Prospective study of microscopic lymph node involvement of the hepatic pedicle during curative hepatectomy for colorectal metastases

Value of multiple models of diffusion-weighted imaging to predict hepatic lymph node metastases in colorectal liver metastases patients

BACKGROUND

About 10%-31% of colorectal liver metastases (CRLM) patients would concomitantly show hepatic lymph node metastases (LNM), which was considered as sign of poor biological behavior and a relative contraindication for liver resection. Up to now, there's still lack of reliable preoperative methods to assess the status of hepatic lymph nodes in patients with CRLM, except for pathology examination of lymph node after resection.

AIM

To compare the ability of mono-exponential, bi-exponential, and stretched-exponential diffusion-weighted imaging (DWI) models in distinguishing between benign and malignant hepatic lymph nodes in patients with CRLM who received neoadjuvant chemotherapy prior to surgery.

METHODS

In this retrospective study, 97 CRLM patients with pathologically confirmed hepatic lymph node status underwent magnetic resonance imaging, including DWI with ten b values before and after chemotherapy. Various parameters, such as the apparent diffusion coefficient from the mono-exponential model, and the true diffusion coefficient, the pseudo-diffusion coefficient, and the perfusion fraction derived from the intravoxel incoherent motion model, along with distributed diffusion coefficient (DDC) and α from the stretched-exponential model (SEM), were measured. The parameters before and after chemotherapy were compared between positive and negative hepatic lymph node groups. A nomogram was constructed to predict the hepatic lymph node status. The reliability and agreement of the measurements were assessed using the coefficient of variation and intraclass correlation coefficient.

RESULTS

Multivariate analysis revealed that the pre-treatment DDC value and the short diameter of the largest lymph node after treatment were independent predictors of metastatic hepatic lymph nodes. A nomogram combining these two factors demonstrated excellent performance in distinguishing between benign and malignant lymph nodes in CRLM patients, with an area under the curve of 0.873. Furthermore, parameters from SEM showed substantial repeatability.

CONCLUSION

The developed nomogram, incorporating the pre-treatment DDC and the short axis of the largest lymph node, can be used to predict the presence of hepatic LNM in CRLM patients undergoing chemotherapy before surgery. This nomogram was proven to be more valuable, exhibiting superior diagnostic performance compared to quantitative parameters derived from multiple b values of DWI. The nomogram can serve as a preoperative assessment tool for determining the status of hepatic lymph nodes and aiding in the decision-making process for surgical treatment in CRLM patients.

Prediction of hepatic lymph node metastases based on magnetic resonance imaging before and after preoperative chemotherapy in patients with colorectal liver metastases underwent surgical resection

BACKGROUND

Patients with colorectal liver metastases (CRLM) combined with hepatic lymph node (HLN) metastases have a poor prognosis. In this study, we developed and validated a model using clinical and magnetic resonance imaging (MRI) parameters to predict HLN status before surgery.

METHODS

A total of 104 CRLM patients undergoing hepatic lymphonodectomy with pathologically confirmed HLN status after preoperative chemotherapy were enrolled in this study. The patients were further divided into a training group (n = 52) and a validation group (n = 52). The apparent diffusion coefficient (ADC) values, including ADC_mean and ADC_min of the largest HLN before and after treatment, were measured. rADC was calculated referring to the target liver metastases, spleen, and psoas major muscle (rADC_-LM, rADC_-SP, rADC_-m). In addition, ADC change rate (Δ% ADC) was quantitatively calculated. A multivariate logistic regression model for predicting HLN status in CRLM patients was constructed using the training group and further tested in the validation group.

RESULTS

In the training cohort, post-ADC_mean (P = 0.018) and the short diameter of the largest lymph node after treatment (P = 0.001) were independent predictors for metastatic HLN in CRLM patients. The model's AUC was 0.859 (95% CI, 0.757-0.961) and 0.767 (95% CI 0.634-0.900) in the training and validation cohorts, respectively. Patients with metastatic HLN showed significantly worse overall survival (p = 0.035) and recurrence-free survival (p = 0.015) than patients with negative HLN.

CONCLUSIONS

The developed model using MRI parameters could accurately predict HLN metastases in CRLM patients and could be used to preoperatively assess the HLN status and facilitate surgical treatment decisions in patients with CRLM.

[The role of lymphadenectomy for treatment of colorectal liver metastases with regional lymph nodes involvement]

Liver resection remains the method of choice for treatment of colorectal liver metastases with good long-term results. Regional lymph nodes involvement is significant negative prognostic factor. Moreover, it has been considered as a contraindication for liver resection for a long time. The role of lymphadenectomy remains controversial. Current state of this problem is reviewed in the article. Liver regional lymph nodes involvement takes place in 10-20% of cases. PET/CT is the most sensitive method of preoperative diagnosis. Involvement of liver regional lymph nodes is currently not absolute contraindication for liver resection. Routine lymphadenectomy does not make sense, and, perhaps, is justified only within scientific trials for more accurate disease staging. Indications for lymphadenectomy are suspicious changes of lymph nodes revealed by preoperative visualization methods or by intraoperative exploration. Modern chemotherapy regimens allow to reconsider the prognostic importance of liver regional lymph node metastases and to extend indications for liver resections.

Prognostic impact of perihepatic lymph node metastases in patients with resectable colorectal liver metastases

BACKGROUND

Although perihepatic lymph node metastases (PLNMs) are known to be a poor prognosticator for patients with colorectal liver metastases (CRLMs), optimal management remains unclear. This study aimed to determine the risk factors for PLNMs, and the survival impact of their number and location in patients with resectable CRLMs.

METHODS

Data on patients with CRLM who underwent hepatectomy during 2003-2014 were analysed retrospectively. Recurrence-free (RFS) and overall (OS) survival were calculated according to presence, number and location of PLNMs. Risk factors for PLNM were evaluated by logistic regression analysis.

RESULTS

Of 1485 patients, 174 underwent lymphadenectomy, and 54 (31·0 per cent) had PLNM. Ten patients (5·7 per cent) who had lymphadenectomy and 176 (13·4 per cent) who did not underwent repeat hepatectomy. Survival of patients with PLNM was significantly poorer than that of patients without (RFS: 5·3 versus 13·8 months, P < 0·001; OS: 20·5 versus 71·3 months; P < 0·001). Median OS was significantly better in patients with para-aortic versus hepatoduodenal ligament PLNMs (58·2 versus 15·5 months; P = 0·011). Patients with three or more PLNMs had significantly worse median OS than those with one or two (16·3 versus 25·4 months; P = 0·039). The presence of primary tumour lymph node metastases (odds ratio 2·35; P = 0·037) and intrahepatic recurrence requiring repeat hepatectomy (odds ratio 5·61; P = 0·012) were significant risk factors for PLNM on multivariable analysis.

