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Hansdotter P, Scherman P, Nikberg M, Petersen SH, Holmberg E, Rizell M, Naredi P, Syk I. Treatment and survival of patients with metachronous colorectal lung metastases. J Surg Oncol 2023; 127:806-814. [PMID: 36607235 DOI: 10.1002/jso.27188] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/06/2022] [Accepted: 12/11/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The lungs are the second most common site for metachronous metastases in colorectal cancer. No treatment algorithm is established, and the role of adjuvant chemotherapy is unclear. This study aimed to map pulmonary recurrences in a modern multimodal treated population, and to evaluate survival depending on management. METHODS Retrospective study based on the COLOFOL-trial population of 2442 patients, radically resected for colorectal cancer stage II-III. All recurrences within 5 years were identified and medical records were scrutinized. RESULTS Of 165 (6.8%) patients developing lung metastases as first recurrence, 89 (54%) were confined to the lungs. Potentially curative treatment was possible in 62 (37%) cases, of which 33 with surgery only and 29 with surgery and chemotherapy combined. The 5-year overall survival (5-year OS) for all lung recurrences was 28%. In patients treated with chemotherapy only the 5-year OS was 7.5%, compared with 55% in patients treated with surgery, and 72% when surgery was combined with chemotherapy. Hazard ratio for mortality was 2.9 (95% confidence interval 1.40-6.10) for chemotherapy only compared to surgery. CONCLUSION A high proportion of metachronous lung metastases after colorectal surgery were possible to resect, yielding good survival. The combination of surgery and chemotherapy might be advantageous for survival.
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Affiliation(s)
- Pernilla Hansdotter
- Department of Surgery, Skåne University Hospital, Malmö, Sweden.,Institute of Clinical Sciences Malmö, Section of Surgery, Lund University, Lund, Sweden
| | - Peter Scherman
- Department of Surgery, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Helsingborg Hospital, Helsingborg, Sweden
| | - Maziar Nikberg
- Department of Surgery, Centre for Clinical Research of Uppsala University, Västmanland's Hospital, Västerås, Sweden
| | - Sune H Petersen
- Department of Paediatrics & Adolescent Medicine, Section of Paediatric Haematology & Oncology, Copenhagen, Denmark
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Rizell
- Department of Surgery, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden.,Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Peter Naredi
- Department of Surgery, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ingvar Syk
- Department of Surgery, Skåne University Hospital, Malmö, Sweden.,Institute of Clinical Sciences Malmö, Section of Surgery, Lund University, Lund, Sweden
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Sakamaki Y, Ishida D, Tanaka R. Prognosis of patients with recurrence after pulmonary metastasectomy for colorectal cancer. Gen Thorac Cardiovasc Surg 2020; 68:1172-1178. [PMID: 32323124 DOI: 10.1007/s11748-020-01368-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/11/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES We investigated the prognosis of patients with recurrence of pulmonary metastases (PM) from colorectal cancer (CRC) after resection. METHODS We reviewed our surgical series of 101 CRC patients with PM who underwent R0 resection with curative intent. The overall survival (OS) and disease-free survival (DFS) rates after metastasectomy as well as the prognostic factors of survival were analyzed. RESULTS Fifty-five patients (54%) experienced recurrence, of whom 21 had developed extrapulmonary metastasis (EPM) before lung resection. Multivariate analysis restricted to patients with recurrence identified a disease-free interval (DFI) shorter than a year as an adverse prognosticator of OS (HR, 2.68; 95% CI 1.40-5.51; P < 0.01) and DFS (HR, 8.54; 95% CI 3.0-24.6; P < 0.001). EPM was also identified as an adverse prognosticator of OS for patients with recurrence (HR, 3.16; 95% CI 1.64-5.88; P < 0.001). There was a significant difference in the 5-year OS rate between patients with and without EPM (27.9% vs 64.9%, P < 0.001), and between those with a DFI shorter and longer than a year (40.0% vs 75.0%, P < 0.01). Among these, 31 patients (56%) bore lung-limited recurrence after their first lung resection, of whom 20 (36%) underwent a total of 29 repeat pulmonary metastasectomies, which resulted in a 5-year OS rate of 71.3% after the second lung resection. CONCLUSIONS Our findings indicate that CRC patients with PM whose DFI is shorter than a year after lung resection or those with prior EPM more frequently experience multisite recurrence.
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Affiliation(s)
- Yasushi Sakamaki
- Department of Chest Surgery, Osaka Police Hospital, Kitayamacho 10-31, Tennoji, Osaka, 543-8502, Japan.
| | - Daisuke Ishida
- Department of Chest Surgery, Osaka Police Hospital, Kitayamacho 10-31, Tennoji, Osaka, 543-8502, Japan
| | - Ryo Tanaka
- Department of Chest Surgery, Osaka Police Hospital, Kitayamacho 10-31, Tennoji, Osaka, 543-8502, Japan
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Kim YI, Song KB, Lee YJ, Park KM, Hwang DW, Lee JH, Shin SH, Kwon JW, Ro JS, Kim SC. Management of isolated recurrence after surgery for pancreatic adenocarcinoma. Br J Surg 2019; 106:898-909. [PMID: 31162655 DOI: 10.1002/bjs.11144] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 07/10/2018] [Accepted: 01/25/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Recurrence of pancreatic cancer after primary pancreatectomy occurs in the vast majority of patients. The role of surgical treatment for recurrent pancreatic cancer is not well established. METHODS Patients who underwent primary pancreatectomy with curative intent from 2000 to 2014 at a single large-volume centre were evaluated retrospectively. CT or PET was used to select patients with an isolated recurrence. The clinicopathological features and survival outcomes were compared according to treatment modalities. RESULTS Of the 1610 patients with pancreatic cancer who underwent resection, 1346 (83·6 per cent) were diagnosed with recurrent pancreatic cancer. Recurrence was locoregional in 366 patients (27·2 per cent), distant multifocal in 251 (18·6 per cent), distant isolated in 188 (14·0 per cent), locoregional plus distant in 153 (11·4 per cent) and peritoneal seeding in 388 (28·8 per cent). Of the 1346 patients with recurrence, 197 (14·6 per cent) had isolated recurrence; of these, 48 (24·4 per cent of all isolated recurrences; 3·6 per cent of all recurrences) underwent resection. Median survival of the 197 patients after diagnosis of isolated recurrence was 14·7 months; it was longer in patients who underwent surgical resection than among those treated non-surgically (23·5 versus 12·0 months; P = 0·014). Multivariable analysis showed that chemotherapy and resection for recurrence were associated with better prognosis. Median survival after recurrence was longest in the 23 patients with isolated pulmonary recurrence (33·3 months). Survival after recurrence was better in patients who underwent resection of isolated recurrence in the remnant pancreas (median 28·0 versus 12·0 months, P = 0·010) and lung (median 36·5 versus 9·5 months; P = 0·010) than in those who did not undergo resection. CONCLUSION Surgical resection may be considered an option for treatment of patients with isolated recurrent pancreatic cancer.
