Second liver resections are safe and effective treatment for recurrent hepatic metastases from colorectal cancer: a bi-institutional analysis

[Oligometastasized stage IV colorectal cancer : Surgical resection and local ablative procedures]

BACKGROUND

By the intensified combination of systemic, surgical and local ablative therapies a significant improvement in therapy results for metastasized colorectal cancer has been achieved in the last decade. Downstaging with subsequent resection is nowadays a standard for oligometastasized primarily unresectable colorectal cancer.

MATERIAL AND METHODS

The value of combining resection and local ablation is unclear; therefore, this article gives an overview of the available literature dealing with the combination of surgery and local ablative methods for oligometastasized stage IV colorectal cancer.

RESULTS

The best results were obtained following surgical resection alone. Whereas nowadays cryoablation is of minor importance, the most successful results are achieved following local ablative methods by radiofrequency and microwave ablation. In the future irreversible electroporation will be the most promising local ablative method. A combination of surgical resection and local ablation appears to be rational in patients if an R0 resection can be achieved.

CONCLUSION

Surgical resection of colorectal liver metastases is the gold standard for oncological therapy whenever possible. The rational combination of non-curative surgical resection and local ablation should be considered in the context of a multimodal therapeutic strategy, particularly in patients with primarily resectable disease.

The feasibility and efficacy of pure laparoscopic repeat hepatectomy

BACKGROUND

Repeat hepatectomy is often required for hepatocellular carcinoma and metastatic tumors. However, this procedure is technically challenging, so laparoscopic repeat hepatectomy (LRH) has not been widely adopted. The aim of this study was to evaluate the feasibility and efficacy of LRH compared with open repeat hepatectomy (ORH) and laparoscopic primary hepatectomy (LPH).

METHODS

We introduced laparoscopic hepatectomy at our institution in April 2014. We performed 127 LPH (LPH group) and 33 LRH procedures (LRH group) from April 2014 to April 2017; 37 patients underwent ORH from January 2010 to April 2017 (ORH group). This study retrospectively compared the patient characteristics and short-term outcomes of the LRH and ORH groups as well as the LRH and LPH groups.

RESULTS

There were no conversions to open surgery in the LRH group. In comparing the LRH and ORH groups, there were no significant differences in patient characteristics except for the type of approach to the previous hepatectomy (p = 0.004) and indocyanine green retention rate at 15 min (median 12.5 vs. 8.75%, p = 0.026). The LRH group had less blood loss (median 30 mL vs. 652 mL; p < 0.001), less intraoperative transfusion (6.1 vs. 32.4%; p = 0.006), and shorter postoperative hospital stays (median 6.5 days vs. 9.0 days; p < 0.001). There were no differences with regard to operation time, severe postoperative complications, and mortality. In comparing the LRH and LPH groups, there was a significant difference only in past history of abdominal surgery (100 vs. 61.4%; p < 0.001). In the short-term outcomes, the postoperative hospital stay was significantly shorter in the LRH group (median 6.5 days vs. 7 days; p = 0.033), and the other results were comparable between the two groups.

CONCLUSIONS

LRH is feasible and useful for repeat hepatectomy, achieving good short-term outcomes.

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.

Right hepatectomy in living donors with previous abdominal surgery

BACKGROUND

Few studies have evaluated the impact of previous abdominal surgery (PAS) on living donor right hepatectomy (LDRH). The aim of this study was to investigate the outcomes of liver transplantation using right lobe grafts of living donors with PAS.

METHODS

Data were reviewed from LDRH patients at the authors' institution between March 2008 and November 2014. LDRH patients with PAS were divided into two groups according to upper PAS (group 1) or lower PAS (group 2), and they were compared to those without PAS (group 3) who were matched 1:1 based on age, gender, and body mass index. Perioperative data, complications by the Clavien classification, and the outcomes with more than 14 months follow-up were compared.

RESULTS

Twenty-three (4.9%) of a total of 471 LDRH donors had PAS. Eleven donors were assigned to group 1, 12 to group 2, and 23 to group 3. Intraperitoneal adhesions were found in 20 (87.0%) of 23 donors with PAS, of whom 5 (21.7%) had adhesiolysis-related injuries that happened more commonly in group 1 than in group 2 (P=0.025). LDRH was successfully completed under upper midline laparotomy in all donors. No donors received perioperative blood transfusion. The peak postoperative AST, ALT, INR, and total bilirubin levels made no difference between the three groups. Compared with group 3, groups 1 and 2 had a longer operative time (P=0.012) and a higher grade I complication rate (P=0.047). All donors recovered fully to their routine activities. The 23 recipients of grafts from donors with PAS showed good liver function with 1-year graft and patient survivals of 100%.

