Detecting curable disease following hepatectomy for colorectal metastases

Follow up after surgery for colorectal liver metastases: A systematic review

INTRODUCTION

Recurrence post hepatectomy for colorectal liver metastases (CRLM) occurs in 70 % of patients within two years. No established guidance on the method or intensity of follow-up currently exists. The aim of this systematic review was to summarise literature and determine whether it is possible to identify an optimal follow up regime. To this date there are no randomised prospective studies investigating this.

METHODS

A systematic review was performed according to PRISMA guidelines. Outcomes included general demographics, method, frequency and duration of follow up, survival and recurrence data. Quality assessment of the papers was performed.

RESULTS

Twenty-five articles published between 1994 and 2022 were included, including 9945 patients. CT was the most common imaging modality (n = 14) and CEA most common blood test (n = 11). Intensity of follow up was higher in the first two years post resection and only two papers continued follow up post 5 years resection. There was wide variation in outcome measures - Overall survival (OS) was most commonly reported. Nine papers reported OS ranging between 39 and 78.1 %.

CONCLUSIONS

There is wide variation in follow up methods and outcome reporting. There is no strong evidence to support intensive follow up, and the benefits of long term follow up are also unknown due to the lack of patient centred data. High quality, prospective studies should be the focus of future research as further retrospective data is unlikely to resolve uncertainties around optimal follow up.

Is four years enough? An audit of post-hepatectomy surveillance for liver metastases

BACKGROUND

Optimal timing and modality of surveillance post hepatectomy for colorectal cancer liver metastases (CLM) has not been established. Recommendations vary between countries and surgical units. Individual clinicians do not always adhere to guidelines.

METHODS

Using a prospectively collected database of consecutive hepatectomy patients at The Queen Elizabeth Hospital in Adelaide, Australia, CLM patients were reviewed for evidence of recurrent disease (20 February 1996-30 June 2018). Timing and modality of disease detection was analysed. Follow up was until 30 June 2020 or death.

RESULTS

244 patients underwent hepatectomy for CLM during the study period. 139 patients (57%) experienced recurrence post initial hepatectomy (mean time 13.2 months; range 0.6-84.7). For all hepatic recurrences (n = 172), majority of disease was detected in the first seven months post hepatectomy (55%) and by four years, 97.7% of recurrent disease was detected. 51 patients underwent curative repeat hepatectomy after recurrence was detected. Nearly all disease was detected via surveillance CT (160/172; 93%); 12 patients presented with clinical symptoms.

CONCLUSION

Hepatectomy patients are likely to experience recurrent disease and clinicians must ensure a robust surveillance plan is in place. We recommend a triple-phase CT at 6, 12, 18, 24, 36 and 48 months.

Resection of Colorectal Liver Metastases: Current Perspectives

BACKGROUND

Metastases to the liver is the leading cause of death in patients with colorectal cancer.

METHODS

The authors review the data on diagnosis and management of this clinical problem, and they discuss management options that can be considered.

RESULTS

Complete surgical resection of metastases from colorectal cancer that are localized to the liver results in 5-year survival rates ranging from 26% to 40%.

CONCLUSIONS

By adding modalities such as targeted systemic therapy and other "local" treatments for liver metastases, further gains in survival are anticipated.

Posttreatment Surveillance in Patients with Prolonged Disease-Free Survival After Resection of Colorectal Liver Metastasis

INTRODUCTION

Posttreatment surveillance protocols most often endure for 5 years after resection of colorectal liver metastasis (CRLM). Most recurrences happen within 3 years after surgical removal of the tumour. This study analysed the need of surveillance for patients with at least 3 years of disease-free survival after potentially curative resection of CRLM.

METHODS

A single-centre, retrospective analysis of all consecutive patients who underwent treatment for CRLM with curative intent between 2000 and 2011.

RESULTS

In total, 152 of 545 patients (28 %) remained disease-free for 3 years after successful resection of the CRLM. The estimated recurrence rate after 10 years of follow-up in this group of 152 patients was 27 %. More than half of these patients (55 %) could be treated with curative intent for their recurrences. Multivariable analysis revealed that the nodal status of the primary tumour is of significant prognostic value for developing recurrences after 3 years of disease-free survival. A disease-free interval of less than 12 months between resection of primary tumour and detection of CRLM shows a trend towards significance. Both factors were used to create a risk score, showing that patients with a low-risk profile (node-negative status and a disease-free interval <12 months) have an estimated recurrence rate of 5 % and might not benefit from intensive surveillance beyond 3 years of follow-up without a recurrence.