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Affiliation(s)
- Y I Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
| | - K B Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
| | - Y-J Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
| | - K-M Park
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
| | - D W Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
| | - J H Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
| | - S H Shin
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
| | - J W Kwon
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
| | - J-S Ro
- Clinical Preventive Medicine Centre, Seoul National University Bundang Hospital, Bundang-gu, South Korea
| | - S C Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
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Rajakannu M, Magdeleinat P, Vibert E, Ciacio O, Pittau G, Innominato P, SaCunha A, Cherqui D, Morère JF, Castaing D, Adam R. Is Cure Possible After Sequential Resection of Hepatic and Pulmonary Metastases From Colorectal Cancer? Clin Colorectal Cancer 2018; 17:41-49. [DOI: 10.1016/j.clcc.2017.06.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 06/16/2017] [Indexed: 12/17/2022]
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Kim S, Kim HK, Cho JH, Choi YS, Kim K, Kim J, Zo JI, Shim YM, Heo JS, Lee WY, Kim HC. Prognostic factors after pulmonary metastasectomy of colorectal cancers: influence of liver metastasis. World J Surg Oncol 2016; 14:201. [PMID: 27473725 PMCID: PMC4966704 DOI: 10.1186/s12957-016-0940-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 07/08/2016] [Indexed: 12/23/2022] Open
Abstract
Background Our objective was to evaluate the influence of liver metastasis on survival after pulmonary metastasectomy in patients with colorectal cancer (CRC). Methods We retrospectively reviewed a total of 524 patients and were classified into two groups based on the presence of liver metastasis. Group HM + PM (n = 106) included patients who previously received a hepatic metastasectomy and then received pulmonary metastasectomy. Group PM (n = 418) included patients who only received pulmonary metastasectomy with no liver metastasis. Results There were more male patients (70 vs. 57 %; P = 0.02) and more patients with colon cancer (60 vs. 42 %, P = 0.001) in group HM + PM than in group PM. Otherwise, there was no significant difference between the two groups in clinicopathologic characteristics and extent of surgery. The 5-year overall survival (OS) and disease-free survival (DFS) rates were 58 and 31 %, respectively. There was no significant difference in OS (group HM + PM, 54 % vs. group PM, 59 %; P = 0.085) and in DFS (group HM + PM, 28 % vs. group PM, 32 %; P = 0.12). For the entire patient cohort, a multivariate analysis revealed that the presence of liver metastasis, CRC T and N stages, disease-free interval, and number and size of lung metastases were significantly associated with OS and DFS. Conclusions Our findings suggest that previous or present liver metastasis should not exclude a patient from pulmonary metastasectomy. When lung metastasis is detected in patients with a history of hepatic metastasectomy, pulmonary metastasectomy is still a viable treatment option especially in patients with a long disease-free interval and a small number of lung metastases.
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Affiliation(s)
- Seok Kim
- Department of Thoracic and Cardiovascular Surgery; Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, 06351, South Korea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery; Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, 06351, South Korea.
| | - Jong Ho Cho
- Department of Thoracic and Cardiovascular Surgery; Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, 06351, South Korea
| | - Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery; Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, 06351, South Korea
| | - Kwhanmien Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Gyeonggi-do, 13620, South Korea
| | - Jhingook Kim
- Department of Thoracic and Cardiovascular Surgery; Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, 06351, South Korea
| | - Jae Ill Zo
- Department of Thoracic and Cardiovascular Surgery; Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, 06351, South Korea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery; Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, 06351, South Korea
| | - Jin Seok Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Woo Yong Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Hee Cheol Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
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Zitt M, DeVries A, Thaler J, Kafka-Ritsch R, Eisterer W, Lukas P, Öfner D. Long-term surveillance of locally advanced rectal cancer patients with neoadjuvant chemoradiation and aggressive surgical treatment of recurrent disease: a consecutive single-centre experience. Int J Colorectal Dis 2015; 30:1705-14. [PMID: 26293791 DOI: 10.1007/s00384-015-2366-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this study was to analyse the long-term outcome of rectal cancer patients who submitted to preoperative chemoradiation with consecutive intensive follow-up and aggressive surgical treatment of recurrent disease. METHODS Patients with locally advanced (cT3-4 Nx M0-1) mid/low rectal cancer were treated at a tertiary university hospital with preoperative long-course chemoradiation followed by resection (according to a prospective study protocol). After resection, all patients were urged to participate in a standardised, risk-independent intensive follow-up program. All curatively treated patients (n = 153, 96 %) were included in our long-term analysis with respect to curative re-resection of recurrent disease. RESULTS Of 153 patients, 143 (93 %) participated in our follow-up program: 63 % were surveyed longer than 5 years after primary therapy (mean follow-up 75 months, 95 % CI 67.8-82.2). Fifty-five (36 %) patients developed cancer recurrence (mean 27.8 months, 95 % CI 20.6-34.9, range 3-108), giving a disease-free survival rate of 68.5 and 60.7 % at 5 and 10 years; 21 (38 %) patients were re-resected curatively and 58 (38 %) patients died during the observation period, giving an overall survival rate of 70.8 and 57.5 % at 5 and 10 years. Multivariate analysis found tumour differentiation (P < 0.01), operative procedure (P < 0.05) and downstaging (P < 0.01) to be independent variables influencing overall survival. CONCLUSIONS The combination of multimodal therapy and aggressive surgical treatment of metastases including repeated re-resections in curative intention is relevant in order to chronify the disease. Thus, both intensive and extended follow-up beyond 5 years appear to be mandatory.
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Affiliation(s)
- Matthias Zitt
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Innsbruck Medical University, Anichstrasse 35, A-6020, Innsbruck, Austria.
| | - Alexander DeVries
- Department of Radiotherapy-Radiooncology, Innsbruck Medical University, Innsbruck, Austria.,Department of Radiooncology, Feldkirch Hospital, Feldkirch, Austria
| | - Josef Thaler
- Department of Internal Medicine V, Innsbruck Medical University, Innsbruck, Austria.,Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Reinhold Kafka-Ritsch
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Innsbruck Medical University, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Wolfgang Eisterer
- Department of Internal Medicine V, Innsbruck Medical University, Innsbruck, Austria
| | - Peter Lukas
- Department of Radiotherapy-Radiooncology, Innsbruck Medical University, Innsbruck, Austria
| | - Dietmar Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Innsbruck Medical University, Anichstrasse 35, A-6020, Innsbruck, Austria
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Shibata J, Kawai K, Nishikawa T, Tanaka T, Tanaka J, Kiyomatsu T, Hata K, Nozawa H, Kazama S, Yamaguchi H, Ishihara S, Sunami E, Kitayama J, Sugihara K, Watanabe T. Prognostic Impact of Histologic Type in Curatively Resected Stage IV Colorectal Cancer: A Japanese Multicenter Retrospective Study. Ann Surg Oncol 2015; 22 Suppl 3:S621-9. [DOI: 10.1245/s10434-015-4846-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Indexed: 12/21/2022]
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Cokmert S, Ellidokuz H, Demir L, Fuzun M, Astarcioglu I, Aslan D, Yilmaz U, Oztop I. Survival outcomes of liver metastasectomy in colorectal cancer cases: a single-center analysis in Turkey. Asian Pac J Cancer Prev 2015; 15:5195-200. [PMID: 25040974 DOI: 10.7314/apjcp.2014.15.13.5195] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was to analyze our series of liver resections for metastatic colorectal carcinoma (mCRC) to determine prognostic factors affecting survival and to evaluate the potential roles of neoadjuvant or adjuvant chemotherapy. MATERIALS AND METHODS Ninety-nine patients who underwent metastasectomy for liver metastases due to colorectal cancer at the Department of Medical Oncology, 9 Eylul University Hospital between 1996 and 2010 were evaluated in this study. The patients were followed through July 2013. Demographic, perioperative, laboratory, radiological and chemotherapy as well as survival data were obtained by retrospective chart review. RESULTS In 47 (47.5%) patients, liver metastases were unresectable at initial evaluation; the remaining 52 (52.5%) patients exhibited resectable liver metastases. Simultaneous hepatic resection was applied to 52 (35.4%) patients with synchronous metastasis, whereas 5 (64.5%) patients underwent hepatic resection after neoadjuvant chemotherapy. Forty-two patients with metachronous metastasis underwent hepatic resection following neoadjuvant chemotherapy. R0 resection was obtained in 79 (79.8%) patients. A second hepatectomy was performed in 22 (23.2%) patients. Adjuvant chemotherapy was given to 85 (85.9%) patients after metastasectomy. The median disease-free and overall survivals after initial metastasectomy were 12 and 37 months, respectively, the 1-year, 3-year and 5-year disease-free survival (DFS) and overall survival (OS) rates being 46.5%, 24.3% and 17.9%and 92.3%, 59.0% and 39.0%, respectively. On multivariate analysis, the primary tumor site, tumor differentiation, resection margin and DFS were independent factors predicting better overall survival. CONCLUSIONS In selected cases, hepatic metastasectomy for mCRC to the liver can result in long-term survival. Neoadjuvant chemotherapy did not exert a positive effect on DFS or OS. Adjuvant chemotherapy also did not appear to impact DFS and OS.