CONCLUSION

A history of PAS is not a contraindication to LDRH in the current era of advanced surgical techniques.

Repeat hepatectomy is independently associated with favorable long-term outcome in patients with colorectal liver metastases

Up to three‐quarters of patients undergoing liver resection for colorectal liver metastases (CRLM) develop intrahepatic recurrence. Repeat hepatic resection appears to provide the optimal chance of cure for these patients. The aim of this study was to analyze short‐ and long‐term outcomes following index and repeat hepatectomy for CRLM. Clinicopathological data were obtained from a prospectively maintained database. Perioperative variables and outcomes were compared using the Chi‐squared test. Variables associated with long‐term survival following index and second hepatectomy were identified by Cox regression analyses. Over the study period, 488 patients underwent hepatic resection for CRLM, with 71 patients undergoing repeat hepatectomy. There was no significant difference in rates of morbidity (P = 0.135), major morbidity (P = 0.638), or mortality (P = 0.623) when index and second hepatectomy were compared. Performance of repeat hepatectomy was independently associated with increased overall and cancer‐specific survival following index hepatectomy. Short disease‐free interval between index and second hepatectomy, number of liver metastases >1, and resection of extrahepatic disease were independently associated with shortened survival following repeat resection. Repeat hepatectomy for recurrent CRLM offers short‐term outcomes equivalent to those of patients undergoing index hepatectomy, while being independently associated with improved long‐term patient survival.

RAS Mutation Is Associated with Decreased Survival in Patients Undergoing Repeat Hepatectomy for Colorectal Liver Metastases

BACKGROUND

The relationship between RAS mutation status and outcome for patients undergoing repeat hepatectomy (RH) for recurrent colorectal liver metastases (CLM) has not been defined.

OBJECTIVE

The objective of this study was to evaluate the relationship between RAS mutation status and outcome in patients undergoing RH for CLM.

METHODS

All patients who underwent RH for CLM with known RAS mutation status between January 2005 and November 2014 were identified, and the outcomes of patients with and without RAS mutations were compared.

RESULTS

Ninety-eight patients underwent RH, of whom 34 (35 %) harbored a RAS mutation. Wild-type (WT) and mutant RAS groups had similar clinicopathologic characteristics. Median recurrence-free survival (RFS) for patients with WT and mutant RAS was 12.2 and 6.1 months, respectively (p = 0.03). Median overall survival (OS) for the WT and mutant RAS patients were 42.5 and 26.6 months, respectively (p < 0.01). On multivariate analysis, RAS mutations [hazard ratio (HR) = 1.69, p = 0.04] were associated with worse RFS, while multiple tumors (HR = 1.92, p = 0.045) and RAS mutations (HR = 2.11, p = 0.02) predicted worse OS.

CONCLUSION

Patients with recurrent CLM that harbor RAS mutations have worse RFS and OS than patients with WT RAS, and RAS mutations are independently associated with worse RFS and OS. RAS mutation status should be determined prior to RH, as it may impact treatment decisions.

Second pancreatectomy for recurrent pancreatic ductal adenocarcinoma in the remnant pancreas: A pooled analysis

OBJECTIVES

The aim of this study was to examine the outcomes of second pancreatectomy for the treatment of recurrent pancreatic ductal adenocarcinoma (PDAC) in the remnant pancreas.

METHOD

Search of the PubMed database was undertaken to identify relevant English language studies. Pooled individually data were examined for clinical outcomes after second pancreatectomy for recurrent PDAC.

RESULTS

A total of 19 articles involving 55 patients were eligible for inclusion. The median disease-free interval after initial resection was 33 (range 7-143) months. Of the 55 patients reported, 52 (94.5%) patients underwent completion total pancreatectomy in the second operation for recurrences, including 15 patients who developed recurrences more than 5 years after the initial operation. There was no perioperative death. The 1-, 3- and 5-year overall survival rate after the second pancreatectomy was 82.2%, 49.2% and 40.6% respectively.

CONCLUSION

Second pancreatectomy for recurrent PDAC can be performed safely with long-term survival in selected patients.

Outcomes of Rehepatectomy for Colorectal Liver Metastases: A Contemporary Multi-Institutional Analysis from the French Surgical Association Database

BACKGROUND

Recurrence remains frequent after curative-intent hepatectomy for colorectal liver metastases (CRLM). We sought to define short- and long-term outcomes, and identify prehepatectomy factors associated with survival, following rehepatectomy (RH) for recurrence.

