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Hellingman T, de Swart ME, Heymans MW, Jansma EP, van der Vliet HJ, Kazemier G. Repeat hepatectomy justified in patients with early recurrence of colorectal cancer liver metastases: A systematic review and meta-analysis. Cancer Epidemiol 2021; 74:101977. [PMID: 34303642 DOI: 10.1016/j.canep.2021.101977] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 06/04/2021] [Accepted: 06/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The benefit of repeat hepatectomy in patients with early recurrence of colorectal cancer liver metastases (CRLM) is questioned, in particular in those suffering from recurrence within three to six months following initial hepatectomy. The aim of this review was therefore to assess whether disease-free interval was associated with overall survival in patients undergoing repeat hepatectomy for recurrent CRLM. METHODS A systematic review and meta-analysis was conducted, according to PRISMA guidelines. PubMed, Embase and Cochrane Library databases were searched from database inception to 6th June 2020. Observational studies describing results of repeat hepatectomy for recurrent CRLM, including (disease-free) interval between hepatic resections and overall survival were included. Patients undergoing repeat hepatectomy within three months or additional resection of extrahepatic disease were excluded from meta-analysis. RESULTS The initial search identified 2159 records, of which 28 were included for qualitative synthesis. A meta-analysis of 15 cohort studies was performed, comprising 1039 eligible patients. Median overall survival of 54.0 months [95 %-CI: 38.6-69.4] was observed after repeat hepatectomy in patients suffering from recurrent CRLM between three to six months compared to 53.0 months [95 %-CI: 44.3-61.6] for patients with recurrent CRLM between seven to twelve months (adjusted HR = 0.89, 95 %-CI: 0.66-1.18; p = 0.410), and 60.0 months [95 %-CI: 52.7-67.3] for patients with recurrent CRLM after twelve months (adjusted HR = 0.70, 95 %-CI: 0.53-0.92; p = 0.012). CONCLUSIONS Disease-free interval is considered a prognostic factor for overall survival, but should not be used as selection criterion per se for repeat hepatectomy in patients suffering from recurrent CRLM.
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Affiliation(s)
- Tessa Hellingman
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Cancer Center Amsterdam, de Boelelaan 1117, Amsterdam, the Netherlands.
| | - Merijn E de Swart
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Cancer Center Amsterdam, de Boelelaan 1117, Amsterdam, the Netherlands
| | - Martijn W Heymans
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Epidemiology & Biostatistics, de Boelelaan 1089a, Amsterdam, the Netherlands
| | - Elise P Jansma
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Epidemiology & Biostatistics, de Boelelaan 1089a, Amsterdam, the Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Medical Information & Library, de Boelelaan 1117, Amsterdam, the Netherlands
| | - Hans J van der Vliet
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Medical Oncology, Cancer Center Amsterdam, de Boelelaan 1117, Amsterdam, the Netherlands; LAVA Therapeutics, Yalelaan 60, Utrecht, the Netherlands
| | - Geert Kazemier
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Cancer Center Amsterdam, de Boelelaan 1117, Amsterdam, the Netherlands
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Repeat hepatectomy for patients with recurrent neuroendocrine liver metastasis: Comparison with first hepatectomy. Surgery 2020; 167:404-409. [DOI: 10.1016/j.surg.2019.08.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 08/06/2019] [Accepted: 08/20/2019] [Indexed: 12/29/2022]
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3
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Bozzetti F, Bignami P, Baratti D. Surgical Strategies in Colorectal Cancer Metastatic to the Liver. TUMORI JOURNAL 2018; 86:1-7. [PMID: 10778758 DOI: 10.1177/030089160008600101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Surgical resection remains a milestone in the treatment of colorectal metastases to the liver. There is a distinct subset of patients who benefit from surgical resection in terms of longer survival or definitive cure. The main effort of the surgical oncological regards the safety of the procedure and the adequacy of the recommendation. Many studies, some of them including multivariate analysis, have shown the presence of prognostic determinants of long-term survival and prognostic indexes of the outcome after hepatectomy. It is now accepted that liver resection should be done when the complete excision of all demonstrable tumor with clear resection margins is feasible. Major contra-indication is represented by the presence of extra-hepatic intra-abdominal disease or of unresectable lung metastatic deposits. There is a wide literature indicating that in very selected patients liver reresection and multiorgan synchronous or metachronous resections are beneficial. The role of neoadjuvant chemotherapy and especially postoperative adjuvant local (intra-hepatic) and systemic chemotherapy is promising and supported by recent multicenter randomised clinical trials.
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Affiliation(s)
- F Bozzetti
- Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy.
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4
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McLoughlin JM, Jensen EH, Malafa M. Resection of Colorectal Liver Metastases: Current Perspectives. Cancer Control 2017; 13:32-41. [PMID: 16508624 DOI: 10.1177/107327480601300105] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Metastases to the liver is the leading cause of death in patients with colorectal cancer. METHODS The authors review the data on diagnosis and management of this clinical problem, and they discuss management options that can be considered. RESULTS Complete surgical resection of metastases from colorectal cancer that are localized to the liver results in 5-year survival rates ranging from 26% to 40%. CONCLUSIONS By adding modalities such as targeted systemic therapy and other "local" treatments for liver metastases, further gains in survival are anticipated.
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Affiliation(s)
- James M McLoughlin
- Gastrointestinal Tumor Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612-9497, USA
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5
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Abstract
For the 20% of patients with resectable colorectal liver metastases (CRLM), hepatic resection is safe, effective and potentially curative. Factors related to the primary and metastatic tumors individually and in clinical risk-scoring schemes are the best prognostic factors, although it is difficult to define patient groups with resectable, liver-limited CRLM that should be excluded from surgery. Systemic chemotherapy for metastatic colorectal cancer has improved but does not improve overall survival as adjuvant therapy after resection. Conversion to complete resection with systemic and/or hepatic arterial infusion chemotherapy is an appropriate goal for patients with unresectable CRLM.
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Gur I, Diggs BS, Wagner JA, Vaccaro GM, Lopez CD, Sheppard BC, Orloff SL, Billingsley KG. Safety and outcomes following resection of colorectal liver metastases in the era of current perioperative chemotherapy. J Gastrointest Surg 2013; 17:2133-42. [PMID: 24091909 DOI: 10.1007/s11605-013-2295-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 07/16/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Preoperative chemotherapy is increasingly utilized in the treatment of colorectal liver metastases (CRLM). Although this strategy may improve resectability, long-term advantages of preoperative chemotherapy for resectable CRLM are less clear. The objective of this study is to report safety and outcomes when perioperative chemotherapy is routinely added to surgery for CRLM. METHODS A retrospective review of patients undergoing liver resections for CRLM during 2003-2011 in single academic oncology center. Demographic data, tumor characteristics, chemotherapy, surgical details, complications and survival were analyzed. RESULTS The study included 157 patients that underwent 168 liver operations. One hundred eighteen patients (70 %) underwent preoperative chemotherapy (75 % oxaliplatin-based). Preoperative portal vein embolization was utilized in 16 (10.1 %) patients. Overall survival (OS) was 89, 57, and 27 % at 1, 3, and 5 years, respectively (median survival-42.8 months). Eleven (7 %) patients had repeat resections for liver recurrence. Thirty-day mortality was 1.26 %, morbidity-24 % (6 %-liver related). Complications were not significantly different in patients that had preoperative chemotherapy. On a multivariate analysis advanced age and >3 lesions predicted poor OS, while advanced age, lesions >5 cm, synchronous lesions, margin-positivity and resection less than hepatectomy were associated with decreased DFS. CONCLUSIONS Our results suggest that even with chemotherapy and resection only a subset of patients remain disease-free after 5 years. However, even in a high-risk patient with multiple lesions, preoperative chemotherapy can be administered safely without apparent increase in postoperative complications. Perioperative chemotherapy should be considered particularly in patients with multifocal or large lesions, synchronous disease and short disease-free interval.