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Affiliation(s)
- Suna Cokmert
- Department of Basic Oncology, Institute of Oncology, Dokuz Eylul University, Izmir, Turkey E-mail :
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Minimally invasive surgery using the open magnetic resonance imaging system combined with video-assisted thoracoscopic surgery for synchronous hepatic and pulmonary metastases from colorectal cancer: report of four cases. Surg Today 2014; 45:652-8. [PMID: 25096001 DOI: 10.1007/s00595-014-1002-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 04/01/2014] [Indexed: 01/17/2023]
Abstract
Simultaneous resection of hepatic and pulmonary metastases (HPM) from colorectal cancer (CRC) has been reported to be effective, but it is also considered invasive. We report the preliminary results of performing minimally invasive surgery using the open magnetic resonance (MR) imaging system to resect synchronous HPM from CRC in four patients. All four patients were referred for thoracoscopy-assisted interventional MR-guided microwave coagulation therapy (T-IVMR-MCT) combined with video-assisted thoracoscopic surgery (VATS). The median diameters of the HPM were 18.2 and 23.2 mm, respectively. The median duration of VATS and T-IVMR-MCT was 82.5 and 139 min, respectively. All patients were discharged without any major postoperative complications. One patient was still free of disease at 24 months and the others died of disease progression 13, 36, and 47 months without evidence of recurrence in the treated area. Thus, simultaneous VATS + T-IVMR-MCT appears to be an effective option as a minimally invasive treatment for synchronous HPM from CRC.
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Kim HK, Cho JH, Lee HY, Lee J, Kim J. Pulmonary metastasectomy for colorectal cancer: How many nodules, how many times? World J Gastroenterol 2014; 20:6133-6145. [PMID: 24876735 PMCID: PMC4033452 DOI: 10.3748/wjg.v20.i20.6133] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 11/01/2013] [Accepted: 03/05/2014] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) is one of the most common cancers worldwide, with 5%-15% of CRC patients eventually developing lung metastasis (LM). Despite doubts about the role of locoregional therapy in the management of systemic disease, many surgeons have performed pulmonary metastasectomy (PM) for CRC in properly selected patients. However, the use of pulmonary metastasectomy remains controversial due to the lack of randomized controlled studies. This article reviews the results of surgical treatment of pulmonary metastases for CRC, focusing on (1) current treatment guidelines and surgical techniques of PM in patients with LM from CRC; (2) outcomes of PM and its prognostic factors; and (3) controversial issues in PM, focusing on repeated metastasectomy, bilateral multiple metastases, and combined liver and lung metastasectomy.
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Hattori N, Kanemitsu Y, Komori K, Shimizu Y, Sano T, Senda Y, Mitsudomi T, Fukui T. Outcomes after hepatic and pulmonary metastasectomies compared with pulmonary metastasectomy alone in patients with colorectal cancer metastasis to liver and lungs. World J Surg 2014; 37:1315-21. [PMID: 23435701 DOI: 10.1007/s00268-013-1954-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Norifumi Hattori
- Department of Gastroenterological Surgery, Aichi Cancer Center, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan.
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Analysis of treatment that includes both hepatic and pulmonary resections for colorectal metastases. Surg Today 2013; 44:702-11. [PMID: 24170275 DOI: 10.1007/s00595-013-0769-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 03/04/2013] [Indexed: 12/23/2022]
Abstract
PURPOSE Hepatic or pulmonary resections for colorectal metastases are regarded as standard treatment worldwide; however, the clinical significance of both hepatic and pulmonary resections for colorectal metastases remains undefined. We reviewed our clinical experience to evaluate the benefit of this treatment. METHODS Between 1986 and 2010, 186 patients underwent potentially curative hepatic and/or pulmonary resections for colorectal metastases. Of these patients, 25 underwent both treatments (Group C), 100 underwent hepatic resections alone (Group H), and 61 underwent pulmonary resections alone (Group L). Univariate and multivariate analyses of the clinical and pathological variables in Group C and comparative survival analyses between Group C and Groups H-L were performed. RESULTS In Group C, the median survival after primary tumor resection, initial metastasectomy, and last metastasectomy were 97, 60, and 35 months, respectively, and the 5-year overall survival rates were 63, 54, and 38%, respectively. Multivariate analyses after initial metastasectomy revealed rectal tumors, multiple hepatic tumors, and simultaneous metastases as poor prognostic factors. Comparative survival analyses revealed no significant difference in overall survival between Group C and Groups H-L. CONCLUSION Hepatic and pulmonary resections for colorectal metastases improve survival and may even offer the potential for cure in selected patients.
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Salah S, Watanabe K, Park JS, Addasi A, Park JW, Zabaleta J, Ardissone F, Kim J, Riquet M, Nojiri K, Gisabella M, Kim SY, Tanaka K. Repeated resection of colorectal cancer pulmonary oligometastases: pooled analysis and prognostic assessment. Ann Surg Oncol 2013; 20:1955-61. [PMID: 23334254 DOI: 10.1245/s10434-012-2860-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Repeated resection of colorectal cancer pulmonary metastasis is associated with long-term survival. Nevertheless, very limited data addressing the best candidates for repeated pulmonary resection is available. PATIENTS AND METHODS We searched the PubMed database for retrospective studies evaluating lung metastasectomy for metastatic colorectal cancer (CRC). We included studies with available data about repeated pulmonary metastasectomy. Potential prognostic factors were analyzed for possible impact on survival following the second metastasectomy through univariate and multivariate analysis. RESULTS Between 1983 and 2008, 944 lung metastasectomies were carried out on 759 patients. Of those, 148 patients had a second metastasectomy. The 5-year survival rate was 52 % for patients who had 1 metastasectomy and 57.9 % from the second metastasectomy for patients who had repeated resection. More than 2 metastatic pulmonary nodules and maximum diameter of largest pulmonary nodule ≥3 cm were the only independent factors associated with inferior survival following repeated pulmonary resection. CONCLUSIONS In selected patients with metastatic CRC, repeated pulmonary metastasectomy offers an excellent chance for long-term survival and is associated with a quite low operative mortality. Patients with more than 2 metastatic nodules and a maximum diameter of the largest metastatic lung nodule of ≥3 cm have a significantly inferior survival.
