met the criteria for potentially curative operation, in particular, control of the primary tumor, ability to resect all metastatic disease, and no other extrapulmonary metastases, were included. RESULTS: The overall 5-year survival was 32.4%. A significantly longer survival was observed in multivariate analysis in patients without lymph node involvement compared with patients with pulmonary or mediastinal lymph node metastases or both. The number of pulmonary metastases significantly influenced survival. In patients with a solitary metastasis, we observed a 5-year survival of 45%, whereas the rate was 19.8% in patients with more than a single metastasis. In multivariate analysis, we also found the prethoracotomy carcinoembryonic antigen serum level to be an independent significant prognostic factor for survival. In patients with a serum carcinoembryonic antigen level exceeding 5 ng/mL and in patients with a serum carcinoembryonic antigen level in the normal range, the 5-year survivals were 22.7% and 48.3%, respectively. CONCLUSIONS: We conclude that pulmonary resection of metastatic colorectal carcinoma is safe and results in long-term survival. Thoracic lymph node metastases, serum carcinoembryonic antigen level before metastasectomy, and the number of pulmonary metastases were identified as prognosis-related criteria for surgery.     

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.     

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.     

Vascular endothelial growth factor expression in metastatic pulmonary tumor from colorectal carcinoma: utility as a prognostic factor

OBJECTIVE: To define the most reliable prognostic factor, we studied the 5-year survival of patients after resection of pulmonary metastases from colorectal cancer in relation to various prognostic factors, including vascular endothelial growth factor expression in primary and metastatic tumors. METHODS: A retrospective study was undertaken in 49 patients who had undergone complete resection of pulmonary metastasis from colorectal carcinoma. All patients were retrospectively analyzed for sex, age, location and stage of primary tumor, number of pulmonary metastases, type of pulmonary resection, size of metastatic tumor, lymph node metastasis, and prethoracotomy carcinoembryonic antigen level. Furthermore, vascular endothelial growth factor expression of both primary and metastatic tumors was investigated. RESULTS: Overall 5-year survival was 34.3%. In the univariate analysis the number of pulmonary metastases (P =.007) and vascular endothelial growth factor expression in metastatic tumors (P =.008) and primary colorectal tumors (P =.011) were significantly associated with poor survival. In the multivariate analysis the number of pulmonary metastases (P =.0031), vascular endothelial growth factor expression in metastatic tumors (P =.0057), and stage of primary tumor (P =.0321) were characteristics that retained a significant independent prognostic effect on overall survival. A statistically significant difference was not found in the 5-year survival of patients with solitary and negative vascular endothelial growth factor expression in metastatic tumors (59.1%) versus those with multiple and positive vascular endothelial growth factor expression in metastatic tumors (10.0%; P 相似文献   

The clinical risk score: emerging as a reliable preoperative prognostic index in hepatectomy for colorectal metastases

HYPOTHESIS: The purpose of this study was to examine the validity of the clinical risk score (CRS), a prognostic tool developed by Fong et al, when translated to another center. DESIGN: This study assesses 5 independent preoperative prognostic criteria, nodal status of the primary lesion, disease-free interval, number of hepatic metastases, size of the largest metastasis, and preoperative carcinoembryonic antigen level, to determine a preoperative CRS for each patient included in the study. SETTING: The hepatobiliary unit of The Queen Elizabeth Hospital, Adelaide, South Australia. PATIENTS: Medical records of patients admitted to The Queen Elizabeth Hospital undergoing potentially curative hepatic resection for colorectal metastases during the period of July 1993 to April 2003 were included in the study.Main Outcome Measure The primary outcome measure of the study was survival. The calculated CRS was analyzed with respect to patient postoperative survival. RESULTS: During the 10-year period, 77 patients underwent hepatic resection. Overall survival rates for 1, 3, and 5 years were found to be 80.9%, 57.5%, and 42.3%, respectively. One- and 5-year survival rates for CRSs of 0 and 1 were found to be 93.8% and 72.5%, respectively; for scores of 2 and 3, 76.6% and 31.2%, respectively;and for scores of 4 and 5, 75% and 0%, respectively. No patient with a CRS greater than 3 survived more than 2 years. CONCLUSION: This study validates the CRS, finding it to be highly predictive of patient outcome and survival.     

