Survival after lung metastasectomy in colorectal cancer patients with previously resected liver metastases. World J Surg. 2012;36:386-391. [PMID: 22167262 DOI: 10.1007/s00268-011-1381-3]

Recurrence Timing and Risk Following Curative Resection of Colorectal Liver Metastases: Insights From a Hazard Function Analysis

INTRODUCTION

There is no consensus on the optimal surveillance interval for patients undergoing resection of colorectal liver metastases (CRLM). We sought to assess the timing and intensity of recurrence following curative-intent resection of CRLM utilizing a recurrence-free survival (RFS) hazard function analysis.

METHODS

Patients with CRLM who underwent curative-intent resection were identified from a multi-institutional database. The RFS hazard function was used to plot hazard rates and identify the peak of recurrence over time.

RESULTS

Among 1804 patients, the median RFS was 19.9 months. In the analytic cohort, the RFS hazard curve peaked at 5.9 months (peak hazard rate: 0.054) and gradually declined, indicative of early recurrence. In subgroup analyses, patients with high and medium tumor burden scores (TBS) had RFS hazard peaks at 4.9 months (peak hazard rate: 0.060) and 5.8 months (peak hazard rate: 0.054), respectively. In contrast, patients with low TBS had a later peak at 7.5 months, with the lowest peak hazard rate of 0.047.

CONCLUSIONS

The recurrence peak for CRLM patients occurred approximately 6 months postsurgery, highlighting the need for intensified early postoperative surveillance. Patients with high TBS experienced earlier recurrence, underscoring the importance of close monitoring, particularly during the first 6 months after surgery.

A Retrospective Analysis of Real-Life Management of Colorectal Cancer Lung-Limited Metastases Treated with Surgery: Outcomes and Prognostic Factors

Background: Unlike liver metastases, the role of surgery in colorectal cancer lung-limited metastases (CCLLM) is not yet established, and data are still poor. We performed a retrospective analysis to evaluate the impact of surgery on the management of CCLLM. Material and Method: We retrospectively analyzed patients who received surgery for CCLLM at our Institution from January 2010 to June 2019. The aim of the study was to evaluate the impact of clinical and pathological features on the survival (OS and DFS) of patients treated with surgery for CCLLM. Results: One hundred and fifty patients were included in the analysis. Seventy-six patients received preoperative chemotherapy (pCT) and 56 an adjuvant treatment (aCT), while 18 underwent up-front surgery without CT. In the whole population, median OS (mOS) and median DFS (mDFS) were 54.1 months (95%CI 44.0-82.1) and 24.0 months (95%CI 20.0-31.2), respectively. In multivariate analysis, number of metastases was the only factor correlated to DFS (p = 0.0006) and OS (p = 0.0018). Conclusion: Our study, although retrospective and of small size, shows that tumor burden (number of metastases) is the main prognostic factor in patients undergoing lung surgery for CCLLM. Moreover, our results suggest that surgery for lung metastases might prolong survival. These data strengthen the role of multidisciplinary management to allow patients with CCLLM to pursue local treatment whenever possible, even regardless of previous liver surgery or RAS mutated status.

Long-Term Outcome After Resection of Hepatic and Pulmonary Metastases in Multivisceral Colorectal Cancer

BACKGROUND/OBJECTIVES

Colorectal cancer (CRC) with hepatic (CRLM) and pulmonary metastases (CRLU) presents a significant clinical challenge, leading to poor prognosis. Surgical resection of these metastases remains controversial because of limited evidence supporting its long-term benefits. To evaluate the impact of surgical resection of both hepatic and pulmonary metastases on long-term survival in patients with multivisceral metastatic colorectal cancer, this retrospective cohort study included 192 patients with UICC stage IV CRC treated at a high-volume academic center.

METHODS

Patients were divided into two groups: those who underwent surgical resection of both hepatic and pulmonary metastases (n = 100) and those who received non-surgical treatment (n = 92). Propensity score matching was used to adjust for baseline differences. The primary outcome was overall survival (OS).

RESULTS

Unadjusted analysis showed a significant OS benefit in the surgical group (median OS: 6.97 years) compared with the conservative group (median OS: 2.17 years). After propensity score matching, this survival advantage persisted (median OS: 5.58 years vs. 2.35 years; HR: 0.3, 95% CI: 0.18-0.47, p < 0.0001).

CONCLUSIONS

Surgical resection of hepatic and pulmonary metastases in multivisceral metastatic CRC significantly improves long-term survival, supporting an aggressive surgical approach in selected patients.

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

BACKGROUND

Long-term survival data are lacking, and prognostic factors are not well-defined for patients with colorectal cancer and hepatic or lung metastases. This study evaluated the outcomes after resection of oligometastatic hepatic or lung metastases from colorectal cancer and sought to identify prognostic factors.

METHODS

We retrospectively investigated 1,123 patients with colorectal cancer and hepatic or pulmonary metastases who underwent curative surgery between January 1991 and December 2016.

RESULTS

Of the 1,123 patients, 719 had hepatic metastases, 287 had pulmonary metastases, and 117 had both. The 5-year overall survival rate was 52.3% in the hepatic metastases group, 70.4% in the pulmonary metastases group, and 71.4% in the hepatic and pulmonary metastases group (P < .001). In total, 1,045 patients had oligometastases (1-5 metastatic lesions in 1 or 2 organs) and 78 had polymetastases (≥6 metastases in 1 or 2 organs). Prognosis was significantly better in patients with oligometastases than in those with polymetastases. The 5-year overall survival rate was 59.0% in the oligometastases group and 35.3% in the polymetastases group (P < .001); the respective 5-year relapse-free survival rates were 37.5% and 11.6% (P < .001). Multivariable analysis identified predictors of both poor overall survival and relapse-free survival to be a high carcinoembryonic antigen level before the first metastasectomy, largest metastasis measuring ≥2 cm, polymetastases, and synchronous metastases.

CONCLUSION

Prognosis after curative resection was better in patients with oligometastatic colorectal cancer in the liver or lung than in those with polymetastases. Multidisciplinary decision-making strategies, including about surgery, should be based on number of metastases rather than their site.

Homogeneous and heterogeneous risk and prognostic factors for lung metastasis in colorectal cancer patients

Background

The lung is one of the most frequent distant metastasis sites in colorectal cancer (CRC) patients; however, lung metastasis risk and prognostic factors have not been comprehensively elucidated. This study aimed to identify the homogeneous and heterogeneous lung metastasis risk and prognostic factors in CRC patients using the Surveillance, Epidemiology, and End Results (SEER) database.