CONCLUSION

Patients undergoing repeat hepatectomy and those with primary tumour lymph node metastases are at significant risk of PLNM. Although PLNM is a poor prognostic factor independent of perihepatic lymph node station, patients with one or two PLNMs have a more favourable outcome than those with more PLNMs.

Combined hepatectomy and hepatic pedicle lymphadenectomy in colorectal liver metastases is justified

BACKGROUND

The aim of this study was to describe the outcome of patients with colorectal liver metastases (CRLM) and radiological or clinical evidence of metastatic hepatic lymph node involvement who underwent combined hepatectomy and hepatic pedicle lymphadenectomy.

METHODS

Retrospective analysis of a prospectively maintained audit of 2082 patients undergoing liver resection for CRLM between 1994 and 2014. Age, type of resection, CT/MRI/PET detection, location, disease recurrence and survival were analysed.

RESULTS

Combined hepatectomy and hepatic pedicle lymphadenopathy was performed on 76 patients who met the inclusion criteria. 46% of enlarged lymph nodes were located in the hepatic ligament, with 38% retroportal, 38% common hepatic and 33% coeliac nodes. 50% of lymph node resections were positive for metastatic tumour. Pre-operative CT, MRI and CT/PET failed to detect histologically proven lymph node disease in 25/38 patients. Patients with negative nodal histology had a significant overall (44 vs 20 months, p = 0.008) and disease free (20 vs 11 months, p < 0.001) survival advantage.

CONCLUSION

Combined hepatectomy and lymph node resection for CRLM in the setting of enlarged or suspicious lymphadenopathy is justified as imaging and operative findings are poor guides in determining positive lymph node disease.

Regional lymph node involvement in patients undergoing liver resection for colorectal cancer metastases

BACKGROUND

While the indications for surgery among patients with colorectal cancer liver metastases (CRCLM) are expanding, the role of surgery in patients with hepatic lymph node involvement remains controversial. We report management and outcomes in a population-based cohort of patients undergoing hepatectomy with concomitant hepatic lymphadenectomy for CRCLM.

METHODS

All cases of hepatectomy for CRCLM in the Canadian Province of Ontario from 2002 to 2009 were identified using the population-based Ontario Cancer Registry and linked electronic records of treatment. Pathology reports were used to identify concomitant lymphadenectomy with liver resection as well as extent of disease and surgical procedure.

RESULTS

Among 1310 patients who underwent resection for CRCLM, 103 (8%) underwent simultaneous regional lymphadenectomy. Seventy-one percent of cases with lymphadenectomy (70/103) had a major liver resection (≥3 segments). Of the 103 lymphadenectomy cases, 80 (78%) were hepatic pedicle, 16 (16%) were celiac and 7 (7%) were para-aortic. The mean number of nodes removed was 2.2 (range 1-15). Ninety-day mortality was 6%. Twenty-nine percent (30/103) of cases had positive nodes. Unadjusted overall survival at 5 years for positive vs negative nodes was 21% vs 42% (p = 0.003); cancer-specific survival was 10% vs 43% (p < 0.001). In adjusted analyses, hepatic node involvement was associated with inferior OS (HR 2.19, p = 0.010) and CSS (HR 3.07, p = 0.002).

CONCLUSIONS

Patients with resected CRC liver metastases with regional lymph node involvement have inferior survival compared to patients with negative nodes. Despite this poor prognostic factor, a small proportion of cases with involved nodes will achieve long-term survival.

Hepatectomy Versus Hepatectomy With Lymphadenectomy in Hepatocellular Carcinoma: A Prospective, Randomized Controlled Clinical Trial

GOALS AND BACKGROUND

The role of preventive lymphadenectomy has not yet been determined for hepatocellular carcinoma (HCC) patients. We designed a study to evaluate the effect of hepatectomy combined with preventive lymphadenectomy on HCC patients.

STUDY

Patients were randomly divided into group A (treated with hepatectomy alone) and group B (underwent hepatectomy combined with lymphadenectomy). The postoperative complications and oncologic prognoses were analyzed.

RESULTS

Of the 85 patients enrolled into this study, 79 cases (38 in group A and 41 in group B) were pathologically confirmed to have HCC and received curative resection. One hundred and sixteen lymph nodes were dissected and evaluated as negative by the pathologist. The 12-, 36-, and 60-month disease-free survival rates of group A were 81.6%, 68.4%, and 63.2%, respectively, whereas they were 78.0%, 65.9%, and 63.4%, respectively, for group B. The 12-, 36-, and 60-month overall survival rates in group A were 94.7%, 78.9%, and 65.8%, respectively, whereas they were 87.8%, 78.0%, and 70.7%, respectively, in group B. The differences in the disease-free survival and overall survival between the 2 groups were not statistically significant according to the log-rank test (P=0.811 and P=0.881, respectively). The difference in the surgical complication rate between groups A and B was not statistically significant (47.4% vs. 36.6%, P=0.332).

CONCLUSIONS

Although hepatectomy combined with regional lymphadenectomy is a safe procedure, preventive lymphadenectomy may not decrease the rate of tumor recurrence nor improve the prognosis in early-stage HCC patients.

Lymphatic drainage of the liver and its implications in the management of colorectal cancer liver metastases

The liver is the most common site of distant metastases in patients with colorectal cancer. Surgery represents the mainstream for curative treatment of colorectal cancer liver metastases (CRCLM) with long-term survival up to 58 and 36 % at 5 and 10 years, respectively. Despite advances on diagnosis, staging and surgical strategies, 60-70 % of patients will develop recurrence of the disease even after R0 resection of CRCLM. Tumor staging, prognosis, and therapeutic approaches for cancer are most often based on the extent of involvement of regional lymph nodes (LNs) and, to a lesser extent, on the invasion of regional lymphatic vessels draining the primary tumor. For CRCLM, the presence of intra hepatic lymphatic and blood vascular dissemination has been associated with an increased risk of intra hepatic recurrence, poorer disease-free and overall survival after liver resection. Also, several studies have reviewed the role of surgery in the patient with concomitant CRCLM and liver pedicle LN metastasis. Although pedicle LN involvement is related to worst survival rates, it does not differentiate patients that will relapse from those that will not. This review aims to briefly describe the anatomy of the liver's lymphatic drainage, the incidence of intrahepatic lymphatic invasion and hilar lymph node involvement, as well as their clinical impact in CRCLM. A better understanding of the role of liver lymphatic metastasis might, in the near future, impact the strategy of systemic therapies after liver resection as for primary colorectal tumors.