Prognostic factors for survival after pulmonary resection of metastatic renal cell carcinoma

BACKGROUND: Pulmonary resection in metastatic renal cell carcinoma is an accepted method of treatment. The purpose of this study was to determine the clinical course, outcome, and prognostic factors after surgery. METHODS: Between 1985 and 1999, 191 patients (145 men, 46 women) with pulmonary metastases from a renal cell carcinoma underwent surgical resection. Inclusion criteria for the study were the absence of primary tumor recurrence and other extrapulmonary metastases. Complete resection (CR) was achieved in 149 patients. RESULTS: The overall 5-year survival rate was 36.9%. The 5-year survival rate after complete metastasectomy and incomplete resection was 41.5% and 22.1%, respectively. In patients with pulmonary or mediastinal lymph node metastases, we observed after complete resection a 5-year survival rate of 24.4%, whereas the rate was 42.1% in patients without lymph node involvement. A significantly longer survival was observed for patients with fewer than seven pulmonary metastases compared with patients with more than seven metastases (46.8% vs 14.5%). For surgically rendered complete resection (CR) patients with a disease-free interval of 0 to 23 months, the 5-year survival rate was 24.7% compared with 47% for those with more than a 23-month disease-free interval. By multivariate analyses, we showed that the number of pulmonary metastases, the involvement of lymph node metastases, and the length of the disease-free interval were all predictors of survival after complete resection. CONCLUSIONS: We conclude that pulmonary resection in metastatic renal cell carcinoma is a safe and effective treatment that offers improved survival benefit. Prognosis-related criteria are identified that support patient selection for surgery.     

Prognostic differences between oligometastatic and polymetastatic disease after resection in patients with colorectal cancer and hepatic or lung metastases: Retrospective analysis of a large cohort at a single institution

BackgroundLong-term survival data are lacking, and prognostic factors are not well-defined for patients with colorectal cancer and hepatic or lung metastases. This study evaluated the outcomes after resection of oligometastatic hepatic or lung metastases from colorectal cancer and sought to identify prognostic factors.MethodsWe retrospectively investigated 1,123 patients with colorectal cancer and hepatic or pulmonary metastases who underwent curative surgery between January 1991 and December 2016.ResultsOf the 1,123 patients, 719 had hepatic metastases, 287 had pulmonary metastases, and 117 had both. The 5-year overall survival rate was 52.3% in the hepatic metastases group, 70.4% in the pulmonary metastases group, and 71.4% in the hepatic and pulmonary metastases group (P < .001). In total, 1,045 patients had oligometastases (1–5 metastatic lesions in 1 or 2 organs) and 78 had polymetastases (≥6 metastases in 1 or 2 organs). Prognosis was significantly better in patients with oligometastases than in those with polymetastases. The 5-year overall survival rate was 59.0% in the oligometastases group and 35.3% in the polymetastases group (P < .001); the respective 5-year relapse-free survival rates were 37.5% and 11.6% (P < .001). Multivariable analysis identified predictors of both poor overall survival and relapse-free survival to be a high carcinoembryonic antigen level before the first metastasectomy, largest metastasis measuring ≥2 cm, polymetastases, and synchronous metastases.ConclusionPrognosis after curative resection was better in patients with oligometastatic colorectal cancer in the liver or lung than in those with polymetastases. Multidisciplinary decision-making strategies, including about surgery, should be based on number of metastases rather than their site.     

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.     