Methods

CRC patients registered in the SEER database between 2010 and 2016 were included to analyse risk factors for developing lung metastasis by using univariable and multivariable logistic regression. Patients diagnosed between 2010 and 2015 were selected to investigate prognostic factors for lung metastasis by conducting Cox regression. Kaplan–Meier analysis was used to estimate overall survival outcomes.

Results

A total of 10,598 (5.2%) patients with synchronous lung metastasis were diagnosed among 203,138 patients with CRC. The median survival time of patients with lung metastasis was 10.0 months (95% CI 9.6–10.5 months). Older age, unmarried status, uninsured status, poor histological differentiation, more lymphatic metastasis, CEA positivity, liver metastasis, bone metastasis and brain metastasis were lung metastasis risk and prognostic factors. Black patients and those with left colon, rectum, and stage T4 disease were more likely to develop lung metastasis, while patients with right colon cancer and no surgical treatment of the primary tumour had poor survival outcomes.

Conclusion

The incidence of lung metastasis in CRC patients was 5.2%. CRC patients with lung metastasis exhibited homogeneous and heterogeneous risk and prognostic factors. These results are helpful for clinical evaluation and individual treatment decision making.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02270-5.

Prognostic Factors for Post-Recurrence Survival in Stage II and III Colorectal Carcinoma Patients

Background and objectives: This study aimed to evaluate prognostic factors for post-recurrence survival in local and locally advanced colorectal cancer patients. Materials and Methods: A total of 273 patients with stage III and high-risk stage II colorectal cancer were prospectively enrolled. All patients underwent operative treatment of the primary tumor and adjuvant fluorouracil-based chemotherapy. Results: Over the three-year period (2008–2010), a cohort of 273 patients with stage III and high-risk stage II colorectal cancer had been screened. During follow up, 105 (38.5%) patients had disease recurrence. Survival rates 1-, 3- and 5-year after recurrence were 53.9, 18.2 and 6.5%, respectively, and the median post-recurrence survival time was 13 months. Survival analysis showed that age at diagnosis (p < 0.01), gender (p < 0.05), elevated postoperative Ca19-9 (p < 0.01), tumor histology (adenocarcinoma vs. mucinous vs. signet ring tumors, p < 0.01) and tumor stage (II vs. III, p < 0.05) had a significant influence on post-recurrence survival. Recurrence interval and metastatic site were not related to survival following recurrence. Multivariate analysis showed that older age (HR 2.43), mucinous tumors (HR 1.51) and tumors expressing Ca19-9 at baseline (HR 3.51) were independently associated with survival following recurrence. Conclusions: Baseline patient and tumor characteristics largely predicted patient outcomes after disease recurrence. Recurrence intervals in local and locally advanced colorectal cancer were not found to be prognostic factors for post-recurrence survival. Older age, male gender, stage III and mucinous histology were poor prognostic factors after the disease had recurred. Stage II patients had remarkable post-recurrence survival compared to stage III patients.

A New Surveillance Algorithm After Resection of Colorectal Liver Metastases Based on Changes in Recurrence Risk and RAS Mutation Status

BACKGROUND

The optimal surveillance strategy after resection of colorectal liver metastases (CLM) is unknown. We evaluated changes in recurrence risk after CLM resection and developed a surveillance algorithm.

METHODS

Patients undergoing CLM resection during 1998 to 2015 were identified from a prospectively compiled database and analyzed if they had the potential for follow-up longer than the longest observed time to recurrence in this cohort. Changes in recurrence risk and risk factors for recurrence were evaluated. All statistical tests were 2-sided.

RESULTS

Among 2,105 patients who were initially identified and underwent CLM resection, the latest recurrence was observed at 87 months; 1,221 consecutive patients from 1998 through 2011 with the potential for at least 87 months of follow-up were included. The risk of recurrence was highest at 0 to 2 years after CLM resection, lower at 2 to 4 years after CLM resection, and steadily lower after 4 years after CLM resection. Factors associated with increased recurrence risk at the time of surgery were primary lymph node metastasis (hazard ratio [HR], 1.54; 95% CI, 1.21-1.97; P<.001), multiple CLM (HR, 1.31; 95% CI, 1.06-1.63; P=.015), largest liver metastasis diameter >5 cm (HR, 1.64; 95% CI, 1.23-2.19; P<.001), and RAS mutation (HR, 1.29; 95% CI, 1.04-1.59; P=.020). In patients without recurrence at 2 years, the only factor still associated with increased recurrence risk was RAS mutation. In those patients, the recurrence rate at 4 years was 59.3% in patients with RAS mutation versus 27.8% in patients with RAS wild-type (P=.019).

CONCLUSIONS

For patients who have undergone CLM resection, we propose surveillance every 3 to 4 months during years 0 to 2, every 3 to 4 months (if mutant RAS) versus every 4 to 6 months (if RAS wild-type) during years 2 to 4, and every 6 to 12 months if recurrence-free at 4 years.

Frameless Single Robotic Radiosurgery for Pulmonary Metastases in Colorectal Cancer Patients

Background

Surgical intervention and radiation therapy are common approaches for pulmonary metastasectomy. The role of minimally invasive techniques in pulmonary metastases remains unclear. Frameless single robotic radiosurgery [CyberKnife (CK); Accuray Incorporated, Sunnyvale, CA] of pulmonary metastases in colorectal cancer (CRC) patients offers high precision local radiation therapy.

Methods

We analyzed the efficacy and safety of CK treatment for lung metastases in CRC in 34 patients and a total of 45 lesions. The primary endpoint was local control (LC); secondary endpoints were progression-free survival (PFS), overall survival (OS), distant control (DC), and safety-relevant events.

Results

Of the treated lesions, 34/45 (77.8%) decreased in size or remained unchanged [complete response (CR), partial response (PR), stable disease (SD)]; 8/45 (17.8%) lesions increased in size [progressive disease (PD)] and 2/45 (4.4%) lesions were not evaluable. Local progression was shown in 2 lesions (4.4 %). The median PFS period was six months. In a median follow-up time of 19.4 months, medium OS was 19.9 months (range: 3-61 months). Distant recurrence was observed in 21/34 patients (61.8 %). Intrapulmonary progression occurred in six patients. In 4/45 cases, fiducial placement led to a pneumothorax; three out of four patients needed chest tube insertion. No radiation-associated side effects were reported in 57.8% of patients. In 10/45 cases (22.2%), patients suffered asymptomatic radiographic changes; 7/45 cases (15.6%) reported a late onset of radiation-associated side effects. Maximal radiation-associated side effects reached the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer (RTOG/EORTC) Grade 1.

Conclusion

CK treatment of pulmonary metastases is safe and well-tolerated. For metastatic colorectal cancer (mCRC) patients with pulmonary metastases and not eligible for surgery, CK radiation offers a valuable treatment option.