Liver resection for colorectal metastases: results and prognostic factors with 10-year follow-up

PURPOSE

Actual 5-year survival rates after resection of colorectal liver metastases (CLM) are 25-45%, whereas 10-year survival rates are extrapolated from survival curves. Few studies have reported long-term survivors with 10 years of actual follow-up. Therefore, no recurrences occurring after 10-plus years have been reported. The aim of our study was to analyze actual 10-year survival rates and prognostic factors.

METHODS

Clinical data of patients with CLM who had undergone first liver resection in our center between January 1990 and December 2000 were retrospectively analyzed.

RESULTS

Eighty-nine patients of mean age 64 years were studied. Three patients were excluded from the study: one because of postoperative death, and two from being lost to follow-up. All other subjects had a potential 10-year follow-up. Only 33% patients received perioperative chemotherapy. The actual 10-year overall and disease-free survival rate were 22 and 19%, respectively. Poor prognostic factors were disease-free interval less than 1 year, wedge liver resection, clinical risk score>2, segment 1 CLM location, and peritumoral lymphangitis. Good prognostic factors were tumors having mucinous components in primary tumor and CLM located in the right lobe.

CONCLUSIONS

With actual long-term follow-up for 10 years, disease-free survival rate is 19% and mainly depends on surgical management. Recurrence continues to occur more than 5 years after liver resection for CLM; cure cannot be assumed at this time. Clinical risk score is a good predictor of cure and should be taken into account when choosing perioperative treatment.

The outcome of liver resection and lymphadenectomy for hilar lymph node involvement in colorectal cancer liver metastases

OBJECTIVE

Hepatic hilar lymph node (HLN) involvement is considered as a poor prognostic factor during liver resection in colorectal liver metastases (CLM). The purpose of this study is to identify the clinical factors that distinguish HLN-positive patients from those who are hilar lymph node negative and to evaluate the frequency of macroscopic involvement of hepatic HLN, to investigate the impact of HLN involvement on survival after resection for CLM with lymphadenectomy and adjuvant chemotherapy.

PATIENTS AND METHODS

Between January 2000 and August 2012, 73 selected CLM patients underwent liver resections with lymphadenectomy in the Hepatopancreatobiliary Surgery Department I of Beijing Cancer Hospital. Clinical data, surgical outcome, and prognosis after operation of patients with HLN involvement were compared with that of patients without HLN involvement.

RESULTS

Of the 73 patients who underwent liver resections with lymphadenectomy, 12 (16.4 %) patients had HLN involvement identified by pathology. Compared with patients without HLN involvement, the frequency of lymph nodes metastasis for primary tumor was significantly higher in HLN-positive patients (p = 0.023). For CLM patients with and without HLN involvement, 5-year overall survival (OS) was 16.2 and 37.1 %, respectively (p = 0.04). Five-year disease-free survival (DFS) rates were 0 and 32.9 % (p = 0.034). Multivariate analysis showed that involved resected HLN was an independent risk factor for overall survival.

CONCLUSION

We should suspect HLN involvement in patients with colorectal cancer liver metastases when they have regional lymph nodes of primary tumor metastasis. Liver resection with HLN dissection might offer a unique curative opportunity for CLM patients with HLN involvement.

Lymphatics and colorectal liver metastases: the case for sentinel node mapping

BACKGROUND

Hepatic resection remains the treatment of choice for patients with colorectal liver metastases (CLM). Indications for hepatic resection have been extended to include extrahepatic lymph node groups, resulting in increased survival benefits. The identification of specific lymph pathways and involved nodes is necessary to support the development of guidelines for a more focused approach to the management of this disease. The feasibility of sentinel node mapping should be investigated to define specific lymphatic groups involved in CLM.

METHODS

Scientific papers published from 1950 to 2012 were sought and extracted from the MEDLINE, PubMed and University of Melbourne databases.

RESULTS

Several studies have reported microscopic lymph node involvement in 10-15% of patients undergoing hepatic resection for CLM in which no macroscopic involvement was evident. In retrospect, over 80% of lymphadenectomies are proven unnecessary. Traditional imaging modalities have limited predictive value in detecting lymph node involvement. Sentinel node mapping has proved an extremely accurate tool in detecting lymph node involvement and can identify patients in whom lymphadenectomy may be beneficial.

CONCLUSIONS

Current imaging techniques are inadequate to detect microscopic lymph node involvement in patients with resectable CLM. The use of sentinel node mapping is proposed to identify nodal groups involved and provide management strategies.

[Resection of liver metastases in patients with extrahepatic disease]

Patients who have liver metastasis and extrahepatic metastatic disease (EMD) have been considered as a patient subgroup with a very poor prognosis. Therefore, the presence of EMD was traditionally considered a contraindication for liver resection. But, survivals of around 30% at 5 years, and higher than that achieved with chemotherapy only obtained in some patients with liver metastasis of colorectal origin and EMD who had a resection performed on the hepatic and extrahepatic disease, obliges us to re-think what we must do in these patients. We have carried out an exhaustive review of the literature in an attempt to establish some working guidelines based on current scientific evidence. In summary, we can say that the presence of resectable EMD in patients with liver metastasis must not be considered as an absolute contraindication for liver resection, although the results are inferior to those obtained in patients without EMD. Patients with EMD localised in the ganglia of the coeliac trunk or aorto-cava have a short survival. The use of chemotherapy prior to the surgery is recommended to operate stable patients, or who respond to the chemotherapy and not in progression.

The role of hilar lymphadenectomy in patients subjected to hepatectomy due to colorectal metastasis

CONTEXT

Hepatectomy is the treatment of choice for colorectal liver metastases, and several studies have shown good results, with 5-year survival rates ranging from 40% to 57%. Several clinical and pathological predictive factors for survival after liver resection have been studied. Involvement of the hepatic hilum lymph nodes, the incidence of which varies from 2% to 10%, indicates a poor long-term prognosis.