METHODS

We conducted a multi-institutional cohort study of hepatectomy for CRLM over 2006-2013. Second-stage resections were excluded. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS) assessed using Kaplan-Meier methods. Secondary outcomes included 30-day overall morbidity and mortality, and survival from recurrence. Outcomes of RH and initial hepatectomy (IH) were compared.

RESULTS

Of 2771 hepatectomies included in the study, 447 were RH. Median operative time, 30-day morbidity, mortality, and median length of stay did not differ for RH and IH. Five-year OS did not statistically differ, i.e. 56.5 % from RH and 67.6 % from IH [adjusted hazard ratio (HR) 0.9, 95 % confidence interval (CI) 0.5-1.7], and 5-year RFS was inferior after RH (18.5 vs. 28.8 %; adjusted HR 1.3, 95 % CI 1.0-1.7). In patients who eventually recurred, 5-year survival from the time of recurrence did not differ whether it was after RH (46.5 %) or after IH (60.3 %) (adjusted HR 1.1, 95  % CI 0.8-1.8). Rectal primary tumor (HR 1.4, 95 % CI 1.0-2.1) and metastasis ≥3 cm (HR 1.3, 95 % CI 1.1-2.7) were independently associated with RFS, but not OS, after RH.

CONCLUSION

Short-term outcomes of RH did not differ from IH. While recurrence was more frequent after RH than IH, it did not impact OS. Survival from the time of recurrence did not differ whether recurrence occurred after RH or after IH. CRLM recurrence can be treated with curative intent with excellent long-term outcomes.

Patterns of progression, treatment of progressive disease and post-progression survival in the New EPOC study

BACKGROUND

The addition of cetuximab (CTX) to perioperative chemotherapy (CT) for operable colorectal liver metastases resulted in a shorter progression-free survival. Details of disease progression are described to further inform the primary study outcome.

METHODS

A total of 257 KRAS wild-type patients were randomised to CT alone or CT with CTX. Data regarding sites and treatment of progressive disease were obtained for the 109 (CT n=48, CT and CTX n=61) patients with progressive disease at the cut-off date for analysis of November 2012.

RESULTS

The liver was the most frequent site of progression (CT 67% (32/48); CT and CTX 66% (40/61)). A higher proportion of patients in the CT and group had multiple sites of progressive disease (CT 8%, 4/48; CT and CTX 23%, 14/61 P=0.04). Further treatment for progressive disease is known for 84 patients of whom 69 received further CT, most frequently irinotecan based. Twenty-two patients, 11 in each arm, received CTX as a further line agent.

CONCLUSIONS

Both the distribution of progressive disease and further treatment are as expected for such a cohort. The pattern of disease progression seen is consistent with failure of systemic micrometastatic disease control rather than failure of local disease control following liver surgery.

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.

Factors influencing recurrence following initial hepatectomy for colorectal liver metastases

BACKGROUND

Data on recurrence patterns following hepatectomy for colorectal liver metastases (CRLMs) and their impact on long-term outcomes are limited in the setting of modern multimodal management. This study sought to characterize the patterns of, factors associated with, and survival impact of recurrence following initial hepatectomy for CRLMs.

METHODS

A retrospective cohort study of patients undergoing initial hepatectomy for CRLMs at 39 institutions (2006-2013) was conducted. Kaplan-Meier methods were used for survival analyses. Overall survival landmark analysis at 12 months after hepatectomy was performed to compare groups based on recurrence. Multivariable Cox and regression models were used to determine factors associated with recurrence.

RESULTS

Among 2320 patients, tumours recurred in 47·4 per cent at median of 10·1 (range 0-88) months; 89·1 per cent of recurrences developed within 3 years. Recurrence was intrahepatic in 46·2 per cent, extrahepatic in 31·8 per cent and combined intra/extrahepatic in 22·0 per cent. The 5-year overall survival rate decreased from 74·3 (95 per cent c.i. 72·2 to 76·4) per cent without recurrence to 57·5 (55·0 to 60·0) per cent with recurrence (adjusted hazard ratio (HR) 3·08, 95 per cent c.i. 2·31 to 4·09). After adjusting for clinicopathological variables, prehepatectomy factors associated with increased risk of recurrence were node-positive primary tumour (HR 1·27, 1·09 to 1·49), more than three liver metastases (HR 1·27, 1·06 to 1·52) and largest metastasis greater than 4 cm (HR 1·19; 1·01 to 1·43).

CONCLUSION

Recurrence after CRLM resection remains common. Although overall survival is inferior with recurrence, excellent survival rates can still be achieved.