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Affiliation(s)
- Ilia Gur
- Division of Surgical Oncology, Oregon Health and Science University, Portland, OR, USA,
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7
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Surgical treatment of hepatic colorectal metastasis: evolving role in the setting of improving systemic therapies and ablative treatments in the 21st century. Cancer J 2010; 16:103-10. [PMID: 20404606 DOI: 10.1097/ppo.0b013e3181d7e8e5] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Liver resection has clearly been established as the standard treatment for resectable colorectal liver metastases. This article will review the expanding role for hepatectomy in this disease. Faster and safer hepatectomies are allowing combined resections of the primary cancer and synchronous hepatic metastases. Effective neoadjuvant chemotherapy, as well as increasing data demonstrating effectiveness and safety of combined hepatectomy and ablative therapies, have further expanded the pool of patients now selected for resection. The end result is that increasing numbers of patients are undergoing acceptably aggressive surgical therapies with extension of life and possible cure. Successful multimodality therapies are also now allowing for long-term survival even in patients not cured of cancer. The prolonged survival of most patients treated by hepatectomy has allowed a long-term analysis of the patterns of recurrence, which emphasize the importance of controlling liver disease for prolongation of life. These improvements in treatments for hepatic metastases have come with a precipitous escalation of the costs of care. This will likely require that future clinical trials and algorithms of care not only be based on cancer outcome data but also on value analysis of treatment and follow-up regimens.
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8
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Abstract
Surgical and oncological treatment of liver metastases of CRC has made a significant progress in the last twenty years. Although chemotherapy has developed enormously, only successfully resected (R0) patients may hope a long-term survival. The almost 60% recurrence rate after resection is a significant challenge. Authors review patients data operated at the Surgical Department of Uzsoki Teaching Hospital between 1995 and 2008 with hepatic metastases of colorectal origin. Oncological and surgical principles are summarized in the sight of the recent literature review and authors own experience with repeat hepatic resection. Recent literature data demonstrate--which is confirmed by our experience--that R0 resection of recurrent hepatic metastases provides similar overall 5 year survival rate than that of patients who underwent a single resection only. In the case of recurrent CLM, the oncoteam should prepare a surgically resectable situation.
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Affiliation(s)
- Ferenc Jakab
- Fovárosi Onkormányzat Uzsoki utcai Kórház, Sebészeti-Ersebészeti Osztály, 1145 Budapest, Uzsoki u. 29
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9
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Cohort Study of the Survival Benefit of Resection for Recurrent Hepatic and/or Pulmonary Metastases After Primary Hepatectomy for Colorectal Metastases. Ann Surg 2010; 251:902-9. [DOI: 10.1097/sla.0b013e3181c9868a] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Yan TD, Sim J, Black D, Niu R, Morris DL. Systematic review on safety and efficacy of repeat hepatectomy for recurrent liver metastases from colorectal carcinoma. Ann Surg Oncol 2007; 14:2069-77. [PMID: 17440785 DOI: 10.1245/s10434-007-9388-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2007] [Accepted: 02/07/2007] [Indexed: 12/21/2022]
Abstract
BACKGROUND We critically appraised the quantity and quality of current clinical evidence to demonstrate the efficacy and safety of repeat hepatectomy for recurrent colorectal liver metastases (CRLM). METHODS Electronic searches for relevant studies published in peer-reviewed medical journals on repeat hepatectomy for recurrent CRLM before January 2007 were performed on six databases. The quality of each included study was independently assessed. Clinical effectiveness was synthesized through a narrative review with full tabulation of results of all included studies. RESULTS Seventeen studies with more than 20 patients were included for quality appraisal and data extraction. All 17 included articles were observational cases series. The overall perioperative morbidity rate ranged from 7% to 30% and mortality rate varied from 0% to 5%. The overall median survival since the repeat hepatectomy ranged from 23 to 56 months, with 3- and 5-year survival of 24% to 68% and 21% to 49%, respectively. The median disease-free survival ranged from 9 to 52 months, with 3- and 5-year disease-free survival of 16% to 68% and 16% to 48%, respectively. CONCLUSIONS The current literature suggests that repeat hepatectomy is associated with a prolonged survival for recurrent CRLM and is justified in selected patients because there is a lack of evidence for effective alternative treatments.
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Affiliation(s)
- Tristan D Yan
- Department of Surgery, University of New South Wales, St George Hospital, Sydney, NSW, Australia
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11
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Thelen A, Jonas S, Benckert C, Schumacher G, Lopez-Hänninen E, Rudolph B, Neumann U, Neuhaus P. Repeat liver resection for recurrent liver metastases from colorectal cancer. Eur J Surg Oncol 2007; 33:324-8. [PMID: 17112697 DOI: 10.1016/j.ejso.2006.10.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2006] [Accepted: 10/09/2006] [Indexed: 12/18/2022] Open
Abstract
AIMS Numerous patients suffer from recurrence after resection of liver metastases from colorectal cancer. Recurrence is frequently restricted to the liver and repeat liver resection may offer a curative option in these patients. This study was conducted to clarify safety and effectiveness of this treatment and to identify prognostic factors of a favourable outcome after repeat hepatectomy. METHODS Between January 1988 and March 2006 in our institution 811 patients underwent 841 liver resections for metastases from colorectal cancer. Among these, 94 patients underwent a repeat hepatectomy. Patients were identified from a prospective database and retrospectively reviewed. Results of different time periods were assessed and prognostic factors for a favourable outcome were determined. RESULTS The perioperative morbidity and mortality was 24% (23 of 94) and 3% (3 of 94), respectively. The one-, three-, five- and ten-year survival for all patients in this series was 89%, 55%, 38% and 23%, respectively. In the univariate analysis, pT-stage of the primary, diameter of the largest metastases, surgical radicality, period of resection and distribution of metastases showed statistically significant influence on survival. The multivariate analysis revealed only pT-stage of the primary tumour, surgical radicality and period of resection as independent prognostic factors. CONCLUSIONS Repeat hepatectomy is a safe and effective treatment for recurrent liver metastases from colorectal cancer. Perioperative risk and long-term survival were similar when compared to the results obtained during the initial resection. Achieving a curative resection is the most relevant prognostic factor for a favourable prognosis after repeat liver resection.
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Affiliation(s)
- A Thelen
- Departmant of General, Visceral and Transplantation Surgery, Campus Virchow-Klinikum, Charité Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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12
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Ayav A, Bachellier P, Habib NA, Pellicci R, Tierris J, Milicevic M, Jiao LR. Impact of radiofrequency assisted hepatectomy for reduction of transfusion requirements. Am J Surg 2007; 193:143-8. [PMID: 17236838 DOI: 10.1016/j.amjsurg.2006.04.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2005] [Revised: 04/23/2006] [Accepted: 04/23/2006] [Indexed: 01/30/2023]
Abstract
BACKGROUND Liver parenchyma transection technique using heat coagulative necrosis induced by radiofrequency (RF) energy is evaluated in this series. METHODS Between January 2000 and October 2004, 156 consecutive patients underwent liver resection with the RF-assisted technique. Data were collected prospectively to assess the outcome, including intraoperative blood loss, blood transfusion requirement, and morbidity and mortality rates. RESULTS There were 30 major hepatectomies and 126 minor resections. While total operative time was 241 +/- 89 minutes, the actual resection time was 75 +/- 51 minutes. Intraoperative blood loss was 139 +/- 222 mL. Nine patients (5%) received blood transfusion, predominantly those receiving major hepatectomy (P = .006). Thirty-six patients (23%) developed postoperative complications, and the mortality rate was 3.2%. Mean hospital stay was 12 +/- 12 days. CONCLUSION The RF-assisted technique is associated with minimal blood loss, a low blood transfusion requirement, and reduced mortality and morbidity rates and can be used for both minor and major liver resections.