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Affiliation(s)
- Samer Salah
- Medical Oncology Department, King Hussein Cancer Center, Amman, Jordan.
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Meimarakis G, Angele M, Conrad C, Schauer R, Weidenhagen R, Crispin A, Giessen C, Preissler G, Wiedemann M, Jauch KW, Heinemann V, Stintzing S, Hatz RA, Winter H. Combined resection of colorectal hepatic-pulmonary metastases shows improved outcome over chemotherapy alone. Langenbecks Arch Surg 2013; 398:265-76. [PMID: 23314791 DOI: 10.1007/s00423-012-1046-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 12/29/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND The objective of this retrospective study was to assess the survival of patients after resection of hepatic and pulmonary colorectal metastases to identify predictors of long-term survival. METHODS Patients receiving chemotherapy alone were compared to patients receiving surgery and chemotherapy in a matched-pair analysis with the following criteria: UICC stage, grading, and date of initial primary tumor occurrence. RESULTS A total of 30 patients with liver and lung metastases of colorectal carcinoma underwent resection. In 20 cases, complete resection was achieved (median survival, 67 months). Incomplete resection and preoperatively elevated carcinoembryonic antigen (CEA) levels are independent risk factors for reduced survival. Patients developing pulmonary metastases prior to hepatic metastases had the worst prognosis. Surgical resection significantly increased survival compared to chemotherapy alone in matched-pair analysis (65 vs. 30 months, p = 0.03). CONCLUSIONS Incomplete resection and elevated CEA levels are predictors of poor outcome. Matched-paired analysis confirmed that surgical resection in combination with chemotherapy appears to be superior to chemotherapy alone.
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Affiliation(s)
- Georgios Meimarakis
- Department of General Thoracic Surgery, University of Munich-Grosshadern, Marchioninistrasse 15, Munich, Germany
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16
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The role of liver resection for colorectal cancer metastases in an era of multimodality treatment: A systematic review. Surgery 2012; 151:860-70. [DOI: 10.1016/j.surg.2011.12.018] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Accepted: 12/22/2011] [Indexed: 12/14/2022]
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Hornbech K, Ravn J, Steinbrüchel DA. Outcome after Pulmonary Metastasectomy: Analysis of 5 Years Consecutive Surgical Resections 2002–2006. J Thorac Oncol 2011; 6:1733-40. [DOI: 10.1097/jto.0b013e3182287da2] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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18
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Cohort Study of the Survival Benefit of Resection for Recurrent Hepatic and/or Pulmonary Metastases After Primary Hepatectomy for Colorectal Metastases. Ann Surg 2010; 251:902-9. [DOI: 10.1097/sla.0b013e3181c9868a] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Fiorentino F, Hunt I, Teoh K, Treasure T, Utley M. Pulmonary metastasectomy in colorectal cancer: a systematic review and quantitative synthesis. J R Soc Med 2010; 103:60-6. [PMID: 20118336 DOI: 10.1258/jrsm.2009.090299] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Surgical removal of pulmonary metastases from colorectal cancer is undertaken increasingly but the practice is variable. There have been no randomized trials of effectiveness. We needed evidence from a systematic review to plan a randomized controlled trial. DESIGN A formal search for all studies concerning the practice of pulmonary metastasectomy was undertaken including all published articles using pre-specified keywords. Abstracts were screened, reviewed and data extracted by at least two of the authors. Information across studies was collated in a quantitative synthesis. RESULTS Of 101 articles identified, 51 contained sufficient quantitative information to be included in the synthesis. The reports were published between 1971 and 2007, and reported on 3504 patients. There was little change over time in patient characteristics such as age, sex, the time elapsed since resection of the primary cancer, its site or stage. The proportion with multiple metastases or elevated carcinoma embryonic antigen (CEA) did not change over time but there was an apparent increase in the proportion of patients who also had hepatic metastasectomy. Differences in 5-year survival between groups defined by CEA or by single versus multiple metastases persisted over time. Few data were available concerning postoperative morbidity, postoperative lung function or change in symptoms. CONCLUSION The quality of evidence available concerning pulmonary metastasectomy in colorectal cancer is not sufficient to draw inferences concerning the effectiveness of this surgery. There is great variety in what was reported and its utility. Given the burdensome nature of the surgery involved, better evidence, ideally in the form of a randomized trial, is required for the continuance of this practice.
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Affiliation(s)
- Francesca Fiorentino
- Clinical Operational Research Unit, Department of Mathematics, University College London London WC1H 0BT
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Limmer S, Oevermann E, Killaitis C, Kujath P, Hoffmann M, Bruch HP. Sequential surgical resection of hepatic and pulmonary metastases from colorectal cancer. Langenbecks Arch Surg 2010; 395:1129-38. [PMID: 20165954 PMCID: PMC2974188 DOI: 10.1007/s00423-010-0595-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 01/13/2010] [Indexed: 12/27/2022]
Abstract
BACKGROUND Resection of isolated hepatic or pulmonary metastases from colorectal cancer is widely accepted and associated with a 5-year survival rate of 25-40%. The value of aggressive surgical management in patients with both hepatic and pulmonary metastases still remains a controversial area. MATERIALS AND METHODS A retrospective review of 1,497 patients with colorectal carcinoma (CRC) was analysed. Of 73 patients identified with resection of CRC and, at some point in time, both liver and lung metastases, 17 patients underwent metastasectomy (resection group). The remaining 56 patients comprised the non-resection group. Primary tumour, hepatic and pulmonary metastases of all patients were surgically treated in our department of surgery, and the results are that of a single institution. RESULTS The resection group had a 3-year survival of 77%, a 5-year survival of 55% and a 10-year survival of 18%; median survival was 98 months. The longest overall survival was 136 months; six patients are still alive. In the resection group, overall survival was significantly higher than in the non-resection group (p < 0.01). Independent from the chronology of metastasectomy, 5-year survival was 55% with respect to the primary resection, 28% with respect to the first metastasectomy and 14% with respect to the second metastasectomy. A disease-free interval (>18 months), stage III (UICC) and age (<70 years) were found to be significant prognostic factors for overall survival. CONCLUSION Our report strongly supports aggressive surgical therapy in patients with both hepatic and pulmonary metastases from CRC. Overall survival for surgically treated selected patients with both hepatic and pulmonary metastases from CRC is comparable to hepatic or pulmonary metastasectomy. Simultaneous metastases tend to have a poorer outcome than metachronous metastases.
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Affiliation(s)
- Stefan Limmer
- Department of Surgery, University Hospital of Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538, Luebeck, Germany.