RESULTS

Despite variable results, some authors have reported a not-insignificant improvement in survival rate in liver-metastasis patients with hilar lymph node involvement who undergo combined liver resection and lymphadenectomy. Due to the low rates of morbidity and mortality for liver-resection surgery, several specialized centers perform liver resections combined with lymphadenectomies in selected cases. It should be noted that the therapeutic value of systemic lymphadenectomy is not yet entirely understood, and only controlled studies comparing groups with and without lymphadenectomy can fully resolve the issue.

CONCLUSION

In any case, hilar lymph node dissection has been shown to be a useful tool for improving the accuracy of extra hepatic disease staging, regardless of its impact on survival.

Neither preoperative computed tomography nor intra-operative examination can predict metastatic lymph node in the hepatic pedicle in patients with colorectal liver metastasis

BACKGROUND

In patients operated on for colorectal liver metastasis (CRLM), metastatic lymph node (LN) of the hepatic pedicle is a major prognostic factor. Efficiency of preoperative computed tomography (CT) and intraoperative examination for the diagnosis of metastatic LN of hepatic pedicle is prospectively evaluated.

METHODS

From January 2008 to June 2010, 76 patients underwent liver resection for CRLM, with systematic LN pedicle dissection. Preoperative CT scan evaluated prospectively location, size, and aspect of LN, whereas the surgeon assessed size and consistency of LN Results of CT and intraoperative findings were compared with pathologic findings to determine sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV).

RESULTS

A total of 241 nodes were analyzed (3.2 ± 2.1 LN per patient). Systematic LN dissection increased the operative time by a mean of 20 ± 12.5 min, without any specific morbidity or mortality related to the LN clearance. Metastatic LN in the hepatic pedicle was observed in 15 (20%) patients and were unrelated to the number, size, and location of CRLM. NPV and PPV of the preoperative CT scan was 85 and 56%, respectively. Intraoperative evaluation of LN had a high NPV of 91% with a low PPV of 43%. Even with the combination of CT and intraoperative evaluation, 27% of the patients with a pathological metastatic LN were not suspected.

CONCLUSIONS

Because neither the preoperative CT nor the surgical evaluation accurately predicts metastatic LN in the hepatic pedicle, accurate oncological staging require a systematic pedicular LN clearance during liver resection for CRLM.

Colorectal liver metastases

BACKGROUND

Despite major advances in therapies for liver metastases, colorectal cancer remains one of the commonest causes of cancer-related deaths in the UK.

SOURCES OF DATA

The international literature on the management of colorectal liver metastases (CLM) was reviewed.

AREAS OF AGREEMENT

Due to a combination of highly active systemic agents and low perioperative mortality achieved by high-volume centres, a growing number of patients are being offered liver resection with curative intent. Patients with bilobar and/or extrahepatic disease who would previously have received palliative treatment only, are undergoing major surgery with good results. This review focuses on preoperative evaluation, surgical planning and the role of adjuvant therapies in the management of patients with CLM.

AREAS OF CONTROVERSY

Can ablative therapies match the outcomes of surgical resection? How can even more patients be rendered resectable?

GROWING POINTS

The use of other therapies, such as radiofrequency ablation and selective internal radiation therapy.

AREAS TIMELY FOR DEVELOPING RESEARCH

New chemotherapy regimens for neo-adjuvant therapy and the development of new modalities of liver tumour ablation.

Lymphatic patterns of colorectal liver metastases

BACKGROUND

Hematogenous spread is considered the predominant pathway for development of colorectal liver metastases (CRLM) and subsequent further tumor dissemination portal nodal involvement is also frequently observed in such cases, suggesting that lymphatics may have a role in the spread of CRLM. The role of lymphatics in the development of liver metastases is, however, controversial. The lymphatic patterns of CRLM were determined using a well established murine model.

METHODS

CRLM were induced using a well established murine intrasplenic colorectal cancer model. Tumors were assessed at varying stages of development, and lymphatic patterns were determined in tumors and liver by immunohistochemistry staining for podoplanin and LYVE-1. Blood vessels were characterized using the vascular marker CD-34. Assessment was undertaken using digital microscopy and image analysis.

RESULTS

Peri- and intratumoral lymphatic vessels were identified by podoplanin staining in all metastases and significantly increased with tumor growth. LYVE-1 staining was also noted but was variable. There was a concurrent significant increase in portal lymphatic staining within the normal liver with increasing growth of CRLM.

CONCLUSION

There is increased expression of lymphatics within CRLM and normal liver with increasing tumor growth. Lymphatic development is likely to play a significant role in the intrahepatic and periportal dissemination of CRLM.

The management of resectable and unresectable liver metastases from colorectal cancer

PURPOSE OF REVIEW

To discuss when and who should get liver resection, how to get to resection and what treatments are useful in the pre or postoperative setting.

RECENT FINDINGS

Colorectal cancer is a significant problem worldwide, with 49,000 deaths a year in the United States. Sixty percent of patients with metastatic disease will develop liver metastases, and, therefore, the control of liver metastases is an important issue. Liver resections improve survival for these patients, and thus there has been an enthusiasm for getting patients to a point where liver resection is possible. The appropriate timing for resection and how to treat patients before and after resection are important issues. The main themes that will be covered in this review are as follows: who is resectable; adjunctive surgical techniques that can improve resection; how patients with synchronous disease should be dealt with; whether neoadjuvant therapy is useful or harmful for these patients; and when liver resection is contemplated, what is the best approach - perioperative therapy, adjuvant postresection with either systemic or hepatic arterial infusion along with systemic. In unresectable disease, the question is how best to get the patients to resection.

SUMMARY

This paper will outline some of the flaws in the studies thus far, and problems for the future including a better definition of which patients are resectable, randomized studies comparing perioperative with postoperative therapy and studies comparing systemic therapy with hepatic arterial infusion along with systemic after resection. It is clear that an interdisciplinary team of surgeons, medical oncologists and radiologists is important to improve results for these patients.

Lymphadenectomy in colorectal cancer liver metastases resection: incidence of hilar lymph nodes micrometastasis

BACKGROUND

Liver resection is considered the best treatment for metastatic colorectal cancer. Several prognostic factors have been investigated, and many studies have shown that hepatic hilum lymph nodes involvement has a negative impact on prognosis. The present study evaluated the frequency of microscopic involvement of hilar lymph nodes, through systematic lymphadenectomy and analysis of micrometastases in patients undergoing hepatectomy due to colorectal metastasis.