Long-term outcome after sequential liver and lung metastasectomy is comparable to outcome of isolated liver or lung metastasectomy in colorectal carcinoma

BACKGROUND AND AIMS

Previously, colorectal cancer (CRC) metastasis of both liver and lungs was considered disseminated disease, which contraindicated surgical metastasectomies. Increasing evidence from studies on patient series have indicated that survival improved after resecting both liver and lung metastases. However, those results and long-term outcomes remain controversial. We aimed to compare surgical outcomes between patients treated for both liver and lung metastases to the patients who had only isolated liver or lung metastases.

MATERIAL AND METHODS

All patients (n = 105) underwent surgery for CRC metastases between July 2002 and September 2015. Three groups were compared: the sequentially operated group (n = 33 patients) underwent sequential liver and lung resections; the liver group (n = 38 patients) underwent liver resections; and the lung group (n = 34 patients) underwent lung resections. The main endpoints were long-term survival rates.

RESULTS

The groups were not different in disease-free survival (P = 0.727) or overall survival (P = 0.218). Five-year survival rates were 69.7% in the sequentially operated group, 65.1% in the liver group, and 50.0% in the lung group.

CONCLUSION

Long-term outcomes after sequential liver and lung resections of CRC metastases were comparable to outcomes after isolated liver or lung metastasectomies. Therefore, aggressive surgical interventions should be considered for patients with both liver and lung metastases of CRC.

UNBS5162 inhibits colon cancer growth via suppression of PI3K/Akt signaling pathway

Colon cancer is a common cause of cancer-related death worldwide. However, the underlying mechanism of tumor progression of colon cancer remains far from being elucidated. In the present study, we report the role of UNBS5162 in colon cancer. UNBS5162 is a naphthalimide that can intercalate into DNA and suppress the expression level of CXCL chemokines. Here, we investigated its effect on cell proliferation, mobility and apoptosis in HCT116 cells, and explored the underlying mechanism. A CCK8 assay revealed that UNBS5162 can block the proliferation of colon cancer cells. Base on a Transwell assay, we showed that cell migration and invasion ability of HCT116 cells are inhibited by UNBS5162. In addition, Annexin V-FITC/PI assay and Western blot analysis were performed to detect whether UNBS5162 could induce cell apoptosis. The results indicated that UNBS5162 increases the number of apoptotic cells remarkably. Furthermore, Western blot analysis demonstrated that UNBS5162 down-regulates the expression level of Bcl2, and up-regulates that of Bax as well as the level of activated Caspase-3. Moreover, we examined the impact of UNBS5162 on PI3K/Akt signaling pathway. UNBS5162 substantially inhibited the phosphorylation of Akt and its downstream effector mTOR, and reduced the expression of p-70. Taken together, these results suggest that UNBS5162 should be considered as a potent therapeutic anticancer agent that targets the PI3K/AKT signaling pathway.

Repeated Resections of Hepatic and Pulmonary Metastases from Colorectal Cancer Provide Long-Term Survival

BACKGROUND

Liver and lungs are the two most frequent sites of metastatic spread of colorectal cancer (CRC). Complete resection of liver and/or lung metastases is the only chance of cure, and several studies have reported an improved survival after an aggressive treatment. Nevertheless, CRC liver metastases (CLM) have been recognized as a pejorative factor for patients undergoing pulmonary metastasectomy. We report our experience with patients successively operated on for CRC hepatic and pulmonary metastasis (CPM) and seek to identify prognostic factors.

METHODS

All consecutive patients who had resection of CPM and CLM between 2001 and 2014 were enrolled in the study. Clinicopathological and survival data were retrospectively analysed.

RESULTS

Forty-six patients underwent resections of both CLM and CPM. Hepatic resection preceded pulmonary resection in most cases (91.3%). The median intervals between the resection of the primary tumour and the hepatic recurrence and between hepatic and pulmonary recurrences were 12 months [0-72] and 21.5 months [1-84], respectively. The mortality rate following CPM resection was 4.3%. After a median follow-up of 41.5 months [0-126], 35 patients recurred of whom 14 (40%) and 11(31.4%) could benefit from repeated resection of recurrent CLM and CPM, respectively. The median and 5-year overall survivals (OS) were 53 months and 49%, respectively. No prognostic factor was identified.

CONCLUSION

An aggressive management of CLM and CPM, including repeated resections, may provide a long-term survival comparable to survival of patients with unique metastasectomy. The absence of prognostic factor may reflect the highly selected pattern of the eligible patients.

Post-pulmonary metastasectomy prognosis after curative resection for colorectal cancer

Purpose

We aimed to compare disease-free survival after pulmonary metastasectomy to that after hepatic metastasectomy, and to identify prognostic factors after pulmonary metastasectomy.

Results

Between 2005 and 2015, 129 patients underwent resection of isolated metachronous lung metastases from colorectal cancer. Three-year DFS after pulmonary metastasectomy was similar to that after hepatic metastasectomy (50.7% vs. 45.5%, respectively; p=0.58). Rectal cancer (hazard ratio [HR]: 2.04, 95% confidence interval [CI]: 1.09–3.79; p=0.03) and ≥2 metastases (HR: 2.17, 95% CI: 1.28–3.68; p=0.004) were independent adverse risk factors associated with disease-free survival after pulmonary metastasectomy on multivariate analysis. Three-year DFS for colon vs. rectal cancer patients was 72.5% vs. 42.6%, respectively (p=0.04). The number of lung metastases was an independent risk factor for DFS after pulmonary metastasectomy in rectal cancer patients.

Patients and Methods

Patients who underwent lung metastasectomy after curative resection of colorectal cancers were investigated. Disease-free survival (DFS) after pulmonary metastasectomy was compared to that after hepatic metastasectomy, which has a relatively well-known prognosis. Multivariate Cox proportional hazards analysis was performed to identify clinical variables predictive of survival after pulmonary metastasectomy.

Conclusions

Disease-free survival rates after resection of lung vs. liver metastases arising from colorectal cancers are similar. However, lung metastases specifically from rectal cancers produce poorer DFS rates. Primary tumor location must be considered for pulmonary metastasis treatment and follow-up in colorectal cancer patients.

Surgical Treatment of Metastatic Colorectal Cancer

Surgical treatment of metastatic colorectal cancer offers a chance for cure or prolonged survival, particularly for those with more favorable prognostic factors and limited tumor burden. The treatment plan requires multidisciplinary evaluation because multiple therapy options exist. Advanced surgical techniques, adjuncts to resection, and modern chemotherapy all contribute to best outcomes for patients with hepatic metastases. Although cure is less common for patients with metastasis to lung or peritoneum, surgical resection for the former and cytoreduction and intraperitoneal chemotherapy for the latter may help to achieve cancer control in selected patients.