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Affiliation(s)
- Ahmet Ayav
- Department of Surgery, Anaesthetics and Intensive Care, Imperial College Faculty of Medicine, Hammersmith Campus, Du Cane Rd., London W12 0NN, UK
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13
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Abstract
BACKGROUND Metastases to the liver is the leading cause of death in patients with colorectal cancer. METHODS The authors review the data on diagnosis and management of this clinical problem, and they discuss management options that can be considered. RESULTS Complete surgical resection of metastases from colorectal cancer that are localized to the liver results in 5-year survival rates ranging from 26% to 40%. CONCLUSIONS By adding modalities such as targeted systemic therapy and other "local" treatments for liver metastases, further gains in survival are anticipated.
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Affiliation(s)
- Irene Kuehrer
- University Clinic of Surgery, General Hospital of Vienna
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14
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Antoniou A, Lovegrove RE, Tilney HS, Heriot AG, John TG, Rees M, Tekkis PP, Welsh FKS. Meta-analysis of clinical outcome after first and second liver resection for colorectal metastases. Surgery 2006; 141:9-18. [PMID: 17188163 DOI: 10.1016/j.surg.2006.07.045] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2006] [Revised: 07/27/2006] [Accepted: 07/29/2006] [Indexed: 01/29/2023]
Abstract
BACKGROUND The perioperative risk and long-term survival benefit of repeat hepatectomy for patients with liver metastases from colorectal cancer, compared with that of a first liver resection, has been reported with varying results in the literature. METHODS The literature was searched using Medline, Embase, Ovid, and Cochrane databases for all studies published from 1992 to 2006. Two authors independently extracted data using the following outcomes: postoperative complications and mortality; disease recurrence; and long-term survival. Trials were assessed using the modified Newcastle-Ottawa Score. Random-effect meta-analytical techniques were used for analysis. RESULTS Twenty-one studies met the inclusion criteria, comprising 3,741 patients. The use of adjuvant chemotherapy was similar in both groups (odds ratio [OR] = 0.97; 95% confidence interval [CI] = 0.54, 1.74; P = .92), as was the number of hepatic nodules present at the time of first or second resection (weighted mean difference [WMD] = 0.18; 95% CI = -0.22, 0.57; P = .380). Wedge resection was carried out less often at first hepatectomy (39% vs 46%; OR = 0.66; 95% CI = 0.44, 1.00; P = .05). There was significantly less blood loss in patients undergoing first versus second hepatectomy (WMD = 238 ml; 95% CI = 90, 385; P = .002). There was no difference in perioperative morbidity (OR = 1.01; 95% CI = 0.65, 1.55; P = .98), mortality (OR = 1.01; 95% CI = 0.18, 5.72; P = .99) or long-term survival (HR = 0.90; 95% CI = .66, 1.24; P = .530) between groups. CONCLUSIONS Repeat hepatectomy for patients with colorectal cancer metastases is safe and provides survival benefit equal to that of a first liver resection.
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Affiliation(s)
- Anthony Antoniou
- Imperial College London, Department of Biosurgery and Surgical Technology, St. Mary's Hospital, London, UK
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15
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Yan TD, Lian KQ, Chang D, Morris DL. Management of intrahepatic recurrence after curative treatment of colorectal liver metastases. Br J Surg 2006; 93:854-9. [PMID: 16705643 DOI: 10.1002/bjs.5359] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- T D Yan
- Department of Surgery, University of New South Wales, St George Hospital, Sydney, New South Wales, Australia
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Pessaux P, Lermite E, Brehant O, Tuech JJ, Lorimier G, Arnaud JP. Repeat hepatectomy for recurrent colorectal liver metastases. J Surg Oncol 2006; 93:1-7. [PMID: 16353192 DOI: 10.1002/jso.20384] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Liver resection represents the best and potentially curative treatment for metastatic colorectal cancer (MCC) to the liver. After resection, however, most patients develop recurrent disease, often isolated to the liver. The aim of this study was to determine the value of repeat liver resection for recurrent MCC and to analyze the factors that can predict survival. PATIENTS AND METHODS From January 1992 to October 2002, 42 patients from a group of 168 patients resected for MCC were submitted to 55 repeat hepatectomies (42 second, 11 third, and 2 fourth hepatectomies). Records were retrospectively reviewed. The primary tumor was carcinoma of the colon in 26 patients and carcinoma of the rectum in 16 patients. Liver metastases were synchronous in 24 patients (57.1%). RESULTS There were 25 men and 17 women with the mean age of 63.5 years (range: 34-80). There was no intraoperative or postoperative mortality. The morbidity rates were 9.5%, 14.3%, and 18.2% (P = 0.6) respectively after a first, second, or third hepatectomies. No patients needed reoperation. Operative duration was longer after a second or third hepatectomie than after a first hepatectomie without difference for operative bleeding. Overall 5-year survivals were 33%, 21%, and 36% respectively after a first, second, or third hepatectomies. Factors of prognostic value on univariate analysis included serum carcinoembryonic antigen levels (P = 0.01) during the first hepatectomy, the presence of extrahepatic disease (P = 0.05) and tumor size larger than 5 cm (P = 0.04) during the second hepatectomie. CONCLUSIONS Repeat hepatectomies can provide long-term survival rates similar to those of first hepatectomies.
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Affiliation(s)
- Patrick Pessaux
- Department of Digestive Surgery, Chu Angers, Angers, France.
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17
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Abstract
The liver is a common site of hematogenous metastasis. In the past, patients with liver metastases were often deemed inoperable, and medical therapy conferred only minor survival benefit. However, advances in surgical techniques and chemotherapeutic agents during the past two decades have led to effective treatments for selected patients with metastases to the liver. Up to approximately 80% of the liver can be resected, and partial hepatectomy is now routinely performed with a perioperative mortality rate of <5%. Surgical resection of colorectal cancer metastatic to the liver results in a 5-year survival rate of 40%. These results are expected to improve even further with multimodality approaches that include newer chemotherapy regimens. Liver metastases from other primary tumors, such as neuroendocrine carcinoma and genitourinary tumors, are also treated effectively with liver resection. The indications for surgical treatment of liver metastases are broadening as a variety of novel therapies are being developed, including hepatic artery embolization, hepatic artery infusion of chemotherapy, and radiofrequency ablation.
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Affiliation(s)
- David J Bentrem
- Hepatobiliary Service, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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18
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Tanaka K, Shimada H, Fujii Y, Endo I, Sekido H, Togo S, Ike H. Pre-hepatectomy prognostic staging to determine treatment strategy for colorectal cancer metastases to the liver. Langenbecks Arch Surg 2004; 389:371-9. [PMID: 15605168 DOI: 10.1007/s00423-004-0490-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2003] [Accepted: 04/18/2004] [Indexed: 02/07/2023]
Abstract
BACKGROUND Attempts at identifying prognostic factors after hepatectomy in patients with colorectal liver metastases have not achieved consensus. We investigated prognostic factors ascertainable before hepatectomy for colorectal metastasis. METHOD Clinicopathological data for 149 consecutive patients with colorectal cancer who underwent curative resection of primary lesions and metastatic liver disease at one institution were subjected to multivariate analysis concerning metastatic status and the primary lesion. RESULTS Poorly differentiated adenocarcinoma or mucinous carcinoma as the primary tumor (Poor/muc; P=0.026), marked vascular invasion by the primary tumor (V; P=0.002), bi-lobar liver metastases ( P=0.048), and short doubling time (DT) of the liver tumor ( P=0.028) were characteristics assessable before hepatectomy that independently indicated poorer survival. A four-stage classification based on these factors was related to overall ( P<0.01) and disease-free ( P<0.01) survival rates. No pattern of recurrence site was evident in stage I (patients with no risk factor). Recurrence was usually extrahepatic in stage IV (patients with Poor/muc) but favored the remnant liver in stage II (patients with bi-lobar metastases or short DT) or III (patients with V; P=0.037). Stage III showed more multiple and early hepatic recurrences than stage II, and repeat hepatectomy was less frequent ( P<0.05). CONCLUSION Pre-hepatectomy prognostic staging should help to guide treatment of liver metastases.