METHODS

A total of 28 patients underwent hepatic resection with hilar lymphadenectomy. Lymph nodes considered negative by conventional hematoxylin and eosin (H&E) staining were analyzed by serial sectioning with 100-microm intervals and immunohistochemistry (IHC) with anti-human pancytokeratin antibody AE1/AE3.

RESULTS

In average, 6.18 lymph nodes were dissected per patient. No morbidity or mortality was associated to lymphadenectomy. In two patients, conventional H&E analysis showed presence of microscopic lymph node metastasis. IHC analysis allowed the identification of three other patients with lymph node micrometastases. The overall frequency of microscopic metastases, including micrometastasis, was 18%.

CONCLUSIONS

Systematic lymphadenectomy allowed the detection of microscopic lymph node metastases, resulting in more accurate staging of extrahepatic disease. The inclusion of IHC increased the detection of lymph node micrometastasis.

Liver resection for metastatic colorectal cancer in the presence of extrahepatic disease

Early studies of liver resection for colorectal cancer metastases identified patients with concomitant extrahepatic disease as a group with poor outcomes. These studies concluded that the presence of extrahepatic disease should be a contraindication to resection. This contraindication has more recently been challenged. In this paper, we review the published work on metastatic colorectal cancer, pertaining to the role of surgery in patients with liver metastases and concomitant extrahepatic disease. 5-year survival after resection is worse in patients with extrahepatic disease than in patients with liver-only disease, but is similar to that seen in patients who underwent resection in the era before the use of modern chemotherapy. Recurrence occurs in most patients. There is a role for surgery in highly selected patients with single sites of extrahepatic disease, although expectations should be different than those of patients with liver-only metastases. Further studies are necessary to define the patient group best suited for resection of hepatic metastases with extrahepatic disease.

Long-term survival after liver resection for colorectal liver metastases in patients with hepatic pedicle lymph nodes involvement in the era of new chemotherapy regimens

SUMMARY AND BACKGROUND

Survival benefit, in patients with colorectal liver metastases (CLM) and hepatic pedicle lymph nodes (HPLN) involvement along the common hepatic artery and celiac axis (area 2 or distal) has not been observed. However, these results are based on historical series, using suboptimal chemotherapy drugs.

OBJECTIVE

The aim of the present study is to investigate the impact of HPLN involvement on survival after resection for CLM in the era of the new chemotherapy regimens.

PATIENTS AND METHODS

Between January 2000 and June 2006, 45 high risk consecutive patients presenting all with pathologically proven HPLN metastases were identified from a prospectively maintained database. Prognostic factors for survival and recurrence were analyzed.

RESULTS

The mean follow-up was 25.5 months. HPLN involvement was located in area 1 in 17 patients, area 2 in 10, and both area 1 and 2 were involved in 18 patients. The overall 3- and 5-year survival rates were 29.7% and 17.3%, respectively. The median survival was 20.9 months. Three patients are alive and disease-free at 32.4, 33.5, and 46.9 months, respectively. The multivariate analysis showed that the carcinoembryonic antigen blood level before hepatectomy, a curative intent R0 liver resection, the ratio of involved/total resected HPLN, and an adjuvant chemotherapy after liver resection were independent risk factors for overall survival.

CONCLUSIONS

This study showed that the localization of HPLN metastases within area 1 or 2 does not anymore affect survival after CLM resection. Furthermore, this study provides a support to perform a routine HPLN dissection in high risk patients undergoing liver resection for CLM to recognize HPLN involvement, to improve the ratio of involved/total resected lymph nodes, and to assign the patients for an adjuvant chemotherapy. Finally, these results indicate that curative intent R0 liver resection with HPLN dissection can offer the only potential cure for patients with CLM who present with HPLN involvement.

Prognostic factors of survival in repeat liver resection for recurrent colorectal metastases: review of sixty-two cases treated at a single institution

PURPOSE

Liver metastases develop in 50 percent of patients with colorectal carcinoma. Recurrent liver disease is usual. Repeat liver resection remains the only curative treatment. The aim of this study was to review our data on repeat hepatectomy and to analyze potential prognostic factors of survival.

METHOD

Patients who underwent repeat liver resection for metastases of colorectal carcinoma between January 1992 and August 2007 were identified from a prospective database and their medical records were analyzed.

RESULTS

Of 62 patients who underwent a second hepatectomy, 15 underwent a third hepatectomy, and two underwent a fourth hepatectomy. There was no perioperative mortality. Morbidity was less than 20 percent for the first and second hepatectomies. Overall 5-year survival rate after first hepatectomy was 40 percent. Univariate analysis identified three risk factors confirmed by log-rank test and multivariate Cox regression analysis: serum carcinoembryonic antigen concentrations >5 ng/ml at first hepatectomy (HR = 2.265; CI = 1.140-4.497; P = 0.020), anatomic resection (HR = 2.124; CI = 1.069-4.218; P = 0.031), and tumors > or =3 cm at the second resection (HR = 2.039; CI = 1.013-4.103; P = 0.046).

CONCLUSION

Our study shows that repeat hepatectomy for liver metastases of colorectal carcinoma may be performed with low mortality and morbidity. Preoperative concentration of carcinoembryonic antigen at first hepatectomy, tumor size, and type of anatomic resection are independent prognostic factors.

Is hepatic resection justified after chemotherapy in patients with colorectal liver metastases and lymph node involvement?

PURPOSE

For patients with colorectal liver metastases (CLM), regional lymph node (RLN) involvement is one of the worst prognostic factors. The objective of this study was to evaluate the ability of a multidisciplinary approach, including preoperative chemotherapy and hepatectomy, to improve patient outcomes.

PATIENTS AND METHODS

Outcomes for a consecutively treated group of patients with CLM and simultaneous RLN involvement were compared with a cohort of patients without RLN involvement. Univariate and multivariate analysis of clinical variables was used to identify prognostic factors in this high-risk group. Results Of the 763 patients who underwent resection at our institution for CLM between 1992 and 2006, 47 patients (6%) were treated with hepatectomy and simultaneous lymphadenectomy. All patients had received preoperative chemotherapy. Five-year overall survival (OS) for patients with and without RLN involvement were 18% and 53%, respectively (P < .001). Five-year disease-free survival rates were 11% and 23%, respectively (P = .004). When diagnosed preoperatively, RLN involvement had an increased 5-year OS compared with intraoperative detection, although the difference was not significant (35% v 10%; P = .18). Location of metastatic RLN strongly influenced survival, with observed 5-year OS of 25% for pedicular, 0% for celiac, and 0% for para-aortic RLN (P = .001). At multivariate analysis, celiac RLN involvement and age >or= 40 years were identified as independent poor prognostic factors.