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Kosmider S, Stella DL, Field K, Moore M, Ananda S, Oakman C, Singh M, Gibbs P. Preoperative investigations for metastatic staging of colon and rectal cancer across multiple centres--what is current practice? Colorectal Dis 2009; 11:592-600. [PMID: 18624816 DOI: 10.1111/j.1463-1318.2008.01614.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The optimal strategy for elective distant staging of colorectal carcinoma (CRC) has yet to be defined, with current guidelines based on small and limited series. One specific issue requiring review is the value of routine computerized tomographic (CT) chest examination. Also lacking is data on current routine clinical practice. METHOD A retrospective chart review of consecutive cases of elective surgery for CRC from five hospitals. RESULTS Two hundred and fifty-seven cases were reviewed, 128 colon and 129 rectal primaries. 164 (64%) of patients overall, ranging from 45% to 88% across the individual centres, had a preoperative serum CEA level performed. CT abdomen/pelvis was performed in 222 (86%) of cases, ranging from 69% to 98% per centre. CT chest was performed in 95 (37%) of cases, 47% of rectal vs 29% of colon cancers (P = 0.004). In 17 cases (18%) CT chest examinations revealed abnormalities suspicious for metastatic disease, leading to a change in management in six (35%) of these cases. Of the 17 cases with an abnormal CT chest, in only 5 of the 14 (36%) where carcinoembryonic antigen (CEA) levels were also recorded was this increased, and in only three (21%) was this markedly (> 10 microg/l) elevated. CONCLUSIONS Substantial variability exists in the preoperative evaluation of patients with CRC. Many patients do not have a CEA and/or abdominal imaging performed. Where performed, CT chest revealed suspicious findings in a significant number of patients, the vast majority of whom had a normal or near normal CEA. Future studies are required to define optimal preoperative staging.
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Affiliation(s)
- S Kosmider
- Western Hospital, Footscray Victoria and BioGrid Australia, Parkville, Victoria, Australia.
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Konopke R, Kersting S, Makowiec F, Gassmann P, Kuhlisch E, Senninger N, Hopt U, Saeger HD. Resection of colorectal liver metastases: is a resection margin of 3 mm enough? : a multicenter analysis of the GAST Study Group. World J Surg 2009; 32:2047-56. [PMID: 18521661 DOI: 10.1007/s00268-008-9629-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND A safety margin of > or =10 mm is generally accepted in surgery for colorectal metastases. It is reasonable that modern methods of liver parenchyma dissection may allow for a reduction in this distance. METHODS A total of 333 patients were included in a multicenter trial after resection of colorectal liver metastases. Dissection of the liver had been performed with a CUSA, UltraCision, or water-jet dissector. The size of the resection margin was correlated with recurrence risk and survival. RESULTS The median hepatic recurrence-free survival reached 35 months for all patients; median recurrence-free survival was 24 months and overall survival was 41 months. Univariate analysis of different groups denoting the extent of resection margin (> or =10 mm, 6-9 mm, 3-5 mm, 1-2 mm, 0 mm (R1)) indicated that a margin of 1-2 mm leads to a significantly reduced median hepatic recurrence-free survival of 20 months (p = 0.004) and recurrence-free survival of 19 months (p = 0.011). Patients with R1 resection had the worst prognosis. Overall survival was not influenced by the size of the resection margin. Surgical margins were significantly reduced in simultaneous resections of four or more liver metastases and in cases in which metastatic infiltration of central liver segments was present. At multivariate analysis, resection margins of 1-2 mm and 0 mm were independent predictors of hepatic recurrence and overall recurrence. CONCLUSION The indication for resection of metastases can be safely extended to cases in which tumors sit closer than 1 cm to nonresectable structures.
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Affiliation(s)
- Ralf Konopke
- Department of General, Thoracic and Vascular Surgery, University of Dresden, Fetscherstr. 74, 01307 Dresden, Germany
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Abstract
The management of advanced colorectal cancer has changed dramatically during the last decade. By redefining resectability, and with the use of modern chemotherapy, nearly 10% of unresectable patients are now alive 5 years after diagnosis, and, overall, 20% are alive at 5 years when the combined results of surgery and chemotherapy are considered. These achievements are not reflected in the current staging, which categorizes all disease spread beyond the lymph node basin of the primary tumor as unstratified stage 4. This article discusses the merits of a number of proposals for a new, meaningful staging system for advanced colorectal cancer.
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Affiliation(s)
- Graeme J Poston
- Division of Digestive Diseases, Critical Care and Anesthesia, Center for Digestive Diseases, University Hospital Aintree, Lower Lane, Liverpool L9 7AL, UK.
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Takahashi S, Nagai K, Saito N, Konishi M, Nakagohri T, Gotohda N, Nishimura M, Yoshida J, Kinoshita T. Multiple resections for hepatic and pulmonary metastases of colorectal carcinoma. Jpn J Clin Oncol 2008; 37:186-92. [PMID: 17472970 DOI: 10.1093/jjco/hym006] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Resections are effective for some patients with both hepatic and pulmonary metastases of colorectal cancer, but the best selection criteria for the resections and effective treatment for recurrence after the resections have not been determined. METHODS A retrospective analysis was performed for 30 consecutive patients who received aggressive multiple resections for both hepatic and pulmonary metastases of colorectal cancer. Recurrences after resections were surgically treated whenever resectable. RESULTS For the 30 patients, 45 hepatectomies and 40 pulmonary resections were performed and 17 patients received three or more resections. No mortality was observed. Overall survival after the first metastasectomy for the second organ (liver or lung) was 58% and nine 5-year survivors were observed. Multivariate analyses revealed that primary colon cancer, stage IV in TNM classification and maximum size of hepatic tumor >3 cm at initial hepatectomy were poor prognostic factors, but several long-term survivors were observed even among patients with those factors. CONCLUSIONS Multiple resections for hepatic and pulmonary metastases of colorectal cancer are safe and effective. No single factor is considered to be a contraindication for the resections. For recurrence after the resections, surgical resection is also recommended if resectable.
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Affiliation(s)
- Shinichiro Takahashi
- Department of Hepato-biliary National Cancer Center Hospital East, Kashiwa, Chiba, Japan.
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26
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Kosmider S, Field K, Jefford M, Jennens R, Gibbs P. Surveillance following treatment for colorectal cancer in Australia. Has best practice been adopted by medical oncologists? Intern Med J 2008; 38:415-21. [PMID: 17725608 DOI: 10.1111/j.1445-5994.2007.01482.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intensive follow up after surgery for colorectal cancer is associated with a significant survival advantage and is endorsed by expert panels, but are physicians convinced of the benefit? METHODS A questionnaire was mailed to all members of the Medical Oncology Group of Australia, assessing surveillance practices after completion of adjuvant treatments. RESULTS Responses were obtained from 141 (55%) medical oncologists of which 121 were considered evaluable. Thirteen per cent (n = 16) routinely did not carry out follow-up investigations. Of those carrying out surveillance, 47% (n = 51) nominated identifying potentially resectable metastatic disease as prime consideration. Many (44%) were motivated by patient reassurance and expectation. Carcinoembryonic antigen levels were commonly monitored 3 monthly in years 1 (77%, n = 85) and 2 (57%, n = 63) and 6 monthly thereafter (67%, n = 74). Eighty per cent (n = 88) carried out computed tomography (CT) surveillance 1 year after surgery, 69% (n = 76) at year 2 and 55% (n = 60) at year 3. Twenty-six per cent (n = 29) continued scanning annually up to 5 years. Inclusion of CT chest was routine for 33% (n = 36) and never carried out by 11% (n = 12). CONCLUSION A significant minority (13%) of oncologists carry out no follow-up investigations, despite level I evidence of a survival advantage similar to standard adjuvant therapies. Further education and study of physician attitudes and reservations to routine surveillance are required.