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Affiliation(s)
- Kuniya Tanaka
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, 236-0004 Yokohama, Japan.
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Tanaka K, Shimada H, Ohta M, Togo S, Saitou S, Yamaguchi S, Endo I, Sekido H. Procedures of Choice for Resection of Primary and Recurrent Liver Metastases from Colorectal Cancer. World J Surg 2004; 28:482-7. [PMID: 15085394 DOI: 10.1007/s00268-004-7214-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Although liver resection offers the only realistic chance of cure for patients with liver metastases from colorectal cancer, no consensus exists as to the procedure of choice for managing these tumors. Data from 193 patients who underwent hepatectomy for liver metastases from colorectal cancer and 26 of 193 patients who underwent repeat hepatectomy for recurrent metastases were collected. The suitability of resection was evaluated retrospectively based on known risk factors for recurrence and patterns of recurrence. On multivariate analysis, a positive surgical margin (SM+) was the only risk factor for recurrence after the initial resection (p < 0.01). SM+ (p < 0.01) and nonanatomic resection (p < 0.05) that was less than a sectionectomy (p < 0.05) were risk factors for recurrence after repeat hepatectomy. Multiple tumors (four or more) was the most common pattern of recurrence after initial hepatectomy, and recurrence close to the line of resection was most common after repeat hepatectomy. Based on tumor doubling times, recurrence after initial hepatectomy seemed to originate from the primary colorectal lesion, whereas recurrence after repeat hepatectomy was derived from a hepatic metastasis. Retrospective analysis suggests that hepatectomy with clear surgical margins is more important than anatomic resection for initial hepatectomy, and at least sectionectomy is necessary for repeat hepatectomy.
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Affiliation(s)
- Kuniya Tanaka
- Department of Surgery II, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, 236-0004 Yokohama, Japan
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Tanaka K, Shimada H, Miura M, Fujii Y, Yamaguchi S, Endo I, Sekido H, Togo S, Ike H. Metastatic tumor doubling time: most important prehepatectomy predictor of survival and nonrecurrence of hepatic colorectal cancer metastasis. World J Surg 2004; 28:263-70. [PMID: 14961200 DOI: 10.1007/s00268-003-7088-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We determined the relative value of the metastatic colorectal cancer doubling time as a predictor of recurrence and survival after hepatectomy in comparison with other established predictors. Consecutive patients who underwent hepatic resection ( n = 144) for colorectal cancer liver metastases were studied retrospectively to identify factors that influence overall survival and recurrence in the remnant liver. Overall 5-year survival and nonrecurrence rates were 49.8% and 50.8%, respectively. By multivariate analysis, large liver tumors ( p = 0.038), p53 expression by the liver tumor (p = 0.011), and a short liver metastasis doubling time (< or = 45 days, p = 0.013) negatively affected survival; doubling times > 45 days (adjusted relative risk 0.06; p < 0.001) positively influenced disease-free survival. In patients with remnant liver recurrence, a short doubling time was associated with short disease-free intervals (7.3 +/- 6.2 months), multiple metastases (63.6%), and fewer attempts at repeat hepatectomy (22.7%). The doubling time determines tumor size and reflects the patient's immune and nutritional status. A short doubling time is the most reliable risk factor for multiple metastases, early recurrence, and poor prognosis. Further studies with a larger number of patients are needed to confirm this conclusion.
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Affiliation(s)
- Kuniya Tanaka
- Department of Surgery II, Yokohama City University School of Medicine, 4-57 Urafune-cho, Minami-ku, 232-0024 Yokohama, Japan
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Adam R, Pascal G, Azoulay D, Tanaka K, Castaing D, Bismuth H. Liver resection for colorectal metastases: the third hepatectomy. Ann Surg 2003; 238:871-83; discussion 883-4. [PMID: 14631224 PMCID: PMC1356169 DOI: 10.1097/01.sla.0000098112.04758.4e] [Citation(s) in RCA: 282] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the risk, the benefit, and the main factors of prognosis of third liver resections for recurrent colorectal metastases. SUMMARY BACKGROUND DATA Recurrence following liver resection is frequent after a first as after a second hepatectomy. Second liver resections yield a similar survival to that obtained with first liver resection, but little is known about third hepatectomy. METHODS This study reports a retrospective analysis of 60 patients who underwent a third liver resection for colorectal metastases in a 16-year experience (1984-2000). Patients were identified from a prospective database that collected 615 consecutive patients who cumulated 883 hepatectomies (615 first, 199 second, 60 thirds, and 9 fourths). Third hepatic resections were compared with first and second procedures, in terms of risk and benefit for the patient. Prognostic factors of survival after third hepatic resection were determined by univariate and multivariate analysis. RESULTS A third hepatic resection was attempted in 68 of 115 of liver recurrences following a second hepatectomy (59%) and achieved in 88% of the cases (60 of 68). There was no intraoperative mortality or postoperative deaths within the 2 months. Fifteen patients developed postoperative complications (25%), a rate similar to that of first and second hepatectomies. Overall 5-year survival was 32% and disease-free survival was 17% after the third resection. Survival compared favorably to that of patients with recurrence following a second hepatectomy who could not be operated (5% at 3 years) or who failed to be resected (15% at 2 years, P = 0.0001). It also compared favorably to that of patients who underwent only two hepatectomies (5-year survival, 27%). When estimated from the time of first hepatectomy, survival was 65% at 5 years for the 60 patients who underwent three hepatic resections. Concomitant extrahepatic tumor was treated in 16 patients (27%) by 11 abdominal procedures and 5 pulmonary resections. By multivariate analysis, tumor size > 30 mm for first liver metastases, presence of extrahepatic tumor at second hepatectomy, and noncurative pattern of third liver resection were independent prognostic factors of reduced survival. CONCLUSIONS Third hepatectomy is safe and provides an additional benefit of survival similar to that of first and second liver resections. It is worthwhile when curative and integrated into an intended multimodal strategy of tumoral eradication.
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Affiliation(s)
- René Adam
- Centre Hépato-Biliaire, Hopital Paul Brousse, 14 Av PV Couturier, 94800 Villejuif, France.
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Tepper JE, O'Connell M, Hollis D, Niedzwiecki D, Cooke E, Mayer RJ. Analysis of surgical salvage after failure of primary therapy in rectal cancer: results from Intergroup Study 0114. J Clin Oncol 2003; 21:3623-8. [PMID: 14512393 DOI: 10.1200/jco.2003.03.018] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Intergroup Study 0114 was designed to study the effect of various chemotherapy regimens delivered after potentially curative surgical resection of T3, T4, and/or node-positive rectal cancer. A subset analysis was undertaken to investigate the prevalence and influence of salvage therapy among patients with recurrent disease. PATIENTS AND METHODS Adjuvant therapy consisted of two cycles of fluorouracil (FU)-based chemotherapy followed by pelvic irradiation with chemotherapy and two more cycles of chemotherapy after radiation therapy. A total of 1,792 patients were entered onto the study and 1,696 were assessable. After a median of 8.9 years of follow-up, 715 patients (42%) had disease recurrence, and an additional 10% died without evidence of disease. Five hundred patients with follow-up information available had a single organ or single site of first recurrence (73.5% of all recurrences). RESULTS A total of 171 patients (34% of those with a single organ or single site of recurrence) had a potentially curative resection of the metastatic or locally recurrent disease. Single-site first recurrences in the liver, lung, or pelvis occurred in 448 patients (90% of the single-site recurrences), with 159 (35%) of these undergoing surgical resection for attempted cure. Overall survival differed significantly between the resected and nonresected groups (P <.0001), with overall 5-year probabilities of.27 and.06, respectively. Controlling for worst performance status at the time of recurrence does not alter this relationship. Patients who underwent salvage surgery had significantly increased survival (P <.001) for each site. CONCLUSION Attempted surgical salvage of rectal cancer recurrence is performed commonly in the United States. The chance of a long-term cure with such intervention is approximately 27%.