CONCLUSION

Combined liver resection and pedicular lymphadenectomy is justified when RLN metastases respond to or are stabilized by preoperative chemotherapy, particularly in young patients. In contrast, this approach does not benefit patients with celiac and/or para-aortic RLN involvement, even when patients' disease is responding to preoperative chemotherapy.

Hepatectomy for colorectal metastases in the presence of extrahepatic disease

This article focuses on hepatectomy for colorectal liver metastases (CLM) in the presence of intra-abdominal extrahepatic disease. The results reported in the literature are reviewed, and the indications and contraindications for hepatectomy in patients who have CLM with extrahepatic disease are discussed in light of the available evidence.

Intrahepatic lymphatic invasion independently predicts poor survival and recurrences after hepatectomy in patients with colorectal carcinoma liver metastases

BACKGROUND

D2-40 monoclonal antibody immunoreactivity is specific for lymphatic endothelium and therefore provides a marker of lymphatic invasion. We hypothesized that intrahepatic lymphatic invasion reflects the nodal status of colorectal carcinoma liver metastases and may function as an adverse prognostic factor.

METHODS

A retrospective analysis of 105 consecutive patients who underwent resection for colorectal carcinoma liver metastases was conducted. Intrahepatic lymphatic invasion was declared when either single tumor cells or cell clusters were clearly visible within vessels that showed immunoreactivity for D2-40 monoclonal antibody. The median follow-up time was 124 months.

RESULTS

Of 105 patients, 13 were classified as having intrahepatic lymphatic invasion. All tumor foci of intrahepatic lymphatic invasion were detected within the portal tracts. Intrahepatic lymphatic invasion was significantly associated with hepatic lymph node involvement (P = 0.039). Survival after resection was significantly worse in patients with intrahepatic lymphatic invasion (median survival time of 13 months; cumulative five-year survival rate of 0%) than in patients without (median survival time of 40 months; cumulative five-year survival rate of 41%; P < 0.0001). Patients with intrahepatic lymphatic invasion also showed decreased disease-free survival rates (P < 0.0001). Intrahepatic lymphatic invasion thus independently affected both survival (relative risk, 7.666; 95% confidence interval, 3.732-15.748; P < 0.001) and disease-free survival (relative risk, 4.112; 95% confidence interval, 2.185-7.738; P < 0.001).

CONCLUSIONS

Intrahepatic lymphatic invasion is associated with hepatic lymph node involvement and is an adverse prognostic factor in patients with colorectal carcinoma liver metastases.

Detection and management of extrahepatic colorectal cancer in patients with resectable liver metastases

The presence of extrahepatic disease has a great effect on the management of patients with metastatic colorectal cancer in the liver. FDG-PET scanning is currently the most sensitive way of detecting extrahepatic metastases in such patients. This is supported by 10 studies, which show that FDG-PET scan will discover extrahepatic disease in about one in six patients who have completed standard imaging. Staging laparoscopy is another means of detecting extrahepatic disease. Its role remains undefined especially in patients who have had FDG-PET scans. It should probably be restricted to patients with high clinical risk scores. In terms of treatment, patients with recurrence at the primary colorectal site as well as resectable liver metastases appear to benefit from resection of both sites provided that R0 resections can be obtained. Resection of involved hepatic pedicle lymph nodes in patients with resectable liver metastases is associated with poor outcome. The situation regarding patients with peritoneal and liver metastases bears a strong resemblance to that of primary site recurrence and liver metastases. Very acceptable survival can be expected if the peritoneal disease can be eradicated. Information regarding treatment of lung and liver metastases is the most complete of any of these areas. Good results may be expected if all the disease can be cleared. Caution is required in interpreting claims of good survival when study numbers are small and confidence intervals of data are not provided.

Liver resection without hilus preparation and with selective intrahepatic hilus stapling for benign tumors and liver metastasis

BACKGROUND

Nowadays, liver resection is a routine operative procedure in surgical centers, and strategies must be aimed at avoiding additional risk factors. Extrahepatic isolation of portal vein, hepatic artery and hepatic duct, as well as lymphadenectomy of the liver hilum are generally accepted steps of liver resection, even for metastatic and benign indications. Our primary aim was to analyze the feasibility, blood loss, blood transfusion requirements, incidence of complications, and outcome using the approach for intrahepatic devascularization leaving the extrahepatic hilus untouched.

MATERIALS AND METHODS

Thirty-eight consecutive patients with resection for metastases and benign liver tumors were selected. After hilar examination, the extrahepatic structures remain intact, and during parenchyma dissection, the whole right or left or the appropriate bi-segmental pedicle is isolated intrahepatically and then transected using a stapler device.

RESULTS

The used technique was feasible in all cases, and no intra- or postoperative surgical complications were observed. To date, no tumor recurrence was found in the hilum during the follow-up period.

CONCLUSION

The intrahepatic pedicle stapling technique appears to be feasible and safe in liver resection. Hilar dissection can, thus, be avoided in liver metastasis and benign liver tumors.

Perihepatic lymph node assessment in patients undergoing partial hepatectomy for malignancy

OBJECTIVE

To assess the value of preoperative imaging studies and the intraoperative assessment of perihepatic lymph nodes in patients undergoing partial hepatectomy for malignancy.

SUMMARY BACKGROUND DATA

Perihepatic lymph node status is an important prognostic factor for patients undergoing hepatic resection for 1(o) and metastatic cancer. The value of preoperative imaging studies and intraoperative assessment of perihepatic nodes is unknown.

METHODS

Perihepatic lymph nodes were sampled in 100 patients undergoing resection for 1(o) and metastatic hepatic malignancy. At the time of sampling, participating surgeons assigned a clinical suspicion score (scale, 1-5: 1 = clinically negative, 5 = clinically positive). Preoperative CT scans and PET scans were reviewed in a blinded fashion by 2 radiologists. Clinical assessment, CT, and PET scan results were analyzed in the context of the pathologic status of the lymph nodes.