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Affiliation(s)
- S Kosmider
- Department of Medical Oncology, Royal Melbourne Hospital, University of Melbourne, Royal Parade, Parkville, Vic. 3052, Australia
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Joosten J, Bertholet J, Keemers-Gels M, Barendregt W, Ruers T. Pulmonary resection of colorectal metastases in patients with or without a history of hepatic metastases. Eur J Surg Oncol 2008; 34:895-899. [PMID: 18280692 DOI: 10.1016/j.ejso.2008.01.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2007] [Accepted: 01/08/2008] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION In selected patients with isolated colorectal lung or liver metastases resection can provide an increase in overall survival and even cure. Here, we evaluate whether also patients with combined or sequential metastatic disease to liver and lung may still be candidates for surgical resection. METHODS From 1997 till 2006 39 patients underwent pulmonary metastasectomy. Two subgroups were identified: resection of pulmonary metastases only (PM) and resection of hepatic and later pulmonary metastases (LPM). RESULTS Patient characteristics were identical in both groups. Median follow-up in group PM was 35 months and 38 months in group LPM. Two-year survival in group PM was 61%, and in group LPM 81% (p=NS). Five-year survival was 30% and 20% in PM and LPM groups, respectively (p=NS). The median disease free survival was 12 months in the PM group and 13 months in the LPM group. The extent of pulmonary resection had no impact on survival. Complications occurred in seven patients in the PM group and two patients in the LPM group. Complication rate and severity were related to the extent of pulmonary resection. A small group of patients underwent repeated pulmonary resection without serious complications. CONCLUSION Resection of pulmonary colorectal metastases may improve survival, even in patients who underwent hepatic resection for colorectal liver metastases at an earlier stage.
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Affiliation(s)
- J Joosten
- Department of Surgery, C22, Canisius Wilhelmina Hospital, P.O. Box 9015, 9500 GS, Nijmegen, The Netherlands.
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Lim E, Thomson BNJ, Heinze S, Chao M, Gunawardana D, Gibbs P. Optimizing the approach to patients with potentially resectable liver metastases from colorectal cancer. ANZ J Surg 2008; 77:941-7. [PMID: 17931254 DOI: 10.1111/j.1445-2197.2007.04287.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Liver metastases are a common event in colorectal carcinoma. Significant advances have been made in managing these patients in the last decade, including improvements in staging and surgical techniques, an increasing armamentarium of chemotherapeutics and multiple local ablative techniques. While combination chemotherapy significantly improves median patient survival, surgical resection provides the only prospect of cure and is the focus of this review. Interpretation of published work in this field is challenging, particularly as there is no consensus to what is resectable disease. Of particular interest recently has been the use of neoadjuvant treatment for downstaging and downsizing disease in patients with initially unresectable liver metastases, in the hope of response leading to potentially curative surgery. This review summarizes the recent developments and consensus guidelines in the areas of staging, chemotherapy, local ablative techniques, radiation therapy and surgery, emphasizing the multidisciplinary approach to this disease and ongoing controversies in this field and examines the changing paradigms in the management of colorectal hepatic metastases.
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Affiliation(s)
- Elgene Lim
- The Walter & Eliza Hall Institute of Medical Research, Department of Surgery, Royal Melbourne Hospital, Victoria, Australia
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29
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de Jong KP. Review article: Multimodality treatment of liver metastases increases suitability for surgical treatment. Aliment Pharmacol Ther 2007; 26 Suppl 2:161-9. [PMID: 18081659 DOI: 10.1111/j.1365-2036.2007.03484.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Liver metastases of colorectal cancer occur frequently, but only 10-20% are eligible for liver surgery. Recent new developments changed the concepts of treating patients with colorectal liver metastases. AIM To describe the available modalities that can result in increasing resectability rate. METHODS Potentials and drawbacks of portal vein embolization, radiofrequency ablation (RFA), trans-ablated tumour hepatectomy, neoadjuvant chemotherapy and the approach to patients with extrahepatic metastases are described. RESULTS Portal vein embolization is a well-established technique to increase the volume of the future liver remnant. RFA should be applied if partial liver resection alone cannot make the liver tumour-free. Neoadjuvant chemotherapy in patients with unresectable liver metastases can result in secondary resectability rates of 15-40%. Hepatotoxicity can lead to a higher complication rate after partial liver resection. A limited number of extrahepatic tumour localizations should be resected as well. CONCLUSIONS A more aggressive approach to patients with colorectal liver metastases improves resectability rate and survival. Unfortunately, these new options have not been thoroughly evaluated in randomized controlled trials. For some of these modalities, the currently available results are so promising that it might be difficult to start such trials in the future.
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Affiliation(s)
- K P de Jong
- Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Gan S, Wilson K, Hollington P. Surveillance of patients following surgery with curative intent for colorectal cancer. World J Gastroenterol 2007; 13:3816-23. [PMID: 17657835 PMCID: PMC4611213 DOI: 10.3748/wjg.v13.i28.3816] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Surveillance after resection of colorectal cancer with curative intent is an important component of post-operative care. Clinical review, imaging, colonoscopy, and cost to the community are among significant issues to consider in planning a surveillance regime. This review aims to identify the available evidence for the use of surveillance and its individual components. The literature pertaining to follow-up of patients following potentially curative surgery for colorectal cancer was reviewed in order to formulate a summary of the wide range of clinical practice. There is evidence of improved survival of patients undergoing more intense follow-up compared with those having minimal surveillance, with an estimated overall 5-year gain of up to 10%. The efficacy of individual components of follow-up regimes remains unclear, but an overall package of ‘intensive’ follow-up including clinical review, liver imaging, and colonoscopy appears to be of benefit. It is cost-effective and can be specialist or community-based.
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Affiliation(s)
- Steven Gan
- Department of Surgery, St George Hospital, Gray Street, Kogarah, NSW 2217, Australia.
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Pfannschmidt J, Dienemann H, Hoffmann H. Surgical resection of pulmonary metastases from colorectal cancer: a systematic review of published series. Ann Thorac Surg 2007; 84:324-38. [PMID: 17588454 DOI: 10.1016/j.athoracsur.2007.02.093] [Citation(s) in RCA: 390] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2007] [Revised: 02/26/2007] [Accepted: 02/28/2007] [Indexed: 12/13/2022]
Abstract
The treatment of patients with pulmonary metastases from colorectal cancer continues to evolve. Recently the use of novel agents as a first-line treatment in metastatic colorectal disease has generated cautious optimism in the oncological community. However, pulmonary metastasectomy remains a mainstay in a multidisciplinary concept for a highly selected subset of patients. A selected group of patients with metastases limited to the lungs may benefit from pulmonary metastasectomy with a 5-year survival rate of up to more than 50%. This review evaluates the current status of surgical resection in pulmonary metastases from colorectal cancer, with special emphasis on prognostic factors that influence survival, as well as on surgical approach and lymph node dissection and its impact on the management of patients with metastatic colorectal disease.