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Affiliation(s)
- J E Tepper
- Department of Radiation Oncology, Campus Box No. 7512, University of North Carolina, Chapel Hill, NC 27599-7512, USA.
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Petrowsky H, Gonen M, Jarnagin W, Lorenz M, DeMatteo R, Heinrich S, Encke A, Blumgart L, Fong Y. Second liver resections are safe and effective treatment for recurrent hepatic metastases from colorectal cancer: a bi-institutional analysis. Ann Surg 2002; 235:863-71. [PMID: 12035044 PMCID: PMC1422517 DOI: 10.1097/00000658-200206000-00015] [Citation(s) in RCA: 247] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the value of repeat liver resection for recurrent colorectal metastases to the liver. SUMMARY BACKGROUND DATA Liver resection represents the best and a potentially curative treatment for metastatic colorectal cancer to the liver. After resection, however, most patients develop recurrent disease, often isolated to the liver. METHODS This study reports the combined experience of repeat liver resection for recurrent liver metastases at an American and a European surgical oncology center. Patients were identified from prospective databases and records were retrospectively reviewed. A total of 126 patients (American n = 96, 1986-2001; European n = 30, 1985-1999) underwent repeat liver resection. Patient characteristics were similar in the two institutions. Median follow-up from first liver resection was 88 and 105 months, respectively. RESULTS Operations performed included 90 minor resections and 36 resections of a lobe or more. The 1-, 3-, and 5-year survival rates were 86%, 51%, and 34%. There were 19 actual 5-year survivors to date. By multivariate regression analysis (proportional hazard model), more than one lesion and tumor size larger than 5 cm were independent prognostic indicators of reduced survival. The interval between the first and second liver resection was not predictive of outcome. CONCLUSIONS Repeat liver resection for colorectal liver metastases is safe. Patients with a low tumor load are the best candidates for a repeat resection. In well-selected patients, further resection of the liver can provide prolonged survival after recurrence of colorectal liver metastases.
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Affiliation(s)
- Henrik Petrowsky
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Schlag PM, Benhidjeb T, Stroszczynski C. Resection and local therapy for liver metastases. Best Pract Res Clin Gastroenterol 2002; 16:299-317. [PMID: 11969240 DOI: 10.1053/bega.2002.0286] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In 30-50% of patients the liver is a preferred site of distant disease for many malignant tumours. Due to the high incidence, most of the available data relate to metastases arising from colorectal primaries. Surgical resection is at present the only treatment offering potential cure. The achievable 5-year survival rate is 30%. However, only 10-15% of patients with colorectal liver metastases can undergo potentially curative liver resection. Therefore, accurate staging is an important prerequisite in selecting patients who would benefit from surgery. Recurrence of hepatic metastases after potentially curative resection occurs in up to 60% of the cases. Results demonstrate that re-resection of liver metastases can provide long-term survival rates in a carefully selected group of patients without extrahepatic disease. Because of the high rate of recurrences following an apparently curative resection several authors investigated the use of adjuvant chemotherapy (systemic, intraportal, and hepatic arterial infusion). Until recently none had shown effectiveness. Pre-operative chemotherapy seems to be a promising approach in patients with liver metastases initially considered unsuitable for radical surgery. Recently, neoadjuvant chemotherapy has been proposed as an alternative approach to conventional surgery as initial management with the aim of improving the results in resectable liver metastases. Interventional strategies (ethanol injection, cryosurgery, laser-induced thermotherapy, radio-frequency ablation) and combined modalities (surgical/interventional) are additive methods which may help to improve treatment results in the future.
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Affiliation(s)
- P M Schlag
- Klinik für Chirurgie und Chirurgische Onkologie, Lindenberger Weg 80, Berlin D-13122, Germany
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Braga L, Semelka RC, Pedro MS, de Barros N. Post-treatment malignant liver lesions. MR imaging. Magn Reson Imaging Clin N Am 2002; 10:53-73. [PMID: 11998575 DOI: 10.1016/s1064-9689(03)00049-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
MR imaging is very accurate in the diagnosis and staging of tumors and in surgical planning. MR imaging is also an excellent method for evaluation of the liver after surgical resection, systemic or local tumor therapies, and liver transplantation. It permits early recognition of complications and the presence of recurrent tumor, providing an opportunity to repeat treatment or use alternative treatment. Surgical resection remains the standard therapy for treating liver metastases. The relatively small number of patients who are candidates for curative resection have provided impetus for the implementation and improvement of other techniques. The variety of techniques and the sensitivity for contrast enhancement have made MR imaging an ideal method to follow the response of tumors to various treatment approaches. The appearance of tumor recurrence and the response to treatment are relatively consistently shown on MR images; however, the time course of change in lesion appearance has not been fully elucidated, particularly in the setting of chemotherapy. Evaluating the response to chemotherapy is rendered complex because of the longer duration of the therapy, the types of response that various chemotherapeutic agents engender, the method of action of this therapy and the time of imaging in relation to therapy. The various local therapies share some general principles of action, and many have similar MR imaging findings. Some local therapies are effective only with certain malignancies (e.g., alcohol therapy and HCC), whereas other therapies are more limited because of the size of the tumor kill zone (e.g., interstitial laser therapy). We are in the early stages of using MR imaging to guide local therapies and to monitor response during treatment in real time. This appears to be an important future direction for MR imaging. The role of MR imaging in liver transplantation involves pre- and postoperative investigation of both donors (in the case of living-related transplantation) and recipients. These issues are described further in the section on MR imaging of liver transplantation.
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Affiliation(s)
- Larissa Braga
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Muratore A, Polastri R, Bouzari H, Vergara V, Ferrero A, Capussotti L. Repeat hepatectomy for colorectal liver metastases: A worthwhile operation? J Surg Oncol 2001; 76:127-32. [PMID: 11223839 DOI: 10.1002/1096-9098(200102)76:2<127::aid-jso1023>3.0.co;2-z] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVES After curative resection of hepatic colorectal metastases, 10-20% of patients experience a resectable hepatic recurrence. We wanted to assess the expected risk-to-benefit ratio in comparison to first hepatectomy and to determine the prognostic factors associated with survival. METHODS Twenty-nine patients from a group of 152 patients resected for colorectal liver metastases underwent 32 repeat hepatectomies. RESULTS In-hospital mortality was 3.5% (1/29 patients); the morbidity after repeat hepatectomy was lower than that after first hepatic resection. Combined extrahepatic surgery was performed on 34.5% of repeat hepatectomies vs. 6.9% of first hepatectomies (P = 0.01). Overall actuarial 3-year survival was 35.1%: four patients have survived more than 3 years and one survived for more than 5 years. The number of hepatic metastases and the carcinoembryonic antigen (CEA) serum levels were significant prognostic factors on univariate analysis. The synchronous resection of hepatic and extrahepatic disease was not associated with a lower survival rate when compared with that of patients without extrahepatic localization: three patients of the former group are alive and disease-free at more than 2 years. CONCLUSIONS Repeat hepatic resection can provide long-term survival rates similar to those of first liver resection, with comparable mortality and morbidity. The presence of resectable extrahepatic disease must not be an absolute contraindication to synchronous hepatectomy because long-term survival is possible.
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Affiliation(s)
- A Muratore
- 1st Department of Surgery, Ospedale Mauriziano "Umberto I" Torino, Italy.