大肠癌伴肝转移的治疗及预后因素分析:附52例报告

目的:探讨大肠癌肝转移手术切除的疗效及影响术后生存率的因素，以改进提高远期疗效的措施。 方法:对52例手术治疗的大肠癌肝转移患者进行随访，比较11例生存5年以上与41例生存5年以内的患者的临床病理资料。结果:全组术后1，3，5年生存率分别为75%，30.8%和21.2%。影响患者愈后的因素主要有：原发癌病理类型、肝转移病灶数目、手术方式及时机选择，术后治疗（均P<0.05）。结论:根治切除以及加强术后综合治疗是提高远期疗效的关键。     

Outcomes after resection of synchronous or metachronous hepatic and pulmonary colorectal metastases

BACKGROUND: Surgical resection of isolated hepatic or pulmonary colorectal metastases prolongs survival in selected patients. But the benefits of resection and appropriate selection criteria in patients who develop both hepatic and pulmonary metastases are ill defined. STUDY DESIGN: Data were prospectively collected from 131 patients with colorectal cancer who underwent resection of both hepatic and pulmonary metastases over a 20-year period. Median followup was 6.6 years from the time of resection of the primary tumor. Patient, treatment, and outcomes variables were analyzed using log-rank, Cox regression, and Kaplan-Meier methods. RESULTS: The site of first metastasis was the liver in 65% of patients, the lung in 11%, and both simultaneously in 24%. Multiple hepatic metastases were present in 51% of patients, and multiple pulmonary metastases were found in 48%. Hepatic lobectomy or trisegmentectomy was required in 61% of patients; most lung metastases (80%) were treated with wedge excisions. Median survival rates from resection of the primary disease, first site of metastasis, and second site of metastasis were 6.9, 5.0, and 3.3 years, respectively. After resection of disease at the second site of metastasis, the 1-, 3-, 5-, and 10-year disease-specific survival rates were 91%, 55%, 31%, and 19%, respectively. An analysis of prognostic factors revealed that survival was significantly longer when the disease-free interval between the development of the first and second sites of metastases exceeded 1 year, in patients with a single liver metastasis, and in patients younger than 55 years old. CONCLUSIONS: Surgical resection of both hepatic and pulmonary colorectal metastases is associated with prolonged survival in selected patients. Patients with a longer disease-free interval between metastases and those with single liver lesions had the best outcomes.     

Surgical treatment for both pulmonary and hepatic metastases from colorectal cancer

OBJECTIVE: The role of surgery in the treatment of patients with pulmonary and hepatic metastases from colorectal cancer has not been delineated. METHODS: Of the 351 patients enrolled in the Metastatic Lung Tumor Study Group of Japan between June 1988 and June 1996 who underwent thoracotomy for pulmonary metastases from colorectal cancer, 47 also underwent hepatic resection for metastatic tumors. The records of these patients were studied. RESULTS: The 47 patients who underwent pulmonary and hepatic resection had a 3-year survival of 36% +/- 8%, a 5-year survival of 31% +/- 8%, and an 8-year survival of 23% +/- 9%. The longest survival was 98 months. This patient was alive without recurrence. There was a significant difference in the cumulative survival of the patients with a solitary pulmonary metastasis and the patients with multiple pulmonary metastases (P =.04). Neither age, sex, location of the primary tumor, maximum diameter of the pulmonary metastases, method of pulmonary resection, number of hepatic metastases, nor method of hepatic resection was correlated with survival. However, 9 of 10 patients who survived 3 years or more after the initial thoracotomy had only one or two hepatic metastases. CONCLUSION: Surgical treatment of a solitary pulmonary metastasis concurrent with or after resection of hepatic metastases from colorectal cancer may be appropriate if the hepatic metastases are resectable for cure. Patients with a solitary pulmonary metastasis and a small number of hepatic metastases are good candidates for resection. Long-term survival can be expected.     

Prognostic value of postoperative carcinoembryonic antigen concentration and extent of invasion of resection margins after hepatic resection for colorectal metastases.