RESULTS

A mean of 3.2 +/- 0.2 nodes were sampled per patient. Fifteen patients had metastatic disease in perihepatic lymph nodes; 13 had suggestive findings on preoperative CT or PET, and 2 were clinically positive at exploration. Clinical assessment had a high negative predictive value (NPV) = 99% but a low positive predictive value (PPV) = 39%. Similarly, CT scans had a high NPV = 95% and a low PPV = 30%. PET scans had a NPV = 88% and a PPV of 100%. Of the 48 patients with both negative preoperative CT and PET scans, only 1 (2.1%) had metastatic nodal disease, and this was suspected based on the clinical assessment. Of the patients with negative CT and PET scans and a negative clinical assessment (n = 39), none had involved perihepatic nodes.

CONCLUSIONS

In patients with 1(o) and metastatic liver cancer, the incidence of truly occult metastatic disease to perihepatic lymph nodes is low. Routine sampling of perihepatic lymph nodes will therefore have a low yield in patients without some evidence of disease on preoperative CT or PET scans or at the time of exploration.

Repeat hepatectomy for recurrent colorectal liver metastases

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.

Impact of microscopic hepatic lymph node involvement on survival after resection of colorectal liver metastasis

BACKGROUND

Macroscopic hepatic lymph node involvement is usually a contraindication to hepatic resection. Only a few studies have investigated the impact of hepatic lymph node involvement on survival. The aim of this retrospective study was to assess microscopic hepatic lymph node involvement in resectable colorectal liver metastasis and outcomes in patients with such involvement.

STUDY DESIGN

From January 1985 to December 2000, 156 patients underwent curative liver resection in association with systematic hepatic lymph node dissection for colorectal liver metastasis. A first analysis was performed to assess the association between hepatic lymph node metastasis and patients' characteristics. A second analysis assessed survival after resection of liver colorectal metastasis by using the Kaplan-Meier method.

RESULTS

Twenty-three of the 156 patients (15%) had microscopically involved hepatic lymph nodes. No predictive factor of lymph node metastasis was identified. Multivariate analysis showed that lymph node metastasis, preoperative carcinoembryonic antigen level, number of metastases, and morbidity were factors influencing survival. The 3- and 5-year survival rates of patients with lymph node metastasis were 27% and 5%, respectively, compared with 56% and 43% without lymph node metastasis (p = 0.0001).

CONCLUSIONS

During resection of liver colorectal metastasis, microscopic lymph node involvement occurred in 15% of the patients and was associated with a poor 5-year survival. Hepatic lymph node dissection should be performed systematically to select high-risk patients.

The significance of hepatic pedicle lymph nodes metastases in surgical management of colorectal liver metastases and of other liver malignancies

BACKGROUND

Surgical resection of colorectal liver metastases (CLM) is the only hope for cure, with a 5-year survival rate ranging from 20% to 54%. However, the resectability rate of CLM is reported to be <20%. This limitation is mainly due to insufficient remnant liver and to extrahepatic disease. Among extrahepatic locations, lymph node metastases are often considered indications of a very poor prognosis and a contra-indication to resection.

METHODS

and

RESULTS

Our studies showed that the prevalence of hepatic pedicle lymph node metastases ranges from 10% to 20%. When located near the hilum and along the hepatic pedicle (area 1) they should not be considered an absolute contra-indication to resection of CLM, and an extended lymphadenectomy should be performed. However, when they reach the celiac trunk (area 2), there is no survival benefit after resection of CLM. For other cases of liver malignancies, lymph node dissection seems justified only in cases of fibrolamellar hepatocellular carcinoma and in case of hilar cholangiocarcinoma. However, few data are available, and they are controversial.

CONCLUSIONS

There is a need for more evaluation of lymph node involvement, at least in patients with high risk of such an extension, i.e., patients with more than three metastases, located in segment 4 or 5. There is also a need for prospective trials in order to evaluate the survival benefit of liver resection in such circumstances and the impact of extensive lymphadenectomy.

The role of lymphadenectomy for liver tumors: further considerations on the appropriateness of treatment strategy

OBJECTIVE

To evaluate the role of regional lymphadenectomy in patients with liver tumors.

BACKGROUND

Lymph node status is 1 of the most important prognostic factors in oncologic surgery; however, the role of lymph node dissection remains unclear for hepatic tumors.

METHODS

A total of 120 consecutive patients undergoing liver resections for primary and secondary hepatic tumors were prospectively enrolled in the study. "Regional" lymphadenectomy was carried out routinely after specimen removal. Incidence, site, and influence on survival of node metastases were analyzed.

RESULTS

Only 1 postoperative complication (intra-abdominal bleeding) was related to lymph node excision. Median number of dissected nodes was 6.8 +/- 3.6. Periportal, pericholedochal, and common hepatic artery stations were always removed. Lymph node metastases were found in 17 (16.5%) patients. The percentage rises to 20.3% when considering only noncirrhotic patients. The incidence of lymph node metastases was 7.5% for hepatocellular carcinoma, 14% for colorectal metastases, 40% for noncolorectal metastases, and 40% for intrahepatic cholangiocarcinoma (P < 0.002). Median survival time was 486 +/- 93.2 days among all patients with node metastases and 725 +/- 29.7 among patients without node metastases. The 2-year survival was 37.1% and 86.7%, in the 2 groups (P < 0.05). The 2-year recurrence rate was 77.6% and 45.3%, respectively (P < 0.05).

CONCLUSIONS

Regional lymphadenectomy is a safe procedure after liver resection, and it should be routinely applied in patients with primary and secondary hepatic tumors, particularly in those without chronic disease. A careful evaluation of node status is nevertheless advisable also in patients with hepatocellular carcinoma on cirrhosis.