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Abstract
The liver is a common site of metastasis from a variety of tumors. In many cases, liver resection for metastatic cancer provides the only chance for a cure and can be performed with less than 5% mortality and acceptable morbidity. The 5-year survival following liver resection for colorectal metastasis is reported in many large series to be 25% to 37%. The data regarding liver resection for other metastatic tumor types are less clear. However, resection for selected tumors, such as neuroendocrine and renal cell, can provide durable palliation and/or cure. We will review important prognostic factors used to guide the selection of patients for resection of metastatic disease and make recommendations for imaging studies and follow-up routines. The role of adjuvant regional and systemic chemotherapy for resectable metastatic disease is also discussed. Methods for ablating unresectable metastatic tumors may prove to be useful adjuncts to current therapies.
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Affiliation(s)
- M D McCarter
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Rodgers MS, McCall JL. Surgery for colorectal liver metastases with hepatic lymph node involvement: a systematic review. Br J Surg 2000; 87:1142-55. [PMID: 10971419 DOI: 10.1046/j.1365-2168.2000.01580.x] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Liver resection for colorectal metastases is the only known treatment associated with long-term survival; extrahepatic disease is usually considered a contraindication to such treatment. However, some surgeons do not regard spread to the hepatic lymph nodes as a contraindication provided that these nodes can be excised adequately. A systematic review of the literature was undertaken to address this issue. METHODS An electronic search using Medline, Cancerlit and Embase databases was performed for studies reporting liver resection for colorectal metastases from 1964 to 1999. Data were extracted from papers reporting outcome for patients with positive hepatic nodes and analysed according to predetermined criteria. RESULTS Fifteen studies were identified that gave survival data on 145 node-positive patients. Five patients were reported to have survived 5 years after liver resection; one was disease free, two had recurrent disease and the disease status was not described in the remaining two. Five studies containing 83 patients specified a formal lymph node dissection as part of the surgical procedure and four of the five node-positive 5-year survivors were from these studies. CONCLUSION There are few 5-year survivors after liver resection, with or without lymph node dissection, for colorectal hepatic metastases involving the hepatic lymph nodes.
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Affiliation(s)
- M S Rodgers
- Department of Surgery, University of Auckland, Auckland, New Zealand
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Imamura H, Kawasaki S, Miyagawa S, Ikegami T, Kitamura H, Shimada R. Aggressive surgical approach to recurrent tumors after hepatectomy for metastatic spread of colorectal cancer to the liver. Surgery 2000; 127:528-35. [PMID: 10819061 DOI: 10.1067/msy.2000.104746] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Liver resection is currently accepted as the only potential cure for patients with metastases of colorectal tumors in the liver. However, cancer will recur in more than 70% of patients. METHODS In the 7 years to December 1997, 60 patients underwent liver resections for colorectal metastases at our institute. Of these, 20 patients had repeated surgical resections for recurrent disease of the liver and other organs. Another 2 patients had undergone previous hepatectomy elsewhere. The clinical data for these patients were reviewed. RESULTS The median interval between the 2 resections was 16 months. Eighteen hepatectomies, 6 lung resections, and 1 pancreatoduodenectomy were performed in 22 patients. Operative mortality and complication rates were 0% and 18%, respectively. At a median follow-up of 25 months after repeated resection, the survival rate in these patients was 73% at 2 years (12 of 16 evaluable patients are surviving) and 22% at 5 years (2 of 10 evaluable patients are surviving); the median survival time was 44 months. CONCLUSIONS Repeated resections for recurrent colorectal metastases yield comparable results to first liver resections in operative mortality and morbidity rates, survival time, and pattern of recurrence. Although the number of patients surviving more than 5 years is still limited, the absence of other proven treatments supports the concept of an aggressive resectional approach for these patients.
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Affiliation(s)
- H Imamura
- First Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
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Tono T, Hasuike Y, Ohzato H, Takatsuka Y, Kikkawa N. Limited but definite efficacy of prophylactic hepatic arterial infusion chemotherapy after curative resection of colorectal liver metastases. Cancer 2000. [DOI: 10.1002/(sici)1097-0142(20000401)88:7<1549::aid-cncr8>3.0.co;2-k] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Yamamoto J, Kosuge T, Shimada K, Yamasaki S, Moriya Y, Sugihara K. Repeat liver resection for recurrent colorectal liver metastases. Am J Surg 1999; 178:275-81. [PMID: 10587183 DOI: 10.1016/s0002-9610(99)00176-2] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND This study aimed to delineate the role of surgery for recurrent colorectal cancer in the liver and to identify prognosticators for better patient selection and outcome. METHODS Data from 90 repeat hepatectomies (second = 75; third = 12; fourth = 3) for recurrent colorectal cancer were collected. RESULTS After the second hepatectomy, the 3-and 5-year survival rates were 48% and 31%, respectively. Twenty-seven percent (20 of 75) of patients are alive without recurrence after a median follow-up of 27 months, and 9 survived more than 5 years. Four or more tumors, positive regional lymph node metastases, concomitant extrahepatic disease, and residual tumor were independent poor prognostic factors after the second hepatectomy. CONCLUSIONS Repeat hepatectomy should be applied for recurrent colorectal cancer, when curative removal of the tumor is possible, although the benefit from treatment was limited in a patient with regional lymph node metastases, 4 or more metastases, or extrahepatic disease.
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Affiliation(s)
- J Yamamoto
- Department of Surgery, National Cancer Center Hospital, Tokyo, Japan
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Abstract
BACKGROUND More than 40% of patients who undergo curative resection of advanced colorectal carcinoma can be expected to have recurrence of the disease. The most frequent sites of recurrence are the liver (33% of patients) and lung (22%). Interest has therefore focused on treating hepatic or pulmonary metastases, or both, to improve the outcomes of these patients. Although surgical resection has become an increasingly accepted treatment for resectable localized hepatic or localized pulmonary metastases from colorectal carcinoma, the value of aggressive surgery for the removal of both hepatic and pulmonary metastases from patients with primary colorectal carcinoma remains to be clarified. METHODS Data on 30 patients who had undergone resection of both hepatic and pulmonary metastases from colorectal carcinoma were included in the study. RESULTS Independent, significant prognostic features were found to be the time that hepatic or pulmonary metastases occurred and the distribution of pulmonary metastases. Median survival times were 30 months (range, 7-108 months) after resection of both hepatic and pulmonary metastases and 48.5 months (range, 11-149 months) after excision of the primary colorectal tumor. Actuarial 1-, 3-, and 5-year survival after resection of both hepatic and pulmonary metastases was 86.7%, 49.3%, and 43.8%, respectively. No perioperative mortality occurred. There were three cases of minor morbidity, which the authors considered acceptable. CONCLUSIONS Resection of both hepatic and pulmonary metastases from colorectal carcinoma may help to prolong the survival of a small group of patients with these metastases.
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Affiliation(s)
- S Murata
- Department of Surgery, National Cancer Center Hospital, Tokyo, Japan
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Eberwein M, Prommegger R, Oberwalder M, Unger A, Klingler A, Glaser K, Tschmelitsch J. Resection of hepatic metastases from colorectal cancer. Eur Surg 1998. [DOI: 10.1007/bf02620215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Rougier P, Neoptolemos JP. The need for a multidisciplinary approach in the treatment of advanced colorectal cancer: a critical review from a medical oncologist and surgeon. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 1997; 23:385-96. [PMID: 9393564 DOI: 10.1016/s0748-7983(97)93715-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Over the last 10 years important advances have been made in the treatment of patients with advanced colorectal cancer, particularly with surgery either alone or in combination with radiotherapy. Furthermore, despite early scepticism, several chemotherapy studies have now reported significant clinical benefits with 5-FU-based regimens and promising results have also been reported with newer agents such as raltitrexed and irinotecan. Taken together these advances now enable a significant proportion of patients to undergo treatment which will improve their quality of life, prolong survival and even result in cure in certain cases. Patients with advanced colorectal cancer can only benefit from these important advances, however, if a truly multidisciplinary approach to patient care is adopted which requires integration of the roles of the surgeon, medical oncologist and radiotherapist.
