Analysis of treatment that includes both hepatic and pulmonary resections for colorectal metastases

Early Versus Late Recurrence in Rectal Cancer: Does Timing Matter?

BACKGROUND

The definition of early recurrence (ER) in rectal cancer is unclear, and the association of ER with post-recurrence survival (PRS) is poorly described. We therefore sought to identify if time to recurrence (TTR) is associated with PRS.

METHODS

We reviewed all curative-intent resections of nonmetastatic rectal cancer from 2003 to 2018 in our institutional registry within an NCI-Designated Comprehensive Cancer Center. Clinicopathologic data at diagnosis and first recurrence were collected and analyzed. ER was pre-specified at < 24 months and late recurrence (LR) at ≥ 24 months. PRS was evaluated by the Kaplan-Meier method and Cox proportional hazards modeling.

RESULTS

At a median follow-up of 53 months, 61 out of 548 (11.1%) patients undergoing resection experienced recurrence. Median TTR was 14 months (IQR 10-18) with 45 of 61 patients (74%) classified as ER. There were no significant baseline differences between patients with ER and LR. Most recurrences were isolated to the liver (26%) or lung (31%), and 16% were locoregional. ER was not associated with worse PRS compared to LR (P > 0.99). On multivariable analysis, detection of recurrence via workup for symptoms, CEA > 10 ng/mL at recurrence, and site of recurrence were independently associated with PRS.

CONCLUSION

ER is not associated with PRS in patients with resected rectal cancer. Symptomatic recurrences and those accompanied by CEA elevations are associated with worse PRS, while metastatic disease confined to the liver or lung is associated with improved PRS. Attention should be directed away from TTR and instead toward determining therapy for patients with treatable oligometastatic disease.

Short- and Long-Term Outcomes of a Transdiaphragmatic Approach for Simultaneous Resection of Colorectal Liver and Lung Metastases

BACKGROUND

Long-term outcomes for simultaneous resection of synchronous colorectal liver and lung metastases are unknown. To address this gap, we compared outcomes and costs of three strategies for such resection.

METHODS

Patients who underwent resection of synchronous colorectal liver and lung metastases during 2000-2018 were grouped by surgical strategy: simultaneous resection via a transdiaphragmatic approach (transdiaphragmatic) or separate abdominal and thoracic incisions (transthoracic) and nonsimultaneous staged resection (staged). Operative and postoperative outcomes, survival, cumulative lung recurrence, and surgical costs were evaluated.

RESULTS

The study included 63 patients, 29 with transdiaphragmatic, 14 with transthoracic, and 20 with staged resection. The groups had similar demographic and clinicopathologic characteristics. Lung resection-associated blood loss for the transdiaphragmatic group was similar to that for the transthoracic group (P = .165) but lower than that for the staged group (P = .006). Hospital stay was shorter for the simultaneous groups than for the staged group (P = .007). Median surgical costs were significantly higher in the staged group ($130,733, interquartile range [IQR] $91,109-$173,573) than in the transdiaphragmatic ($70,620, IQR $58,376-$86,203, P < .001) or transthoracic ($62,991, IQR $57,405-$98,862, P < .001) group but did not differ between the transdiaphragmatic and transthoracic groups (P = .786). Rates of postoperative complications, recurrence-free survival, overall survival, and cumulative lung recurrence were similar among the groups.

CONCLUSIONS

Simultaneous resection of synchronous colorectal liver and lung metastases via a transdiaphragmatic approach is associated with lower blood loss, lower costs, and similar survival compared with staged resection.

Stereotactic Ablative Radiation Therapy for Unresectable Colorectal Oligometastases

Purpose

Patients with oligometastatic colorectal cancer have demonstrated excellent clinical outcomes with surgical resection of hepatic and pulmonary metastases. Stereotactic ablative radiation therapy (SABR) has emerged as an alternative local therapy for nonsurgical candidates. Herein, we report the oncologic and patient-reported quality-of-life (PR-QoL) outcomes for a subset of patients with oligometastatic colorectal cancer who were treated in a prospective phase 2 multicenter clinical trial.

Methods and materials

Patients with a pathologically proven diagnosis of oligometastatic colorectal cancer were enrolled as part of a prospective study. SABR dose and fractionation schedules were dependent on the lesion location and size. Patient follow-up occurred 6 weeks after completion of SABR and at 3-month intervals for the following 3 years. Patients received the Functional Assessment of Cancer Therapy-General questionnaire at baseline and at each follow-up visit to assess PR-QoL. The total Functional Assessment of Cancer Therapy-General questionnaire scores were compared with those from baseline using the Wilcoxon signed rank test. Overall survival, local progression-free survival (PFS), and distant PFS were calculated using the Kaplan-Meier estimation to the date of the last follow-up visit/death or local/distant failure.