The safety and efficacy of microwave ablation for the treatment of CRC pulmonary metastases

PURPOSE

Microwave ablation (MWA) is a recently developed thermal ablation technique that has been used for the treatment of different types of tumours. In the present study, we retrospectively evaluated the safety and efficacy of CT-guided percutaneous MWA for the treatment of colorectal cancer (CRC) pulmonary metastases.

MATERIALS AND METHODS

From June 2010 to June 2015, 48 unresectable lesions in 32 patients with CRC pulmonary metastases were subjected to CT-guided MWA. Imaging follow-up was with contrast-enhanced CT and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT.

RESULTS

Oncologic imaging showed that 42 (87.5%) of the 48 lesions in the 32 patients were completely ablated. Needle track metastatic seeding was not found, and no patient deaths occurred within 30 d after ablation. The mean hospital stay was 3 d (range, 2-7 d). Pneumothorax was the most frequent complication and occurred in 6 (12.5%) of the 48 lesions. The median survival time was 31 months (95% CI: 15.4-46.6). The 1-, 2- and 3-year survival rates were 79.5%, 63.1% and 44.4%, respectively. Univariate Cox regression analysis showed that tumour size, disease-free interval (DFI) and number of tumours were significantly related to the overall survival time (p = .007, p = .022 and p = .030, respectively). Multivariate analysis showed that tumour size was an independent prognostic factor for survival (p = .017).

CONCLUSION

CT-guided percutaneous MWA is a safe and effective minimally invasive method for treating CRC pulmonary metastases.

The impact of pulmonary metastasectomy in patients with previously resected colorectal cancer liver metastases

Background

40–50% of patients with colorectal cancer (CRC) will develop liver metastases (CRLM) during the course of the disease. One third of these patients will additionally develop pulmonary metastases.

Methods

137 consecutive patients with CRLM, were analyzed regarding survival data, clinical, histological data and treatment. Results were stratified according to the occurrence of pulmonary metastases and metastases resection.

Results

39% of all patients with liver resection due to CRLM developed additional lung metastases. 44% of these patients underwent subsequent pulmonary resection. Patients undergoing pulmonary metastasectomy showed a significantly better five-year survival compared to patients not qualified for curative resection (5-year survival 71.2% vs. 28.0%; p = 0.001). Interestingly, the 5-year survival of these patients was even superior to all patients with CRLM, who did not develop pulmonary metastases (77.5% vs. 63.5%; p = 0.015). Patients, whose pulmonary metastases were not resected, were more likely to redevelop liver metastases (50.0% vs 78.6%; p = 0.034). However, the rate of distant metastases did not differ between both groups (54.5 vs.53.6; p = 0.945).

Conclusion

The occurrence of colorectal lung metastases after curative liver resection does not impact patient survival if pulmonary metastasectomy is feasible. Those patients clearly benefit from repeated resections of the liver and the lung metastases.

BRAZILIAN CONSENSUS FOR MULTIMODAL TREATMENT OF COLORECTAL LIVER METASTASES. MODULE 3: CONTROVERSIES AND UNRESECTABLE METASTASES

In the last module of this consensus, controversial topics were discussed. Management of the disease after progression during first line chemotherapy was the first discussion. Next, the benefits of liver resection in the presence of extra-hepatic disease were debated, as soon as, the best sequence of treatment. Conversion chemotherapy in the presence of unresectable liver disease was also discussed in this module. Lastly, the approach to the unresectable disease was also discussed, focusing in the best chemotherapy regimens and hole of chemo-embolization.

Preoperative selection of patients with colorectal cancer liver metastasis for hepatic resection

Surgical resection of colorectal liver metastases (CRLM) has a well-documented improvement in survival. To benefit from this intervention, proper selection of patients who would be adequate surgical candidates becomes vital. A combination of imaging techniques may be utilized in the detection of the lesions. The criteria for resection are continuously evolving; currently, the requirements that need be met to undergo resection of CRLM are: the anticipation of attaining a negative margin (R0 resection), whilst maintaining an adequate functioning future liver remnant. The timing of hepatectomy in regards to resection of the primary remains controversial; before, after, or simultaneously. This depends mainly on the tumor burden and symptoms from the primary tumor. The role of chemotherapy differs according to the resectability of the liver lesion(s); no evidence of improved survival was shown in patients with resectable disease who received preoperative chemotherapy. Presence of extrahepatic disease in itself is no longer considered a reason to preclude patients from resection of their CRLM, providing limited extra-hepatic disease, although this currently is an area of active investigations. In conclusion, we review the indications, the adequate selection of patients and perioperative factors to be considered for resection of colorectal liver metastasis.

Phase II multicenter clinical trial of pulmonary metastasectomy and isolated lung perfusion with melphalan in patients with resectable lung metastases

INTRODUCTION

The 5-year overall survival rate of patients undergoing complete surgical resection of pulmonary metastases (PM) from colorectal cancer (CRC) and sarcoma remains low (20-50%). Local recurrence rate is high (48-66%). Isolated lung perfusion (ILuP) allows the delivery of high-dose locoregional chemotherapy with minimal systemic leakage to improve local control.

METHODS

From 2006 to 2011, 50 patients, 28 male, median age 57 years (15-76), with PM from CRC (n = 30) or sarcoma (n = 20) were included in a phase II clinical trial conducted in four cardiothoracic surgical centers. In total, 62 ILuP procedures were performed, 12 bilaterally, with 45 mg of melphalan at 37°C, followed by resection of all palpable PM. Survival was calculated according to the Kaplan-Meier method.

RESULTS

Operative mortality was 0%, and 90-day morbidity was mainly respiratory (grade 3: 42%, grade 4: 2%). After a median follow-up of 24 months (3-63 mo), 18 patients died, two without recurrence. Thirty patients had recurrent disease. Median time to local pulmonary progression was not reached. The 3-year overall survival and disease-free survival were 57% ± 9% and 36% ± 8%, respectively. Lung function data showed a decrease in forced expiratory volume in 1 second and diffusing capacity of the alveolocapillary membrane of 21.6% and 25.8% after 1 month, and 10.4% and 11.3% after 12 months, compared with preoperative values.

CONCLUSION

Compared with historical series of PM resection without ILuP, favorable results are obtained in terms of local control without long-term adverse effects. These data support the further investigation of ILuP as additional treatment in patients with resectable PM from CRC or sarcoma.