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Affiliation(s)
- P Rougier
- Hôpital Ambroise Pare, Boulogne, France
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VanderMeer TJ, Callery MP, Meyers WC. The approach to the patient with single and multiple liver metastases, pulmonary metastases, and intra-abdominal metastases from colorectal carcinoma. Hematol Oncol Clin North Am 1997; 11:759-77. [PMID: 9257154 DOI: 10.1016/s0889-8588(05)70459-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Recurrent colorectal carcinoma constitutes a major health care problem, with 90,000 patients diagnosed annually with metastatic disease. Recent advances have offered treatment to selected patients with liver, lung, and intra-abdominal metastases. Resection of liver secondary tumors improves 5-year survival from 0% to approximately 30% and offers the only possibility for cure. As experience mounts, hepatic surgery can be performed with quite acceptable morbidity and mortality. Adjuvant therapies are being developed that may improve results with surgery alone. Cryoablation is a new technique that appears to effectively eradicate liver tumors, but its role remains to be defined. In patients with unresectable disease, the benefit of hepatic artery infusion of chemotherapy is unproven. Resection of pulmonary metastases significantly improves survival in patients with solitary nodules. Consistent data regarding the benefit of pulmonary metastatectomy in patients with multiple nodules are not available. Combined cytoreductive surgery and intraperitoneal hyperthermic chemotherapy is being investigated as a treatment for peritoneal carcinomatosis from colorectal cancer. Although selected patients may benefit, this combined treatment modality appears to be less effective in patients with colorectal cancer than with other types of cancer.
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Affiliation(s)
- T J VanderMeer
- Department of Surgery, University of Massachusetts Medical Center, Worcester, USA
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Tuttle TM, Curley SA, Roh MS. Repeat hepatic resection as effective treatment of recurrent colorectal liver metastases. Ann Surg Oncol 1997; 4:125-30. [PMID: 9084848 DOI: 10.1007/bf02303794] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- T M Tuttle
- Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, USA
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Surgical management of recurrence after resection of colorectal liver metastases. ACTA ACUST UNITED AC 1997. [DOI: 10.1007/bf01211350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Millikan KW, Staren ED, Doolas A. Invasive therapy of metastatic colorectal cancer to the liver. Surg Clin North Am 1997; 77:27-48. [PMID: 9092116 DOI: 10.1016/s0039-6109(05)70531-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Resection, when possible, is still the best hope for cure of colorectal metastasis to the liver. Poor prognostic indicators for survival include heavy tumor burden, the presence of extrahepatic disease, synchronous metastasis, and the inability to perform resection with a 1-cm margin. Questionable poor prognostic indicators include multiple metastases (more than three), bilobar disease, and the need to transfuse patients during resection. Preoperatively, a patient must be evaluated for the extent of liver disease and the presence of extrahepatic disease with a CT of the abdomen and routine studies of the chest. Intraoperatively, a surgeon should be able to perform or obtain ultrasonography of the liver to detect occult metastases and delineate anatomy. The surgeon should be experienced in wedge, segmental, and lobar resection. Equipment for cryotherapy and arterial infusion devices should be available, and staff experienced in these modalities should be present. If all of these factors are present, the options for the invasive treatment of colorectal metastasis to the liver can be carried out in a manner that should provide the most benefit at a low morbidity to this population of patients.
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Affiliation(s)
- K W Millikan
- Department of Surgery, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois, USA
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Adam R, Bismuth H, Castaing D, Waechter F, Navarro F, Abascal A, Majno P, Engerran L. Repeat hepatectomy for colorectal liver metastases. Ann Surg 1997; 225:51-60; discussion 60-2. [PMID: 8998120 PMCID: PMC1190605 DOI: 10.1097/00000658-199701000-00006] [Citation(s) in RCA: 243] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The authors assess the long-term results of repeat hepatectomies for recurrent metastases of colorectal cancer and determine the factors that can predict survival. SUMMARY BACKGROUND DATA Safer techniques of hepatic resection have allowed surgeons to consider repeat hepatectomy for colorectal metastases in an increasing number of patients. However, higher operative bleeding and increased morbidity have been reported after repeat hepatectomies, and the long-term benefit of these procedures needs to be evaluated. STUDY POPULATION Sixty-four patients from a group of 243 patients resected for colorectal liver metastases were submitted to 83 repeat hepatectomies (64 second, 15 third, and 4 fourth hepatectomies). Combined extrahepatic surgery was performed in 21 (25%) of these 83 repeat hepatectomies. RESULTS There was no intraoperative or postoperative mortality. Operative bleeding was not significantly increased in repeat hepatectomies as compared to first resections. Morbidity and duration of hospital stay were comparable to first hepatectomies. Overall and disease-free survival after a second hepatectomy were 60% and 42%, respectively, at 3 years and 41% and 26%, respectively, at 5 years. Factors of prognostic value on univariate analysis included the curative nature of first and second hepatectomies (p = 0.04 and p = 0.002, respectively), an interval between the two procedures of more than 1 year (p = 0.003), the number of recurrent tumors (p = 0.002), serum carcinoembryonic antigen levels (p = 0.03), and the presence of extrahepatic disease (p = 0.03). Only the curative nature of the second hepatectomy and an interval of more than 1 year between the two procedures were independently related to survival on multivariate analysis. CONCLUSIONS Repeat hepatectomies can provide long-term survival rates similar to those of first hepatectomies, with no mortality and comparable morbidity. Combined extrahepatic surgery can be required to achieve tumor eradication. Repeat hepatectomies appear worthwhile when potentially curative.
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Affiliation(s)
- R Adam
- Liver Transplant Unit, Hôpital Paul Brousse, Université Paris Sud, Villejuif, France
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Bines SD, Doolas A, Jenkins L, Millikan K, Roseman DL. Survival after repeat hepatic resection for recurrent colorectal hepatic metastases. Surgery 1996; 120:591-6. [PMID: 8862365 DOI: 10.1016/s0039-6060(96)80004-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND This is a retrospective clinical study done to examine survival of patients undergoing repeat hepatic resection for recurrent colorectal hepatic metastases. METHODS The records of 131 patients undergoing hepatic resection for metastatic colorectal cancer were reviewed. Curative resection was performed in 107 of these patients. Thirty-one experienced recurrences confined to the liver. Thirteen (13 of 107, 12%) of them underwent resection and make up the study population. RESULTS The eight men (62%) and five women (38%) had a median age of 60 years (range, 32 to 75 years). In 30% of patients recurrence developed near the original resection site. In 70% the recurrences were remote from the original site. The patients underwent a total of six wedge resections, two left lateral segmentectomies, three right lobectomies, and two trisegmentectomies. Average blood loss was 2995 cc; average hospital stay was 17.2 days. Morbidity was 23% (3 of 13); mortality was 8% (1 of 13). Four patients died of recurrent disease, with a mean disease-free survival of 9.7 months (median, 7.5 months; range, 3 to 21 months) and mean total survival of 39 months (median, 24 months; range, 8 to 99 months). One of these patients had a second recurrence resected at month 21 and lived an additional 78 months. Seven patients were alive with no evidence of disease, with a mean follow-up time of 34.9 months (median, 14 months; range, 1 to 186 months). Actual 5-year survival was 23% (3 of 13). Actual disease-free 5-year survival was 15% (2 of 13). CONCLUSIONS In properly selected patients morbidity, mortality, and survival after repeat resection are similar to those after initial resection.