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Welter S, Jacobs J, Krbek T, Krebs B, Stamatis G. Long-term survival after repeated resection of pulmonary metastases from colorectal cancer. Ann Thorac Surg 2007; 84:203-10. [PMID: 17588413 DOI: 10.1016/j.athoracsur.2007.03.028] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2006] [Revised: 03/08/2007] [Accepted: 03/12/2007] [Indexed: 12/18/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the outcome of patients undergoing repeated resection of pulmonary metastases from colorectal cancer and specify factors promising long-term survival. METHODS From January 1993 to December 2003, 175 patients were diagnosed and resected for pulmonary metastases of colorectal cancer. Follow-up information was collected for 169 patients, and 33 (19.5%) had had recurrent metastasectomies up to three times. Their follow-up information was updated in August 2006. The first repeated resection was performed for up to six bilateral metastases, the second and third metastasectomies were each unilateral and for a single metastasis only. Lymph node involvement was present in 5 patients who underwent repeat resections. RESULTS The overall (n = 169) median survival was 47.2 months after the first metastasectomy. The 33 patients with repeated resections had a median survival of 72.6 months, with survival of 53.8% at 5 years and 20.6% at 10 years. After reoperation, age, sex, primary tumor stage, preoperative carcinoembryonic antigen, disease-free interval, prior resection of liver metastases, and lymph node involvement were not found to be of prognostic importance. The only factor that significantly influenced survival was the number of metastases (hazard risk, 1.299). Perioperative mortality even for repeated resections was 0%. CONCLUSIONS Repeated resection of pulmonary metastases secondary to colorectal cancer is safe and can provide long-term survival for highly selected patients.
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Affiliation(s)
- Stefan Welter
- Department of Thoracic Surgery, Ruhrlandklinik, Essen, Germany.
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Yang YYL, Fleshman JW, Strasberg SM. Detection and management of extrahepatic colorectal cancer in patients with resectable liver metastases. J Gastrointest Surg 2007; 11:929-44. [PMID: 17593417 DOI: 10.1007/s11605-006-0067-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Yolanda Y L Yang
- The Permanente Medical Group, Kaiser, South San Francisco, San Francisco, CA, USA
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Turrini O, Viret F, Guiramand J, Lelong B, Bège T, Delpero JR. Strategies for the treatment of synchronous liver metastasis. Eur J Surg Oncol 2007; 33:735-40. [PMID: 17400418 DOI: 10.1016/j.ejso.2007.02.025] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Accepted: 02/19/2007] [Indexed: 12/12/2022] Open
Abstract
AIM Observe the outcomes after complete simultaneous or delayed resection of synchronous liver metastasis (SLM) from colorectal cancer (CRC). METHODS From 1994 to 2005, 119 patients were diagnosed with CRC and SLM; 57 patients had simultaneous resection (group I) and 62 patients had staged resection (group II). Perioperative chemotherapy was considered completed if all expected cycle were administrated. RESULTS Overall survival rates of group I-group II at 1, 3 and 5 years were respectively 91%-93% (p=0,3), 59%-57% (p=0,09) and 32%-25% (p=0,06). The median survival time of group I-group II were respectively 46 months-40 months (p=0,07). There was no statistical difference on survival regarding location of metastasis (p=0,09) or primary tumor location (p=0,2). Patients with simultaneous or staged resection receiving optimal treatment (R0 liver surgery and complete chemotherapy) were respectively 89% and 67% (p=0,04). Twenty three patients developed isolated liver recurrence with higher frequency in staged patients (26% vs 9% p=0,03) without impairment of survival. CONCLUSIONS Because of postoperative morbidity and prolonged tiring treatment, many patients having staged resection were under treated. However we did not observe statistical difference on survival but we supported that simultaneous resection has to be prefer to achieve an optimal treatment. Lung and bone metastasis are the new challenge for oncologists.
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Affiliation(s)
- O Turrini
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France.
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Antoniou A, Lovegrove RE, Tilney HS, Heriot AG, John TG, Rees M, Tekkis PP, Welsh FKS. Meta-analysis of clinical outcome after first and second liver resection for colorectal metastases. Surgery 2006; 141:9-18. [PMID: 17188163 DOI: 10.1016/j.surg.2006.07.045] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2006] [Revised: 07/27/2006] [Accepted: 07/29/2006] [Indexed: 01/29/2023]
Abstract
BACKGROUND The perioperative risk and long-term survival benefit of repeat hepatectomy for patients with liver metastases from colorectal cancer, compared with that of a first liver resection, has been reported with varying results in the literature. METHODS The literature was searched using Medline, Embase, Ovid, and Cochrane databases for all studies published from 1992 to 2006. Two authors independently extracted data using the following outcomes: postoperative complications and mortality; disease recurrence; and long-term survival. Trials were assessed using the modified Newcastle-Ottawa Score. Random-effect meta-analytical techniques were used for analysis. RESULTS Twenty-one studies met the inclusion criteria, comprising 3,741 patients. The use of adjuvant chemotherapy was similar in both groups (odds ratio [OR] = 0.97; 95% confidence interval [CI] = 0.54, 1.74; P = .92), as was the number of hepatic nodules present at the time of first or second resection (weighted mean difference [WMD] = 0.18; 95% CI = -0.22, 0.57; P = .380). Wedge resection was carried out less often at first hepatectomy (39% vs 46%; OR = 0.66; 95% CI = 0.44, 1.00; P = .05). There was significantly less blood loss in patients undergoing first versus second hepatectomy (WMD = 238 ml; 95% CI = 90, 385; P = .002). There was no difference in perioperative morbidity (OR = 1.01; 95% CI = 0.65, 1.55; P = .98), mortality (OR = 1.01; 95% CI = 0.18, 5.72; P = .99) or long-term survival (HR = 0.90; 95% CI = .66, 1.24; P = .530) between groups. CONCLUSIONS Repeat hepatectomy for patients with colorectal cancer metastases is safe and provides survival benefit equal to that of a first liver resection.
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Affiliation(s)
- Anthony Antoniou
- Imperial College London, Department of Biosurgery and Surgical Technology, St. Mary's Hospital, London, UK
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Zitt M, Mühlmann G, Weiss H, Kafka-Ritsch R, Oberwalder M, Kirchmayr W, Margreiter R, Ofner D, Klaus A. Assessment of risk-independent follow-up to detect asymptomatic recurrence after curative resection of colorectal cancer. Langenbecks Arch Surg 2006; 391:369-75. [PMID: 16680479 DOI: 10.1007/s00423-006-0045-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2005] [Accepted: 01/29/2006] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Colorectal cancer is one of the leading causes of cancer death. We analyzed the value of standardized, risk-independent postoperative surveillance. MATERIALS AND METHODS Between 1995 and 2001, 564 patients with colorectal cancer underwent standardized oncologic resection. One hundred thirty-four were unable to take part in the surveillance program, while 430 patients were grouped as follows: group I (n=272, risk-independent follow-up), group II (n=113, follow-up at other departments), and group III (n=45, no follow-up). RESULTS The 5-year cancer-specific survival rate for UICC III and IV was significantly higher in group I (87%) as compared to group II (35%). In group I, the 5-year disease-free survival rate was 70%. Cancer recurrence occurred at mean 17 (+/-12) months after colorectal resection and yielded a 5-year survival rate of 63%. Reresection was performed in 17 (35%) patients, of whom ten remained disease-free (5-year survival rate, 91%). The money spent for one patient's 5-year follow-up was 1665. CONCLUSIONS A standardized, risk-independent follow-up program allows early diagnosis of asymptomatic recurrence of colorectal cancer. Reresection improves the 5-year survival rate in this setting.