Long Survival and Severe Toxicity Under 5-Fluorouracil-Based Therapy in a Patient With Colorectal Cancer Who Harbors a Germline Codon-Stop Mutation in TYMS

We report the first clinical description of a patient with cancer with a heterozygous germline codon-stop mutation in the TYMS gene. The mutation g.657795_657826del, c.53_84del (NM_001071.2), p.Gln18Argfs*42 causes loss of function of one of the TYMS alleles, resulting in a truncated protein. This gene codifies for the target enzyme of 5-fluorouracil (5-FU), the basic treatment in colorectal cancer. The patient, diagnosed with metastatic colorectal cancer, had diarrhea and neutropenia grade 4 and mucositis and neurological toxicity grade 3 under 5-FU-based therapy and exceeded by more than 50% the average survival after metastasectomy. On the basis of the patient's characteristics and the key role of TYMS in 5-FU activity, we hypothesize that this mutation may contribute to the drug response and toxicities suffered by the patient.

Anti-angiogenic agents in metastatic colorectal cancer

Colorectal cancer (CRC) is a major public health concern being the third leading cause of cancer mortality in the United States. The availability of better therapeutic options has led to a decline in cancer mortality in these patients. Surgical resection should be considered in all stages of the disease. The use of conversion therapy has made surgery a potentially curative option even in patients with initially unresectable metastatic disease. In this review we discuss the role of various anti-angiogenic agents in patients with metastatic CRC (mCRC). We describe the mechanism of action of these agents, and the rationale for their use in combination with chemotherapy. We also review important clinical studies that have evaluated the safety and efficacy of these agents in mCRC patients. Despite the discovery of several promising anti-angiogenic agents, mCRC remains an incurable disease with a median overall survival of just over 2 years in patients exposed to all available treatment regimens. Further insights into tumor biology and tumor microenvironment may help improve outcomes in these patients.

Outcome after liver resection in patients presenting with simultaneous hepatopulmonary colorectal metastases

BACKGROUND

The most common sites of metastasis from colorectal cancer (CRC) are hepatic and pulmonary; they can present simultaneously (hepatic and pulmonary metastases) or sequentially (hepatic then pulmonary metastases, or vice versa). Simultaneous disease may be aggressive, and thus may be approached with caution by the clinician. The aim of this study was to determine the outcomes following hepatic and pulmonary resection for simultaneously presenting metastatic CRC.

METHODS

A retrospective review was undertaken of a prospectively maintained database to identify patients presenting with simultaneous hepatopulmonary disease who underwent hepatic resection. Patients' electronic records were used to identify clinicopathological variables. The log rank test was used to determine survival, and χ(2) analysis to determine predictors of failure of intended treatment.

RESULTS

Fifty-nine patients were identified and underwent hepatic resection; median survival was 45·4 months and the 5-year survival rate 38 per cent. Twenty-two patients (37 per cent) did not have the intended pulmonary intervention owing to progression or recurrence of disease. Thirty-seven patients who progressed to hepatopulmonary resection had a median survival of 54·2 months (5-year survival rate 43 per cent). Those who had hepatic resection alone had a median survival of 24·0 months (5-year survival rate 30 per cent). Failure to progress to pulmonary resection was predicted by heavy nodal burden of primary colorectal disease and bilobar hepatic metastases. Redo pulmonary surgery following pulmonary recurrence did not confer a survival benefit.

CONCLUSION

Selected patients with simultaneous hepatopulmonary CRC metastases should be considered for attempted curative resection, but some patients may not receive the intended treatment owing to progression of pulmonary disease after hepatic resection.

Surgical resection of pulmonary metastases from colorectal cancer: Efficacy and prognostic factors

AIM: To assess the efficacy and prognostic factors for surgical resection of pulmonary metastases from colorectal cancer.

METHODS: Forty patients underwent surgical resection of pulmonary metastases from colorectal cancer at our hospital between May 1996 and March 2012. Data of follow-up till June 30, 2013 were obtained. The disease-free interval, progression-free survival and overall survival were used for survival analysis. Records of general information, operation mode and history were analyzed.

RESULTS: The median overall survival time was 36.5 (4.0-159.0) mo, and the 5-year survival rate was 37%. Location of primary tumor, chemotherapy, preoperative CEA level and tumor TNM stage were significantly related with the survival of patients after resection of pulmonary metastases (P = 0.012, 0.033, 0.007, 0.008). Multi-factor Cox regression model analysis showed that location of primary tumor and preoperative CEA level were independent risk factors for death (OR = 5.023, 4.332; P = 0.002, 0.017).

CONCLUSION: Pulmonary metastasectomy can significantly improve the survival of patients with pulmonary metastases of colorectal carcinoma, and the prognosis is related with location of primary tumor, chemotherapy, preoperative CEA level and tumor TNM stage, with location of primary tumor and preoperative CEA level being independent risk factors for mortality of patients.

Pulmonary metastasectomy in colorectal cancer patients with previously resected liver metastasis: pooled analysis

BACKGROUND

Data addressing the outcomes and patterns of recurrence after pulmonary metastasectomy (PM) in patients with colorectal cancer (CRC) and previously resected liver metastasis are limited.

METHODS

We searched the PubMed database for studies assessing PM in CRC and gathered individual data for patients who had PM and a previous curative liver resection. The influence of potential factors on overall survival (OS) was analyzed through univariate and multivariate analysis.

RESULTS

Between 1983 and 2009, 146 patients from five studies underwent PM and had previous liver resection. The median interval from resection of liver metastasis until detection of lung metastasis and the median follow-up from PM were 23 and 48 months, respectively. Five-year OS and recurrence-free survival rates calculated from the date of PM were 54.4 and 29.3 %, respectively. Factors predicting inferior OS in univariate analysis included thoracic lymph node (LN) involvement and size of largest lung nodule ≥2 cm. Adjuvant chemotherapy and whether lung metastasis was detected synchronous or metachronous to liver metastasis had no influence on survival. In multivariate analysis, thoracic LN involvement emerged as the only independent factor (hazard ratio 4.86, 95 % confidence interval 1.56-15.14, p = 0.006).

CONCLUSIONS

PM offers a chance for long-term survival in selected patients with CRC and previously resected liver metastasis. Thoracic LN involvement predicted poor prognosis; therefore, significant efforts should be undertaken for adequate staging of the mediastinum before PM. In addition, adequate intraoperative LN sampling allows proper prognostic stratification and enrollment in novel adjuvant therapy trials.

ALDH1 is a prognostic factor for patients treated with neoadjuvant chemoradiotherapy and radical resection for stage III rectal cancer

BACKGROUND AND OBJECTIVES

The factors relating to changes within a tumor after preoperative chemoradiotherapy associated with rectal cancer prognosis remain to be determined. The aim of this study was to investigate the expression of CD133 and ALDH1 and to analyze the predictive and prognostic roles in patients with rectal cancer after chemoradiotherapy.