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Affiliation(s)
- S D Bines
- Department of General Surgery, Rush-Presbyterian-St. Luke's Medical Center, Chicago, III., USA
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Wang JY, Chiang JM, Jeng LB, Changchien CR, Chen JS, Hsu KC. Resection of liver metastases from colorectal cancer: are there any truly significant clinical prognosticators? Dis Colon Rectum 1996; 39:847-51. [PMID: 8756838 DOI: 10.1007/bf02053981] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE This study was designed to evaluate the prognostic significance of various prognostic factors affecting recurrence after resection of colorectal hepatic metastases. PATIENTS AND METHODS Records of 54 patients who had hepatic resection between 1986 and 1993 for metastatic liver tumor from colorectal cancer were reviewed. Factors analyzed were those reported to be of prognostic significance in other studies, including gender, primary tumor site, Dukes stage, diagnostic interval, grade, preoperative carcinoembryonic antigen (CEA) level, number of metastases, size of metastases, distribution of metastases, type of resection, resection margin, and estimated blood loss. RESULTS Average follow-up of surviving patients was 28 (range, 12-89) months. Average survival time from date of hepatic resection was 26 months, with an estimated actuarial survival rate of 25.5 percent at five years. Using the multivariate analysis of factors, gender and preoperative CEA level were shown to be significantly related to overall survival (P = 0.0455 and 0.054, respectively). Cancer of the right side colon had significant correlation with hepatic "recurrence" (P = 0.0071). CONCLUSIONS Female patients and those with peroperative CEA values higher than 20 ng/ml have a better chance of survival following hepatic resection. Cancer of the right colon has a greater tendency for hepatic recurrence than that of the left colon.
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Affiliation(s)
- J Y Wang
- Department of Surgery Chang Gung College of Medicine and Technology Chang Gung Memorial Hospital Taipei, Taiwan, Republic of China
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Abstract
Almost one-third of patients dying from colorectal cancer have tumor limited to the liver. Systemic chemotherapy is the appropriate palliative management of patients with metastases to the liver and other sites. For many patients with isolated hepatic metastases, systemic chemotherapy is also the most appropriate treatment. However, results with systemic chemotherapy indicate that one-third or less of patients will respond to such treatments, and long-term survival is rare. In this report we provide information concerning the natural history of colorectal hepatic metastases, followed by the expected benefits with systemic chemotherapy. This information provides background for the regional therapeutic strategies of surgical resection, cryosurgery, and hepatic artery chemotherapy. We discuss the selection factors appropriate for such treatments, morbidity and mortality, and the potential long-term benefits of such approaches. The last section focuses on surgical considerations in hepatic resection and hepatic artery chemotherapy.
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Affiliation(s)
- Y Fong
- Colorectal Service, Department of Surgery, Gastrointestinal Oncology Service, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Abstract
Patients with cancer recurrence limited to the liver alone after a first liver resection may be candidates for a repeat resection. Some 191 second and ten third liver resections for recurrent colorectal metastases, and 128 second and ten third liver resections for recurrent hepatocellular carcinoma (HCC), were evaluated after reviewing the literature. The 5-year survival rate after second liver resection for colorectal metastases was 26 per cent with a median survival time of 30 months. Mortality and morbidity rates were 1.2 and 27.4 per cent respectively. The 5-year survival rate after second resection for HCC was 40 per cent with a median survival time of 40 months. The operative mortality rate was 2.3 per cent; morbidity occurred in 13 per cent of patients with HCC. Survival after primary colorectal resection was significantly better for patients with metachronous metastases than for those with synchronous disease; survival correlated with a long interval between the first and second liver resection (in both colorectal liver cancer and HCC). Repeated liver resection may be performed in selected patients and yield a similar survival to that obtained after first liver resection.
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Affiliation(s)
- N Neeleman
- Department of Surgery, Lund University Hospital, Sweden
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Pinson CW, Wright JK, Chapman WC, Garrard CL, Blair TK, Sawyers JL. Repeat hepatic surgery for colorectal cancer metastasis to the liver. Ann Surg 1996; 223:765-73; discussion 773-6. [PMID: 8645050 PMCID: PMC1235229 DOI: 10.1097/00000658-199606000-00015] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The authors addressed whether a repeat hepatic operation is warranted in patients with recurrent isolated hepatic metastases. Are the results as good after second operation as after first hepatic operation? SUMMARY BACKGROUND DATA Five-year survival after initial hepatic operation for colorectal metastases is approximately 33%. Because available alternative methods of treatment provide inferior results, hepatic resection for isolated colorectal metastasis currently is well accepted as the best treatment option. However, the main cause of death after liver resection for colorectal metastasis is tumor recurrence. METHODS Records of 95 patients undergoing initial hepatic operation and 10 patients undergoing repeat operation for isolated hepatic metastases were reviewed for operative morbidity and mortality, survival, disease-free survival, and pattern of failure. The literature on repeat hepatic resection for colorectal metastases was reviewed. RESULTS The mean interval between the initial colon operation and first hepatic resection was 14 months. The mean interval between the first and second hepatic operation was 17 months. Operative mortality was 0%. At a mean follow-up of 33 +/- 27 months, survival in these ten patients was 100% at 1 year and 88% +/- 12% at 2 years. Disease-free survival at 1 and 3 years was 60% +/- 16% and 45% +/- 17%, respectively. After second hepatic operation, recurrence has been identified in 60% of patients at a mean of 24 +/- 30 months (median 9 months). Two of these ten patients had a third hepatic resection. Survival and disease-free survival for the 10 patients compared favorably with the 95 patients who underwent initial hepatic resection. CONCLUSIONS Repeat hepatic operation for recurrent colorectal metastasis to the liver yields comparable results to first hepatic operations in terms of operative mortality and morbidity, survival, disease-free survival, and pattern of recurrence. This work helps to establish that repeat hepatic operation is the most successful form of treatment for isolated recurrent colorectal metastases.
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Affiliation(s)
- C W Pinson
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Wanebo HJ, Chu QD, Avradopoulos KA, Vezeridis MP. Current perspectives on repeat hepatic resection for colorectal carcinoma: a review. Surgery 1996; 119:361-71. [PMID: 8643998 DOI: 10.1016/s0039-6060(96)80133-4] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recurrence occurs in 65% to 85% of patients after initial hepatectomy for metastases from colorectal cancer. Approximately one half of these have liver metastases, and in 20% to 30% only the liver is involved. Opportunity for resection is frequently limited because of diffuse liver disease or extrahepatic extension, and only 10% to 25% of these patients have conditions amenable to resection. This current review is focused on the rationale, indications, and results of resection of hepatic metastases from colorectal cancer. METHODS The major series of liver resection were reviewed, and the cases of repeat resections were culled out. In addition to standard clinical parameters, the indications and timing after initial resection and the survival and subsequent recurrence after repeat resection were recorded. RESULTS A comprehensive review of the 28 series showed that the mean interval between the first and second liver varied from 9 to 33 months and was about 17.5 months in the two largest series. The median survival in series reporting 10 or more patients was 19 months (mean, 24 months), which is comparable to data in single resection series. In the large French Association series containing 1626 patients with single resections and 144 patients with two resections, the 5-year survival was 25% and 16%, respectively. The recurrence rate after repeat resection is high (greater than 60%), and one half are in the liver. The prognostic factors favoring repeat resection are variable, but they include absence of extrahepatic extension of tumor and a complete resection of the liver metastases. CONCLUSIONS Repeat hepatic liver resection for metastatic colorectal cancer in carefully selected patients appears warranted in view of reasonable survival expectations, which approach that of single liver resection. Risk of recurrence is high, however, suggesting the need for rigorous preoperative and intraoperative assessment and postoperative adjuvant therapy
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Affiliation(s)
- H J Wanebo
- Division of Surgical Oncology, Brown University School of Medicine, Providence, Rhode Island 02908, USA
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