Incidence, distribution, and significance of hilar lymph node metastases in hepatic colorectal metastases

For many surgeons, the presence of HLNM has been a formal contraindication to resection of LM from colorectal cancer. This attitude is based on the very poor survival seen in small subgroups of patients with HLNM who have been included in large-scale studies of patients with LM. The incidence of macroscopic HLNM in patients with LM has been reported at 1% to 12%. In the authors' experience, the rate of macroscopic HLNM is 7% and the incidence of macroscopic and microscopic HLNM is 19%. The reported 5-year survival rate of patients with resected HLNM is generally poor (12%), although this article reports a study with a 5-year overall survival rate of 27%. The authors do not recommend routine hilar lymph node biopsy and frozen section for all patients with LM undergoing resection; however, they do recommend a systematic palpation of hepatoduodenal lymph nodes with frozen section of suspicious lymphadenopathy prior to resection. In cases of proven HLNM, combined liver resection and lymphadenectomy could be considered in selected patients. This selection should be performed on an individual basis guided by the absence of important comorbid condition, the biology of the disease, and the surgeon's judgment that this is limited hilar lymphatic involvement without other sites of extrahepatic disease. Systematic routine en bloc lymphadenectomy currently has no prognostic value and no known therapeutic effects.

Intraoperative Hepatic Lymphatic Mapping in Patients with Liver Metastases from Colorectal Carcinoma

The survival of patients undergoing liver resection for colorectal metastases is poor in the presence of extrahepatic disease. Therefore identification of periportal and celiac lymph node metastases is central to proper patient selection. In this study we examined the technique of intraoperative hepatic lymphatic mapping with isosulfan blue dye in humans. Intrahepatic dye injection was performed in patients undergoing surgical exploration for colorectal liver metastases. The location of all blue-stained lymphatics and lymph nodes was recorded. All stained and unstained lymph nodes were biopsied for pathologic examination. Thirteen intraoperative lymphatic mapping procedures were performed in 11 patients. A blue-stained lymphatic was visualized in 11 of 13 injections (85%). A blue lymph node was visualized in seven of 13 injections (54%). Three of the seven blue nodes (43%) were not detected by the surgeon before the mapping procedure. There were no complications associated with the intrahepatic dye injections. All biopsied lymph nodes were negative for metastatic tumor. We conclude that intraoperative hepatic lymphatic mapping with isosulfan blue dye is a simple, rapid, and safe technique in humans. It may serve as an adjunct to random lymph node biopsy for the identification of periportal and celiac nodal metastases before liver resection in patients with metastatic colorectal carcinoma.

Significance of hepatic pedicle lymph node involvement in patients with colorectal liver metastases: a prospective study

BACKGROUND

We investigated whether hepatic pedicle lymph node (HP-LN) involvement is a more significant prognostic factor and whether HP-LN dissection could be efficient in patients with positive HP-LN involvement.

METHODS

From 1988 to 1998, HP-LN dissection was prospectively performed in 160 patients undergoing hepatectomy for colorectal liver metastases. Survival of patients with HP-LN involvement limited to the hepatoduodenal ligament and retropancreatic portion (area 1) was compared with that of patients with HP-LN involvement spreading over the common hepatic artery and celiac axis (area 2).

RESULTS

HP-LN involvement was detected in 17 patients. The survival rate was significantly lower in patients with HP-LN involvement. HP-LN involvement was the most significant prognostic factor. Survival was significantly higher in patients with HP-LN involvement limited to area 1 than in those with HP-LN involvement spreading over area 2.

CONCLUSIONS

HP-LN involvement was the most significant prognostic indicator in patients with colorectal liver metastases. Positive LNs of area 1 should no longer be considered an absolute contraindication to liver resection, but in case of area 2 lymph node involvement, liver resection does not seem justified.

A new staging system for mass-forming intrahepatic cholangiocarcinoma: analysis of preoperative and postoperative variables

BACKGROUND

The objective of this study was to analyze the clinicopathologic variables and the postoperative outcome in patients with mass-forming intrahepatic cholangiocarcinoma (ICC) to identify important factors for predicting postresection prognosis. Although it has been reported that mass-forming ICC has a different etiology and biologic features compared with hepatocellular carcinoma (HCC), patients with ICC have been dealt with clinicopathologically in the same manner as patients with HCC.

METHODS

Sixty patients who underwent hepatectomy for mass-forming ICC with curative intent between 1981 and 1999 were studied. Fourteen preoperative clinical and diagnostic parameters and 12 postoperative surgicopathologic parameters were analyzed.

RESULTS

The rate of operative mortality in this patient cohort was 5%, and the overall 1-year, 3-year, and 5-year survival rates were 68%, 35%, and 29%, respectively, with a median survival of 19.6 months. A multivariate analysis revealed that independent negative prognostic factors were 1) hepatic regional lymph node metastasis, 2) multiple tumor presentation, 3) symptomatic tumor, and 4) the presence of vascular invasion. Using these factors, a new staging system was devised: Stage I disease was defined as a solitary tumor without vascular invasion, Stage II disease was defined as a solitary tumor with vascular invasion, Stage IIIA disease was defined as multiple tumors with or without vascular invasion, Stage IIIB disease was defined as any tumor with regional lymph node metastasis, and Stage IV disease was defined as any tumor with distant metastases. The Kaplan-Meier estimated 3-year survival rate and the median survival for each subgroup were 74% for patients with Stage I disease (median survival is the time when the cumulative survival rate of some patients' group declined to 50%; thus, the median survival could not be calculated in patients with Stage I disease because survival was 74% at the latest follow-up), 48% and 26.2 months for patients with Stage II disease, 18% and 16.8 months for patients with Stage IIIA disease, and 7% and 11.2 months for patients with Stage IIIB disease, respectively (P < 0.0001). None of the patients met the criteria for Stage IV disease.

CONCLUSIONS

The current results support the use of a new staging system for patients with ICC that is simple and predicts well the differences in survival after patients undergo hepatic resection.

Treatment of liver metastases from colorectal cancer: what is the best approach today?

Liver is the common site for metastases from colorectal cancer. The 5-year overall survival rate of patients following radical operations is 25%. Surgery can be carried out in only 10-15% of the patients, yet it remains the potential curative treatment for resectable lesions. For the unresectable cancers, only chemotherapy is recommended. New drugs such as Irinotecan prolongs the overall survival of patients affected by advanced disease. In patients with unresectable metastases at diagnosis, pre-surgical treatment with Oxaliplatin leads to reduction of the lesions, allowing resection in 16% of cases. Chemotherapy may be delivered directly into the liver via the hepatic artery. No, clinical trials, to date, have shown convincing survival results in patients treated with this procedure. Combined hepatic artery and systemic treatment may provide a new strategy as adjuvant therapy for patients undergoing resections.

Surgery for colorectal liver metastases with hepatic lymph node involvement: a systematic review

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.

Repeat liver resection for recurrent colorectal liver metastases

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.