CONCLUSIONS

The currently developed risk score shows that follow-up can be stopped in a specific subgroup 3 years after treatment for their CRLM with curative intent.

Outcomes after resection and/or radiofrequency ablation for recurrence after treatment of colorectal liver metastases

BACKGROUND

Repeat liver resection for colorectal liver metastases (CRLMs) is possible in a limited number of patients, with radiofrequency ablation (RFA) as an alternative for unresectable CRLMs. The aim of this study was to analyse survival rates with these interventions.

METHODS

This was a database analysis of patients who underwent first and repeat interventions for synchronous and metachronous CRLMs between 2000 and 2013. Descriptive and survival statistics were calculated.

RESULTS

Among 431 patients who underwent resection or RFA for CRLMs, 305 patients developed recurrences for which 160 repeat interventions (resection and/or RFA or ablative radiotherapy) were performed. In total, after 707 first or repeat interventions, 516 recurrences (73·0 per cent) developed, of which 276 were retreated curatively. At the time of first intervention, independent risk factors for death were lymph node-positive primary tumour (hazard ratio (HR) 1·40; P = 0·030), more than one CRLM (HR 1·53; P = 0·007), carcinoembryonic antigen level exceeding 200 ng/ml (HR 1·89; P = 0·020) and size of largest CRLM greater than 5 cm (HR 1·54; P = 0·014). The 5-year overall survival rates for liver resection and percutaneous RFA as first intervention were 51·9 and 53 per cent, with a median overall survival of 65·0 (95 per cent c.i. 47·3 to 82·6) and 62·1 (52·2 to 72·1) months, respectively.

CONCLUSION

RFA had good oncological outcomes in patients with unresectable CRLMs. Radiofrequency ablation is progressively more applied with each additional intervention.

[Assessment of resectability of colorectal liver metastases and extended resection]

Most patients with colorectal liver metastases are treated within a multimodal therapy regime whereby liver resection is a key point in the curative treatment concept. The achievement of an R0 situation is of vital importance for long-term survival. Besides general operability and the assessment of comorbidities, resection depends on the quality of liver parenchyma (functional resectability) and the anatomical position of the tumor (oncological resectability). The improvement of operation techniques and perioperative medicine nowadays allow complex surgical procedures for metastasis surgery. This article presents the methods for the assessment of resectability and modern strategies of preoperative conditioning as well as approaches for extended liver resection.

Prognostic significance of early recurrence: a conditional survival analysis in patients with resected colorectal liver metastasis

BACKGROUND

For patients undergoing liver resection for colorectal metastases, specific clinico-pathological variables have been shown to be prognostic at baseline. This study analyses how the prognostic capability of these variables changes in a conditional survival model.

METHODS

Retrospective review of a prospectively maintained database of patients who underwent an R0 resection of colorectal liver metastases from 1994 to 2004 at a single institution.

RESULTS

In total, 807 patients were identified, with an 87-month median follow-up for survivors. Five- and 10-year disease-specific survivals (DSS) were 68% and 55%, respectively. The probability of further survival increased as the survival time increased. For 3-year survivors (n = 504), DSS were no longer significantly different between patients with a low (0-2) or high (3-5) clinical risk score (CRS, P = 0.19). On multivariate analysis, independent predictors of DSS for 3-year survivors were recurrence within the first 3 years after a liver resection, a pre-operative carcinoembryonic antigen (CEA) >200 ng/ml and disease-free interval <12 months prior to the diagnosis of liver metastasis. However, for those patients who were recurrence free at 1 year, no clinico-pathological variables retained prognostic significance.

DISCUSSION

After 3 years of DSS and 1 year of recurrence-free survival, baseline clinico-pathological variables have a limited ability to predict future survival. Early post-operative recurrence appears to be the most useful single clinical feature in estimating conditional DSS.

Detection of recurrences during follow-up after liver surgery for colorectal metastases: both carcinoembryonic antigen (CEA) and imaging are important

BACKGROUND

The follow-up of patients treated for colorectal liver metastases (CRLM) is not standardized. The accuracy of an increase in carcinoembryonic antigen (CEA) levels for finding recurrences after treatment for CRLM is compared in this retrospective cohort study with the accuracy of routine imaging modalities of liver and chest.

METHODS

Data from all patients in follow-up after intentionally curative treatment for CRLM from 1990 to 2010 were analyzed. All patients underwent the same follow-up schedule. The way in which recurrences became apparent (i.e., CEA increase, routine imaging, or both) was registered. The specificity and sensitivity of increases in CEA before finding recurrent disease were calculated by receiver operating characteristic (ROC) curves. An economic evaluation of the cost per resectable tumor recurrence was performed.