OBJECTIVE: To evaluate the prognostic value of postoperative concentration of carcinoembryonic antigen (CEA) and extent of surgical margins after resection of liver metastases from colorectal cancer. DESIGN: Retrospective study. SETTING: Teaching hospital, Switzerland. SUBJECTS: 49 patients with hepatic metastases after primary colorectal cancer. INTERVENTIONS: Resection of hepatic metastases MAIN OUTCOME MEASURES: Assessment of prognostic value of variables by univariate and multivariate analysis. RESULTS: Median survival was 24 months (range 5-86 months). Resection margins were clear (> 1-cm) in 10, close (< 1-cm) in 25 and invaded in 9 patients. On univariate analysis, a postoperative concentration of CEA of <4ng/ml was correlated with prolonged survival (p < 0.001), but the width of the resection margin was not of prognostic importance. There was no correlation between width of resection margins and postoperative concentration of CEA (p = 0.5). On multivariate analysis, postoperative concentrations of CEA of 4 ng/ml or more were associated with increased risk of death (relative risk 7.3; 95% confidence interval (CI) 2.8-18.7, p < 0.001). CONCLUSION: Postoperative CEA offers better prognostic discrimination than the width of resection margins after resection of liver metastases from colorectal tumours. Some patients with invaded resection margins did survive for 3 years, but no patient did whose CEA concentration was 4 ng/ml or more. The definition of a potentially curative hepatic resection should include a postoperative CEA concentration of <4 ng/ml (within the reference range).     

Hepatic resection of colorectal metastases. Influence of clinical factors and adjuvant intraperitoneal 5-fluorouracil via Tenckhoff catheter on survival.

This report analyzes an experience with 33 hepatic resections for metastatic colorectal cancer over a 7-year period and with intraperitoneal 5-FU administered as a postresection adjuvant in 21 of these patients. Particular emphasis is placed on the identification of clinical determinants of postresection survival. There was no operative mortality in this series. Postoperative complications occurred in 27% of patients, and the incidence of complications correlated with intraoperative blood loss (p = 0.002). Two- and 4-year estimated survivals were 72% and 53%, respectively. Patients with three or fewer metastases resected or with unilobar disease had improved survival when compared with patients having more than three metastases or bilobar disease, respectively (p less than 0.05). Disease-free survival was improved in patients with microscopically negative resection margins (p = 0.019). Dukes' stage of the primary lesion, interval between bowel resection and detection of hepatic metastases, method of detection of metastases, preoperative CEA level, and type of operation performed were not predictive of postresection survival. Intraperitoneal 5-FU was well tolerated. There was a trend toward improved survival in patients receiving adjuvant chemotherapy, but this was not statistically significant. It is concluded that the number of metastases resected, the distribution of the metastases, and the technical adequacy of the excision are all predictive of outcome following hepatic resection of colorectal metastases. Encouraging results with the use of intraperitoneal 5-FU as a postresection adjuvant have led to the initiation of a prospective randomized trial investigating this modality at the NCI.     

One hundred patients with hepatic metastases from colorectal cancer treated by resection: analysis of prognostic determinants

One hundred patients with hepatic metastases from colorectal cancer underwent 'radical' liver resection from 1980 to 1989. At least 1 cm of normal parenchyma surrounded the tumour and no microscopic invasion of resection margins was evident. The disease was staged according to our own staging system. Lobectomy was performed in 50 patients and non-anatomical resection in the remainder. The postoperative mortality rate was 5 per cent and the major morbidity rate was 11 per cent. The actuarial 5-year survival rate for patients in stages I, II and III was 42 per cent, 34 per cent and 15 per cent respectively (P less than 0.001). The overall actuarial 5-year survival rate was 30 per cent. The prognostic importance of various patient and tumour variables was evaluated by univariate analysis and then by multivariate analysis. Age of patient, site of primary, disease-free interval between treatment of primary and of hepatic metastases, preoperative carcinoembryonic antigen levels, and number of metastases, did not relate to prognosis, while sex (P = 0.024), stage of primary (P = 0.026), extent of liver involvement (P less than 0.001), distribution of metastases (P = 0.01) and type of surgery (P = 0.028) significantly affected prognosis as single factors. Multivariate analysis revealed that only the extent of liver involvement and stage of the primary tumour were independent predictors of survival. We conclude that liver resection is effective in selected patients with hepatic metastases from colorectal cancer. In resectable patients it is not yet possible to formulate a clear prognosis based on clinical factors. The extent of liver involvement and the staging system used may be significant, although not absolute, indicators of outcome.