METHODS

We analyzed the expression levels of ALDH1 and CD133 in patients with middle and lower rectal cancers who underwent preoperative chemoradiotherapy between March 2005 and December 2011.

RESULTS

The expression of CD133 was not associated with survival. The 5-year overall survival rates were lower in patients with high ALDH1 expression compared to low ALDH1 expression in stage III rectal cancer (61.0% vs. 89.7%, P=0.031). Cox multivariate analysis demonstrated that high ALDH1 expression (HR, 5.425; 95% CI, 1.116-26.373; P=0.036), cT (HR, 12.861; 95% CI, 2.188-75.591; P=0.005), and pN2 (HR, 28.481; 95% CI, 4.757-170.518; P<0.001) were independently associated with overall survival in 51 patients with stage III rectal cancer.

CONCLUSIONS

Expression of ALDH1 indicates a more aggressive feature of stage III rectal cancer and can stratify stage III rectal cancer into different survival groups.

Colorectal cancer with liver metastases: Neoadjuvant chemotherapy, surgical resection first or palliation alone?

Colorectal cancer (CRC) is one of the commonest cancers with 1.2 million new cases diagnosed each year in the world. It remains the fourth most common cause of cancer-related mortality in the world and accounts for > 600000 cancer-related deaths each year. There have been significant advances in treatment of metastatic CRC in last decade or so, due to availability of new active targeted agents and more aggressive approach towards the management of CRC, particularly with liver-only-metastases; however, these drugs work best when combined with conventional chemotherapy agents. Despite these advances, there is a lack of biomarkers to inform us about the accurate management of the patients with metastatic CRC. It is therefore imperative to carefully select the patients with comprehensive multi-disciplinary team input in order to optimise the management of these patients. In this review we will discuss various treatment options available in management of colorectal liver metastases with potential guidance on how and when to choose these options along with consideration on future directions in management of this disease.

Advances in the management of colorectal cancer: from biology to treatment

BACKGROUND

Colorectal cancer (CRC) is the third most common malignant neoplasm worldwide and the fourth leading cause of cancer-related deaths. This article reviews the epidemiology, risk factors, pathogenesis, and prognosis of CRC with special emphasis on advances in the management of CRC over the past decade.

METHODS

A review of the published English literature was conducted using the search engines PubMed, Medline, EMBASE, and Google Scholar. A total of 127 relevant publications were identified for further review.

RESULTS

Most CRC are sporadic and are due to genetic instability and multiple somatic mutations. Approximately 80% of cancers are diagnosed at the early stage and are curable. The pathologic stage at presentation is the most important predictor of outcome after resection of early stage cancer. Surgery is the primary treatment modality for localized CRC. Advances in (neo)adjuvant chemotherapy and radiation have reduced the disease recurrence and increased survival in high risk diseases. Although recent advancements in combination chemotherapy and target agents have increased the survival of incurable CRC, it is remarkable that only selected patients with advanced CRC can be cured with multimodality therapy.

CONCLUSION

Over the past decade, there has seen substantial progress in our understanding of and in the management of CRC.

The prognosis of pulmonary metastasectomy depends on the location of the primary colorectal cancer

BACKGROUND

Rectal cancer has a higher risk of developing lung metastasis compared with colon cancer. It is unclear whether the prognosis after pulmonary metastasectomy for these distinct tumors is different.

METHODS

Patients who underwent pulmonary metastasectomy for colorectal carcinoma were analyzed for survival and patterns of recurrence depending on the location of the primary colorectal cancer. Multivariate regression analysis was performed to identify clinical variables predictive of survival after pulmonary metastasectomy.

RESULTS

Between 1985 and 2012, 698 patients underwent pulmonary metastasectomy for metastatic colorectal cancer. Complete information was available in 626 patients. These patients were divided into groups based on whether the primary tumor was colon or rectal in origin. Median follow-up was 45.5 months (range, 23 to 287 months). There were no statistical differences between the two groups in terms of number of lung metastases, tumor size, or lymph node involvement. There was no difference in overall survival (p = 0.545). Five-year disease-free survival for colon cancer patients was 67.2% compared with 60.1% for rectal cancer (p = 0.004). The most common sites of recurrence after pulmonary metastasectomy were liver in colon cancer and lung in rectal cancer. Multivariate Cox proportional hazards analysis indicated that rectal cancer (hazard ratio, 1.39; 95% confidence interval, 1.07 to 1.83; p = 0.015) and multiple metastases (>3; hazard ratio, 1.41; 95% confidence interval, 1.04 to 1.89; p = 0.027) were independent adverse risk factors affecting disease-free survival after pulmonary metastasectomy.

CONCLUSIONS

Disease-free survival and site of recurrence after pulmonary metastasectomy for colorectal carcinoma are dependent on the site of the primary tumor. Lung metastases from rectal cancer have a worse disease-free survival compared with colon cancer. This may influence treatment and follow-up strategies.

Management of locally advanced and metastatic colon cancer in elderly patients

Colon cancer is the second leading cause of cancer mortality in the United States with a median age at diagnosis of 69 years. Sixty percent are diagnosed over the age of 65 years and 36% are 75 years or older. At diagnosis, approximately 58% of patients will have locally advanced and metastatic disease, for which systemic chemotherapy has been shown to improve survival. Treatment of cancer in elderly patients is more challenging due to multiple factors, including disabling co-morbidities as well as a decline in organ function. Cancer treatment of elderly patients is often associated with more toxicities that may lead to frequent hospitalizations. In locally advanced disease, fewer older patients receive adjuvant chemotherapy despite survival benefit and similar toxicity when compared to their younger counterparts. A survival benefit is also observed in the palliative chemotherapy setting for elderly patients with metastatic disease. When treating elderly patients with colon cancer, one has to consider drug pharmacokinetics and pharmacodynamics. Since chronological age is a poor marker of a patient’s functional status, several methods of functional assessment including performance status and activities of daily living (ADL) or instrumental ADL, or even a comprehensive geriatric assessment, may be used. There is no ideal chemotherapy regimen that fits all elderly patients and so a regimen needs to be tailored for each individual. Important considerations when treating elderly patients include convenience and tolerability. This review will discuss approaches to the management of elderly patients with locally advanced and metastatic colon cancer.

Lung metastasectomy for postoperative colorectal cancer in patients with a history of hepatic metastasis

OBJECTIVES

Our objective was to evaluate the efficacy of pulmonary metastasectomy for postoperative colorectal cancer with hepatic metastasis, and to investigate the role of clinicopathological factors as predictors of outcome.