RESULTS

ROC curves showed that a significant CEA increase was defined as a 25 % increase from the previous value. Recurrences were detected in 46 % of the procedures through CEA increase concomitant with positive imaging, in 23 % through CEA increase without positive findings on routine imaging, and in 31 % through positive imaging without an increase in CEA. The resectability of recurrences did not differ between triggers. Cost per curable recurrence was <euro>2,196 for recurrences found via CEA alone and <euro>6,721 for recurrences found with imaging and CEA.

CONCLUSIONS

In the follow-up of patients after liver surgery for CRLM, a 25 % increase in CEA serum level can accurately detect recurrences, but routine imaging is indispensable. In patients with CRLM, we advocate both CEA monitoring and imaging in the follow-up after liver surgery.

Systematic review and meta-analysis of follow-up after hepatectomy for colorectal liver metastases2

Background

The evidence surrounding optimal follow-up after liver resection for colorectal metastases remains unclear. A significant proportion of recurrences occur in the early postoperative period, and some groups advocate more intensive review at this time.

Methods

A systematic review of literature published between January 2003 and May 2010 was performed. Studies that described potentially curative primary resection of colorectal liver metastases that involved a defined follow-up protocol and long-term survival data were included. For meta-analysis, studies were grouped into intensive (more frequent review in the first 5 years after resection) and uniform (same throughout) follow-up.

Results

Thirty-five studies were identified that met the inclusion criteria, involving 7330 patients. Only five specifically addressed follow-up. Patients undergoing intensive early follow-up had a median survival of 39·8 (95 per cent confidence interval 34·3 to 45·3) months with a 5-year overall survival rate of 41·9 (34·4 to 49·4) per cent. Patients undergoing routine follow-up had a median survival of 40·2 (33·4 to 47·0) months, with a 5-year overall survival rate of 38·4 (32·6 to 44·3) months.

Conclusion

Evidence regarding follow-up after liver resection is poor. Meta-analysis failed to identify a survival advantage for intensive early follow-up.

Effect on outcome of recurrence patterns after hepatectomy for colorectal metastases

BACKGROUND

Despite improvements in surgery and chemotherapy, most patients develop recurrence after hepatectomy for metastatic colorectal cancer. Data are lacking on the effect of these patterns on outcome.

METHODS

A retrospective review of a prospectively maintained hepatobiliary database was performed. Pattern and timing of recurrence and outcome after recurrence were analyzed. Univariate and multivariate analyses of factors associated with outcome after recurrence were carried out.

RESULTS

From January 1997 through May 2003, a total of 733 patients underwent hepatectomy for colorectal metastases. Of these, 637 patients (87%) were included in the analysis, and in 393 patients (62%), recurrence was documented at the time of last follow-up. Initial recurrence patterns included the following: liver only in 120 patients (31%), lung only in 107 (27%), other single sites in 49 (12%), and multiple sites in 117 (30%). Recurrence occurred within 2 years of hepatectomy in 75% of patients and after 3 years in 11%. Margins at hepatectomy, recurrence pattern, resected recurrence, and disease-free interval from time of colectomy to hepatic metastasis and from time of hepatectomy to recurrence were independently associated with survival as measured from the time of recurrence. Recurrence in the lung, resected recurrence, and time to recurrence after hepatectomy were associated with prolonged survival as measured from the time of hepatectomy and the time of recurrence.

CONCLUSIONS

The timing and pattern of recurrence after hepatic resection for metastatic colorectal cancer are important predictors of long-term survival.

Outcomes of intensive surveillance after resection of hepatic colorectal metastases

BACKGROUND

The impact of computed tomography (CT)-based follow-up for the detection of resectable disease recurrence following surgery for colorectal liver metastases (CRLM) was evaluated.

METHODS

Some 705 patients undergoing resection of CRLM between January 1993 and March 2007 were included. Surveillance comprised 3-monthly CT (thorax, abdomen and pelvis) in the first 2 years after surgery, 6 monthly for 3 years and annually from years 6 to 10. Survival differences following recurrence between patients managed surgically and palliatively were determined, and the cost was calculated.

RESULTS

Five-year disease-free and overall survival rates were 28.3 and 32.3 per cent respectively. Of 402 patients who developed recurrence within 2 years, 88 were treated with liver resection alone and 36 with lung and/or liver resection. Their 5-year overall survival rates were 31 and 30 per cent respectively, compared with 3.9 per cent in 278 patients managed palliatively (P < 0.001). For each 3-month interval during the first year of follow-up, patients with recurrence treated surgically had better overall survival than those treated palliatively. The cost of surveillance that identified 124 patients amenable to further resection was 12,338 pounds per operated recurrence. Assuming that patients with recurrence gained 5 years' survival, the mean survival gain was 4.28 years per resection and the cost per life-year gained was 2883 pounds.