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Affiliation(s)
- Matthias Zitt
- Department of General and Transplant Surgery, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
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Abstract
The liver is the most common site of metastases in patients with colorectal cancer (CRC), and hepatic metastases are responsible for fatalities in at least two thirds of patients with colorectal malignancy. However, the only available treatment associated with long-term survival in patients with CRC metastases is liver resection. While recent studies have shown that liver resection achieves a 5-year overall survival from 37% to 58%, only 10% to 20% of patients with colorectal liver metastases are eligible for resection. Pharmacologic developments and conceptual advances in chemotherapy, regional treatment, and aggressive surgical strategies have ultimately changed the current treatment of patients with primary unresectable liver metastases caused by CRC. Patients who were treated by only palliative chemotherapy a few years ago presently have a variety of strategies available to render their disease surgically resectable with the potential for long-term survival. These advances are the result of a strong collaboration between medical oncologists and surgeons. The development of new chemotherapy protocols that offer the potential for curative surgery with optimum timing within the natural history of this metastatic disease is a shared therapeutic challenge.
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Affiliation(s)
- Eric Vibert
- Centre Hépato-biliaire, Hopîtal Paul Brousse Hospital, Assistance Publique / Hôpitaux de Paris, Université de Paris -Sud, Villejuif, France
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Shah SA, Haddad R, Al-Sukhni W, Kim RD, Greig PD, Grant DR, Taylor BR, Langer B, Gallinger S, Wei AC. Surgical resection of hepatic and pulmonary metastases from colorectal carcinoma. J Am Coll Surg 2006; 202:468-75. [PMID: 16500252 DOI: 10.1016/j.jamcollsurg.2005.11.008] [Citation(s) in RCA: 187] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2005] [Revised: 11/07/2005] [Accepted: 11/09/2005] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with hepatic and pulmonary metastases from colorectal cancer (CRC) may benefit from aggressive surgical therapy. We examined the longterm outcomes of patients who underwent both lung and liver resections for colorectal metastases over a 10-year period. STUDY DESIGN Four hundred twenty-three hepatectomies were performed for metastatic CRC between 1992 and 2002 at two university-affiliated hospitals. Patients who underwent both lung and liver resections for metastatic CRC were studied. Demographic, perioperative, and survival data were evaluated by retrospective chart review. Disease-free survival (DFS) and overall survival (OS) were evaluated by Kaplan-Meier analysis and survival curves were compared using the log-rank test. RESULTS Thirty-nine patients underwent both lung and liver resections for metastatic CRC. Eleven patients (28%) underwent staged liver and lung metastasectomy from synchronously identified metastases. Twenty-eight patients (72%) underwent sequential metastasectomy because of recurrent disease. The median disease-free and overall survivals after initial metastasectomy were 19.8 and 87 months, respectively. Serial metastasectomy was common in this patient population. The mean number of metastasectomies performed was 2.6 per patient (range 1 to 4). There was no difference in overall survival for patients with synchronous versus metachronous presentation of liver and lung metastases (p=0.45). The site of first recurrence after initial metastasectomy was, most commonly, the lung (n=19, 49%), followed by the liver (n=8, 21%). Nineteen patients (49%) underwent subsequent resections for recurrences. Seven patients (18%) underwent 2 or more liver resections for recurrent disease, and 12 (31%) underwent multiple lung resections. CONCLUSIONS An aggressive multidisciplinary surgical approach should be undertaken for recurrent CRC metastases. In selected patients, serial metastasectomy for recurrent metastatic disease is safe and results in excellent longterm survival after CRC resection.
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Affiliation(s)
- Shimul A Shah
- Department of Surgery, University Health Network, University of Toronto, Toronto, Canada
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Chau I, Allen MJ, Cunningham D, Norman AR, Brown G, Ford HER, Tebbutt N, Tait D, Hill M, Ross PJ, Oates J. The value of routine serum carcino-embryonic antigen measurement and computed tomography in the surveillance of patients after adjuvant chemotherapy for colorectal cancer. J Clin Oncol 2004; 22:1420-9. [PMID: 15007086 DOI: 10.1200/jco.2004.05.041] [Citation(s) in RCA: 134] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE This analysis aims to evaluate routine carcino-embryonic antigen (CEA) and computed tomography (CT) of thorax, abdomen, and pelvis as part of protocol-specified follow-up policy for colorectal cancer (CRC). PATIENTS AND METHODS Patients with resected stage II and III CRC were randomly assigned to bolus fluorouracil/leucovorin or protracted venous infusion fluorouracil. Following completion of chemotherapy, patients were seen in clinic at regular intervals for 5 years. CEA was measured at each clinic visit, and CT of thorax, abdomen, and pelvis was performed at 12 and 24 months after commencement of chemotherapy. RESULTS Between 1993 and 1999, 530 patients were recruited. The median follow-up was 5.6 years. Disease relapses were observed in 154 patients. Relapses were detected by symptoms (n = 65), CEA (n = 45), CT (n = 49), and others (n = 9). Fourteen patients, whose relapses were detected by CT, had a concomitant elevation of CEA and were included in both groups. The CT-detected group had a better survival compared with the symptomatic group from the time of relapse (P =.0046). Thirty-three patients (21%) proceeded to potentially curative surgery for relapse and enjoyed a better survival than those who did not (P <.00001). For patients who underwent hepatic or pulmonary metastatic resection, 13 (26.5%) were in the CT group, eight (17.8%) in the CEA group, and only two (3.1%) in the symptomatic group (CT v symptomatic, P <.001; CEA v symptomatic, P =.015). CONCLUSION Surveillance CT and CEA are valuable components of postoperative follow-up in stage II and III colorectal cancer.
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Affiliation(s)
- Ian Chau
- Department of Medicine, Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT, UK
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Mineo TC, Ambrogi V, Tonini G, Bollero P, Roselli M, Mineo D, Nofroni I. Longterm results after resection of simultaneous and sequential lung and liver metastases from colorectal carcinoma. J Am Coll Surg 2003; 197:386-91. [PMID: 12946793 DOI: 10.1016/s1072-7515(03)00387-9] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although simple lung or liver metastasectomy from colorectal cancer have proved effective in selected patients, the value of simultaneous biorgan metastasectomies is still debated. STUDY DESIGN Of 155 patients who underwent operation for lung or liver colorectal metastases between March 1987 and December 1998, we retrospectively reviewed 29 patients who presented simultaneous (n = 12) or sequential liver-->lung (n = 10) and lung-->liver (n = 7) metastases. All metastases were successfully resected in a total of 56 separate procedures. In 35 thoracic procedures, 45 metastases were removed by wedge resection (n = 36) or lobectomy (n = 9). In addition, 47 liver metastases were resected with wedge (n = 24), segmentectomy (n = 13), or lobectomy (n = 10). There were no perioperative deaths and the morbidity rate was low (10.7%). All patients were followed for a minimum of 3 years. Factors possibly influencing survival were evaluated by univariate and subsequently by multivariate analyses. RESULTS Median survival from the second metastasectomy was 41 months, with a 5-year survival rate of 51.3%. Risk factor distribution among the three metastastic pattern groups was insignificant. Premetastasectomy elevated levels of both CEA and CA19-9 (p = 0.0001), and mediastinal or celiac lymph node status (p = 0.03) were significantly associated with survival in the univariate analysis, although number of metastasectomies, disease-free interval, and simultaneous versus sequential diagnosis were not. In the multivariate analysis, only elevated CEA plus CA19-9 (p = 0.01) was significantly associated with survival. CONCLUSIONS We conclude that either simultaneous or sequential lung and liver metastasectomy can be successfully treated by surgery. Poor results were obtained in the presence of high levels of CEA plus CA19-9.
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