METHODS

Consecutive patients undergoing pulmonary metastasectomy for colorectal cancer with (group PH, n = 27) or without (group P, n = 46) a history of hepatic metastasis were included in the study. Clinicopathological variables, including sex, age, site, carcinoembryonic antigen in the primary tumor, disease-free interval, prior hepatic resection, timing of pulmonary metastases, preoperative chemotherapy, type of pulmonary resection, and number, size, and location of pulmonary metastases were retrospectively collected and investigated for prognostic significance.

RESULTS

Five-year survival rates were 59.5 and 70.0 % for patients with and without a history of hepatic metastasis, respectively; these values did not differ significantly. Among all investigated prognostic variables, sex and number of pulmonary metastases (1 vs. >1) were the most important factors affecting the outcome after colorectal and pulmonary resection. There was no significant difference in overall survival whether it was calculated from the time of resection of the primary colorectal cancer or of pulmonary metastases.

CONCLUSIONS

Pulmonary resection is not contraindicated in clinical practice. Significant factors indicating a good prognosis were female sex and the number of pulmonary metastases. Special attention should be paid to comparison of survival among studies.

The Presence of Mutations in the K-RAS Gene Does Not Affect Survival after Resection of Pulmonary Metastases from Colorectal Cancer

Introduction. Our objective was to identify mutations in the K-RAS gene in cases of pulmonary metastases from colorectal cancer (CRC) and determine whether their presence was a prognostic factor for survival. Methods. We included all patients with pulmonary metastases from CRC operated on between 1998 and 2010. K-RAS mutations were investigated by direct sequencing of DNA. Differences in survival were explored with the Kaplan-Meier method log-rank tests and multivariate Cox regression analysis. Results. 110 surgical interventions were performed on 90 patients. Factors significantly associated with survival were disease-free interval (P = 0.002), age (P = 0.007), number of metastases (P = 0.001), lymph node involvement (P = 0.007), size of the metastases (P = 0.013), and previous liver metastasis (P = 0.003). Searching in 79 patients, K-RAS mutations were found in 30 cases. We did not find statistically significant differences in survival (P = 0.913) comparing native and mutated K-RAS. We found a higher rate of lung recurrence (P = 0.040) and shorter time to recurrence (P = 0.015) in patients with K-RAS mutations. Gly12Asp mutation was associated with higher recurrence (P = 0.022) and lower survival (P = 0.389). Conclusions. The presence of K-RAS mutations in pulmonary metastases does not affect overall survival but is associated with higher rates of pulmonary recurrence.

Outcomes after hepatic and pulmonary metastasectomies compared with pulmonary metastasectomy alone in patients with colorectal cancer metastasis to liver and lungs

BACKGROUND

Surgical resection is the most effective treatment for colorectal cancer that has metastasized to the liver. Similarly, surgical resection improves survival for selected patients with pulmonary colorectal metastases. However, the indication for pulmonary metastasectomy is not clear in patients with both hepatic and pulmonary colorectal metastases. Therefore, we evaluated outcomes after pulmonary resection of colorectal metastases in patients with or without a history of curative hepatic metastasectomy.

METHODS

We retrospectively analyzed 96 patients who underwent pulmonary metastasectomy from March 1999 to November 2009. Patients were grouped according to treatment: resection of pulmonary metastases alone (lung metastasectomy group) or resection of both hepatic and pulmonary metastases (liver and lung metastasectomy group). Overall survival (OS) and disease-free survival (DFS) were evaluated by Kaplan-Meier analysis. Survival curves were compared using the log-rank test.

RESULTS

The 5-year OS for all patients was 61.3 %, and the 5-year DFS was 26.7 %. Group comparisons showed that the 5-year OS of the lung metastasectomy group was significantly better than that of the liver and lung metastasectomy group (69 vs. 43 %; p = 0.030). However, the 5-year DFS rates of the lung metastasectomy group (25.8 %) and liver and lung metastasectomy group (28.0 %) did not differ significantly. Recurrence was higher after resection of both hepatic and pulmonary metastases than after pulmonary metastases alone (79 vs. 45 %; p = 0.025).

CONCLUSIONS

Resection of pulmonary colorectal metastases may increase survival. However, the combination of liver and lung metastasectomies had a worse prognosis than pulmonary metastasectomy alone. In selected patients, combined liver and lung metastasectomy can be beneficial and result in acceptable DFS.

Survival after resection of liver and lung colorectal metastases in the era of modern multidisciplinary therapy

PURPOSE

Despite recent improvement of the outcomes of colorectal cancer (CRC), the benefits of resection and appropriate selection criteria in patients with both liver and lung metastases remain controversial. The aim of this study was to analyze the outcomes and prognostic factors for survival in patients who underwent both hepatic and pulmonary resection for CRC metastases in the era of modern multidisciplinary therapy.

METHODS

A retrospective analysis of 43 consecutive patients who underwent both liver and lung resections for metastatic CRC at our institute from 2003 to 2011 was performed. All patients in this study had achieved cancer-free status after resection of the second metastatic site.

RESULTS

Of the patients, 24 (56 %) had synchronous metastatic disease with their primary tumor. Twenty-seven patients had developed recurrence after resection of the second metastatic site. In 14 cases, re-metastasectomy was performed for recurrence. Fourteen patients received palliative chemotherapy after recurrence, and all of these patients received oxaliplatin and/or irinotecan-based chemotherapy. After resection of the second metastatic organ, the 5-year relapse-free and overall survival rates were 29.6 and 70.0 %, respectively. Patients with multiple lung metastases had worse relapse-free survival than patients with solitary lung metastases at first lung resection (p = 0.046).

CONCLUSIONS

Aggressive surgical resection and a combination of modern chemotherapeutic agents improve the survival of patients with lung and liver metastases from CRC. The presence of multiple lung metastases at resection suggests a poor prognosis.

Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC International)

SUMMARY Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC) is a randomized controlled trial. Patients with resected colorectal cancer found to have one or more pulmonary metastases are randomized to have a metastasectomy or not. Both arms include active monitoring. Patients considered possible candidates for pulmonary metastasectomy are asked to first give consent to be assessed according to protocol after which a decision to have or not have metastasectomy may be made. If there is uncertainty, patients are invited to consent to randomization, including minimization for known prognostic factors: the number of metastases, the interval since primary resection, carcinoembryonic antigen levels and the TNM stage of the primary cancer. The primary outcomes are survival and quality of life. The trial is open in England, and in Serbia and Italy as PulMiCC International.

Pulmonary metastasectomy in colorectal cancer

Surgeons need to do difficult trials

Do metastatic colorectal cancer patients who present with late relapse after curative surgery have a better survival?

Background:

Patients who relapse after potentially curative surgery for colorectal cancer tend to relapse within 5 years. There is, however, a group of patients who relapse beyond 5 years after resection and this late relapsing group may have a different behaviour and prognosis.