CONCLUSION

Intensive 3-monthly CT surveillance after liver resection for CRLM detects recurrence that is amenable to further resection in a considerable number of patients. These patients have significantly better survival with a reasonable cost per life-year gained.

Prognostic scores for colorectal liver metastasis: clinically important or an academic exercise?

OBJECTIVES

Over the last decade, various groups have proposed prognostic scoring systems for patients with colorectal liver metastasis (CLM) treated with hepatic resection. The aims of the current study were to evaluate the differences between and clinical importance of these prognostic scoring systems and to determine their clinical applicability.

METHODS

Relevant articles were reviewed from the published literature using the MEDLINE database. The search was performed using the keywords 'colorectal cancer', 'metastases', 'liver resection' and 'hepatectomy'.

RESULTS

Twelve prognostic scoring systems were identified from 1996 to 2009. Six of these originated from European institutions, three from Asian and three from North American centres. The median study sample was 288 patients (range 81-1568 patients) and median follow-up was 35 months (range 16-52 months). All studies were retrospective in nature and the numbers of groups proposed by the various scoring systems ranged from three to six. All the studies used the Cox proportional hazard model for multi-variable analysis.

CONCLUSIONS

There is no 'ideal' prognostic scoring system for the clinical management of patients with CLM for hepatic resection. These prognostic scoring systems are clinically relevant with respect to survival but have not been used for risk stratification in controversial areas such as the administration of chemotherapy or surveillance programmes.

Management of hepatic metastasis from colorectal cancers: an update

Approximately 50%-60% of patients with colorectal cancers will develop liver lesions in their life span. Despite the potential of surgical resection to provide long-term survival in this subset of patients, only 15%-20% are found to be resectable. The introduction of new neoadjuvant chemotherapeutic agents and the expanding criteria of resection have enhanced the overall 5-year survival from 30% to 60% in the past decade. The use of technical innovations such as staged resection; portal vein embolization, and repeat resection have allowed higher resection rates in patients with bilobar disease. Extrahepatic primary and liver-exclusive recurrent disease no longer represent an absolute contraindication to resection. The role of regional therapy using hepatic arterial infusion is being redefined for liver-exclusive unresectable disease. Adjuvant chemotherapy in combination with regional therapies is being looked at from fresh perspectives. Ablative approaches have gained a firm role both as an adjunct to surgical resection and in the management of patients who are not surgical candidates. Overall, the management of hepatic metastasis from colorectal cancers requires a multimodal approach.

Role of ultrasonography in the detection of resectable recurrence after hepatectomy for colorectal liver metastases

Background

Recurrence develops in most patients after hepatectomy for colorectal liver metastases. Repeat resection is feasible in some of these patients. The aim of this study was to evaluate an ultrasound-based follow-up protocol in the detection of resectable recurrent disease.

Methods

All patients undergoing hepatectomy for colorectal liver metastases at a single hepatobiliary referral centre in the UK from January 1999 to December 2004 were identified. Variables reviewed included rates of recurrence, mode and timing of detection, rates of repeat hepatectomy and survival.

Results

During the study period 191 patients underwent initial resection of colorectal liver metastases, of whom 109 developed recurrent disease. In total, 21 patients underwent potentially curative intervention, including 16 hepatic resections, four pulmonary resections and one staged pulmonary/hepatic resection. Ten of 72 patients who presented with recurrent disease within 12 months after initial resection were amenable to curative resection, compared with 11 of 37 patients presenting after 12 months. Sonographic surveillance identified all of the potentially resectable recurrent hepatic disease in the series.

Conclusion

Ultrasonography is effective in the detection of potentially resectable hepatic recurrence after hepatectomy for colorectal liver metastases; however, routine chest imaging is needed.

Multimodal treatment of metastatic colorectal cancer

BACKGROUND

Metastases to the liver is the leading cause of death in patients with colorectal cancer.

METHODS

The authors review the data on diagnosis and management of this clinical problem, and they discuss management options that can be considered.

RESULTS

Complete surgical resection of metastases from colorectal cancer that are localized to the liver results in 5-year survival rates ranging from 26% to 40%.

CONCLUSIONS

By adding modalities such as targeted systemic therapy and other "local" treatments for liver metastases, further gains in survival are anticipated.