Results

A total of 31 patients with oligometastatic colorectal cancer with 1 (71.0%), 2 (16.1%), 3 (3.2%), 4 (3.2%), or 5 (6.5%) metastatic lesions were identified. After a median follow-up time of 50.1 months, the median OS from the time of completion of the SABR was 53.9 months (95% confidence interval, 23.2-84.6), and the 5-year OS, local PFS, and distant PFS were 45%, 83%, and 27%, respectively. Acute grade 2+ toxicity was 9.7% (pain, nausea, fatigue) and late grade 3+ toxicity (small bowel obstruction) was 3.2% with no significant change in PR-QoL in the year after SABR.

Conclusions

This subset analysis of a prospective phase 2 study demonstrates that SABR is a safe and effective treatment option for patients with unresectable oligometastic colorectal cancer. In addition, SABR of oligometastatic disease preserves PR-QoL.

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.

Hepatic Metastasis from Colorectal Cancer

The liver is the most common site of metastasis in patients with colorectal cancer due to its anatomical situation regarding its portal circulation. About 14 to 18% of patients with colorectal cancer present metastasis at the first medical consultation, and 10 to 25% at the time of the resection of the primary colorectal cancer. The incidence is higher (35%) when a computed tomography (CT) scan is used.

In the last decades, a significant increase in the life expectancy of patients with colorectal cancer has been achieved with different diagnostic and treatment programs. Despite these improvements, the presence of metastasis, disease recurrence, and advanced local tumors continue to remain poor prognostic factors.

Median survival without treatment is <8 months from the moment of its presentation, and a survival rate at 5 years of 11% is the best prognosis for those who present with local metastasis. Even in patients with limited metastatic disease, 5-year survival is exceptional. Patients with hepatic metastasis of colorectal cancer have a median survival of 5 to 20 months with no treatment. Approximately 20 to 30% of patients with colorectal metastasis have disease confined to the liver, and this can be managed with surgery. Modern surgical strategies at the main hepatobiliary centers have proved that hepatectomy of 70% of the liver can be performed, with a mortality rate of <5%.

It is very important to have knowledge of predisposing factors, diagnostic methods, and treatment of hepatic metastasis. However, the establishment of newer, efficient, preventive screening programs for early diagnosis and adequate treatment is vital.

How to cite this article: Valderrama-Treviño AI, Barrera-Mera B, Ceballos-Villalva JC, Montalvo-Javé EE. Hepatic Metastasis from Colorectal Cancer. Euroasian J Hepato-Gastroenterol 2017;7(2):166-175.

Survival after pulmonary metastasectomy in colorectal cancer patients: does a history of resected liver metastases worsen the prognosis? A literature review

Objective

: To assess the impact of past liver metastases on the survival duration of patients who are undergoing surgery for lung metastases.

Methods

: We conducted a review of literature published from 2007 to 2014. The studies were identified by searching PubMed, MEDLINE, and Embase and were supplemented by a manual search of the references listed by the retrieved studies. The following search terms were used: lung metastasectomy, pulmonary metastasectomy, lung metastases, and lung metastasis. We selected retrospective and prospective studies published from 2007 to 2014 on patients with lung metastases from colorectal cancer and were undergoing surgery with curative intent. We excluded reviews, studies that focused on surgical techniques, patients who were treated non-surgically, analyses of specific subgroups of patients, and those that did not report follow-up of the patients undergoing surgery.

Results

: We identified 28 papers that assessed survival after lung metastases, 21 of which were mostly retrospective studies that identified previous liver metastases to explore their impact on patient survival. In more than half of the papers analyzed (63.2%), patients with a history of resected liver metastases had a lower survival rate than those who did not have such a history, and the difference was statistically significant in eight of these studies. However, data were presented differently, and authors reported mean survival time, survival rates, or hazard ratios.

Conclusions

: A history of liver metastases seems to be a negative prognostic factor, but the individual data need to undergo a meta-analysis.

Surgical outcomes of pulmonary metastases from esophageal carcinoma diagnosed by both pathological and clinical criteria

PURPOSE

This investigation was performed to examine the surgical outcomes of pulmonary metastases from esophageal carcinoma (EC) diagnosed by both pathological and clinical criteria.

METHODS

Based on the pathological criteria, we identified 22 patients who had undergone pulmonary metastasectomy for EC between 1997 and 2011. Thehistological type of EC was squamous cell carcinoma (SCC) in all patients. After specific clinical criteria were applied, seven patients suspected of having primary lung SCC were excluded. The surgical outcomes of the remaining 15 patients were reviewed. The overall survival (OS) was calculated as the period from pulmonary resection until death or the date of the last follow-up.

RESULTS

The 1-, 3- and 4-year OS rates of the 15 patients were 93, 44 and 0% respectively, with a median OS of 32 months. A larger diameter of the pulmonary metastasis was marginally associated with a poorer OS (p = 0.087); however, none of the parameters were significant prognostic factors.

CONCLUSIONS

The median OS of patients who underwent surgical resection for pulmonary metastases from EC was comparable to that in previous reports, even after excluding patients clinically suspected of having a second primary lung SCC. The poor long-term survival might indicate that our clinical criteria are helpful in selecting true metastatic patients, considering the aggressive clinical course of metastatic EC.