Methods:

We analysed data from a prospective population-based registry to compare the characteristics and survival of relapsed patients with metachronous mCRC. Patients were categorised into relapse at <2, 2–5 and >5 years following their initial surgery. Univariate log-rank tests and multivariate Cox regression was performed to determine whether time to relapse (TTR) and other factors were associated with overall survival (OS).

Results:

A total of 750 metachronous mCRC patients were identified. In all, 56% relapsed ⩽2 years, 32.4% at 2–5 years and 11.6% >5 years. Median survival time from the time of diagnosis of mCRC for the three groups was 17.6, 26.1 and 27.5 months, respectively. Short TTR (<2 years) was significantly associated with survival (HR=0.75, 95% confidence interval (CI)=0.60–0.93 and HR=0.73, 95% CI=0.53–1.01, respectively, for 2–5 and >5 years vs <2 years, P<0.05). However, there was no significant difference in survival between patients who relapsed at 5 years or later compared with those who relapsed between 2 and 5 years (HR=0.98, 95% CI=0.69–1.38, P=0.90).

Conclusion:

TTR within 2 years is an independent predictor of shorter survival time for mCRC patients who experience a relapse. These data do not support the hypothesis that patients who have late relapse late (>5 years) have a ‘better' biology or survival compared with patients with a TTR of 2–5 years.

Designing liver resections and pushing the envelope with resections for hepatic colorectal metastases

Current concepts in the management of hepatic metastases have changed dramatically over the past two decades. Multidisciplinary therapies including chemotherapy, surgery, and regional therapy have alone and in combination significantly improved the survival of patients with metastatic colorectal cancer. Conditions that were previously considered hopeless and treated merely for palliation can now be approached with curative intent. In this paper, we review the surgical treatment for colorectal cancer liver metastasis (CRLM) and describe a paradigm-shift in the management of complex heretofore-considered unresectable CRLM. Utilizing advanced multidisciplinary treatment strategies has improved the prognosis of patients with stage IV colorectal cancer to the point where we may question whether CRLM are now a chronic disease.

Pulmonary metastasectomy in colorectal cancer: a prospective study of demography and clinical characteristics of 543 patients in the Spanish colorectal metastasectomy registry (GECMP-CCR)

OBJECTIVES

To capture an accurate contemporary description of the practice of pulmonary metastasectomy for colorectal carcinoma in one national healthcare system.

DESIGN

A national registry set up in Spain by Grupo Español de Cirugía Metástasis Pulmonares de Carcinoma Colo-Rectal (GECMP-CCR).

SETTING

32 Spanish thoracic units.

PARTICIPANTS

All patients with one or more histologically proven lung metastasis removed by surgery between March 2008 and February 2010.

INTERVENTIONS

Pulmonary metastasectomy for one or more pulmonary nodules proven to be metastatic colorectal carcinoma.

PRIMARY AND SECONDARY OUTCOME MEASURES

The age and sex of the patients having this surgery were recorded with the number of metastases removed, the interval between the primary colorectal cancer operation and the pulmonary metastasectomy, and the carcinoembryonic antigen level. Also recorded were the practices with respect to mediastinal lymphadenopathy and coexisting liver metastases.

RESULTS

Data were available on 543 patients from 32 units (6-43/unit). They were aged 32-88 (mean 65) years, and 65% were men. In 55% of patients, there was a solitary metastasis. The median interval between the primary cancer resection and metastasectomy was 28 months and the serum carcinoembryonic antigen was low/normal in the majority. Liver metastatic disease was present in 29% of patients at some point prior to pulmonary metastasectomy. Mediastinal lymphadenectomy varied from 9% to 100% of patients.

CONCLUSIONS

The data represent a prospective comprehensive national data collection on pulmonary metastasectomy. The practice is more conservative than the impression gained when members of the European Society of Thoracic Surgeons were surveyed in 2006/2007 but is more inclusive than would be recommended on the basis of recent outcome analyses. Further analyses on the morbidity associated with this surgery and the correlation between imaging studies and pathological findings are being published separately by GECMP-CCR.

Outcome of strict patient selection for surgical treatment of hepatic and pulmonary metastases from colorectal cancer

BACKGROUND

Surgery is currently the only potentially curative treatment for hepatic or pulmonary metastases from colorectal cancer. However, the benefit of surgery and the criteria for the inclusion of patients developing hepatic and pulmonary metastases are not well defined.

OBJECTIVE

The aim of this study was to describe the outcome for patients who undergo surgery for both hepatic and pulmonary metastases from colorectal cancer, to present a set of preoperative criteria for use in patient selection, and to analyze potential prognostic factors related to survival.

DESIGN

This was an observational study with retrospective analysis of data collected with a prospective protocol.

SETTINGS

This investigation was conducted at a tertiary centre.

PATIENTS

Between January 1996 and January 2010, of 319 patients who underwent surgery for hepatic metastases from colorectal cancer, 44 also had resection of pulmonary metastases. A set of strict selection criteria established by a panel of liver surgeons, chest surgeons, oncologists, and radiologists was used.

MAIN OUTCOME MEASURES

Survival was estimated with the Kaplan-Meier method, and univariate analyses were performed to evaluate potential prognostic factors for survival, including variables related to patient, primary tumour, hepatic, and pulmonary metastases and chemotherapy.

RESULTS

The 44 patients received a total of 53 pulmonary resections: 36 patients had 1, 7 patients had 2, and 1 patient had 3 resections. There was no postoperative mortality and the morbidity rate after pulmonary resection was 1.8%. No patient was lost to follow-up. Overall survival was 93% at 1 year, 81% at 3 years, and 64% at 5 years. Factors related to poor prognosis in the univariate analysis were presence of more than 1 pulmonary metastasis (p = 0.04), invasion of the surgical margin (p = 0.006), and administration of neoadjuvant chemotherapy (p = 0.01 for hepatic metastases and p = 0.02 for pulmonary metastases).

LIMITATIONS

The study was limited by its observational nature and the relatively small number of patients.

CONCLUSION

In patients with hepatic and pulmonary metastases from colorectal cancer selected according to strict inclusion criteria, surgical treatment performed in a specialized center is a safe option that offers prolonged survival.

Aggressive surgical management in patients with lung metastases originating from colorectal cancer: addressing the controversy

SUMMARY Pulmonary metastasis of stage IV colorectal cancer was long considered to be an incurable disease with an indication for palliative treatment. While technical advances in surgical therapy led to a broad acceptance of surgical resection of solitary lung metastases, the feasibility of removing all pulmonary metastases with a curative intention has now come to the center of attention. Despite the lack of randomized clinical trials giving evidence in support of the value of surgical resection, we postulate an aggressive surgical strategy within a multidisciplinary management framework.