Postoperative complications following aggressive repeat hepatectomy for colorectal liver metastasis have adverse oncological outcomes

PURPOSES

Repeat hepatectomy remains the only curative treatment for recurrent colorectal liver metastasis (CLM) after primary hepatectomy. However, the repeat resection rate is still low, and there is insufficient data on the outcomes after repeat hepatectomy. The aim of this study was to investigate the feasibility and prognostic benefit of aggressive repeat hepatectomy for recurrent CLM.

METHODS

Data were reviewed from 282 consecutive patients who underwent primary curative hepatectomy for CLM between January 1994 and March 2015. The short- and long-term outcomes were analyzed.

RESULTS

One hundred ninety-three patients (68 %) developed recurrence, and repeat hepatectomy was conducted in 62 patients. Overall, 62 s, 11 third, 4 fourth, and 1 fifth hepatectomies were performed. The postoperative morbidity and mortality rates were low (11.5 and 1.3 %, respectively). The overall survival rates at 3 and 5 years after primary hepatectomy for CLM in the repeat hepatectomy group were 79.5 and 57.4 %, respectively. A multivariate analysis indicated that postoperative complications were independently associated with overall survival after repeat hepatectomy.

CONCLUSIONS

Repeat hepatectomy for CLM is feasible, with acceptable rates of perioperative morbidity and mortality, and the potential for long-term survival. However, postoperative complications following aggressive repeat hepatectomy for CLM are associated with adverse oncological outcomes.

Repeat Hepatectomy for Recurrent Colorectal Liver Metastases: Is it Worth the Challenge?

INTRODUCTION

Repeat hepatectomy (RH) is considered a valuable option for management of recurrent colorectal liver metastases (R-CLM). Here, the outcome of RH for R-CLM was compared to that of patients who underwent single hepatectomy (SH) after subdividing the later according to re-recurrence status.

METHODS

Between 2001 and 2013, patients who received hepatectomy for CLM and R-CLM were included in study. Patients with non-resectable R-CLM were excluded.

RESULTS

One hundred sixteen patients were included: 86 patients in SH group and 30 patients in RH group. Repeat hepatectomy group had more synchronous CLM (76.7 versus 50 %, p = 0.011). From the 86 patients who underwent SH, 69 patients did not have R-CLM. Survival analysis was done from the time of first hepatectomy for the no R-CLM group and the time of RH for the RH group. The 3- and 5-year survival rates for the no R-CLM group were 66.4 and 48.8%, respectively, and for the RH group were 56 and 44.8% respectively (p = 0.841). Multivariate analysis showed that larger size of R-CLM is an independent risk factor for survival after RH.

CONCLUSION

Repeat hepatectomy for R-CLM shows a comparable OS to non-recurrent CLM after single hepatectomy, despite the RH group had higher incidence of synchronous CLM.

Surgical management of hepatic metastases of colorectal cancer

For the 20% of patients with resectable colorectal liver metastases (CRLM), hepatic resection is safe, effective and potentially curative. Factors related to the primary and metastatic tumors individually and in clinical risk-scoring schemes are the best prognostic factors, although it is difficult to define patient groups with resectable, liver-limited CRLM that should be excluded from surgery. Systemic chemotherapy for metastatic colorectal cancer has improved but does not improve overall survival as adjuvant therapy after resection. Conversion to complete resection with systemic and/or hepatic arterial infusion chemotherapy is an appropriate goal for patients with unresectable CRLM.

Repeat resection leads to long-term survival: analysis of 10-year follow-up of patients with colorectal liver metastases

BACKGROUND

Some reports have shown that a significant number of patients experience recurrence, even after 5 or more years after surgery for colorectal liver metastases (CLMs). This study aimed to determine the actual cure rate and identify clinical characteristics among long-term survivors.

METHODS

A prospectively maintained database was used to retrospectively review patients who underwent liver resection for CLM between 1994 and 2001.

RESULTS

A total of 130 patients underwent liver resection for CLM with a complete 10-year follow-up. The 10-year disease-specific survival rate was 31.1%, and the survival curve reached a plateau after 10 years from the time of hepatic resection. There were 35 actual 10-year survivors. Multivariate analysis revealed that female patients and those with negative surgical margins were independent prognostic factors for disease-specific survival.

CONCLUSION

A 10-year survival following initial hepatectomy should be defined as cure.

Pure laparoscopic hepatectomy as repeat surgery and repeat hepatectomy

AIM: To assess clinical outcomes of laparoscopic hepatectomy (LH) in patients with a history of upper abdominal surgery and repeat hepatectomy.

METHODS: This study compared the perioperative courses of patients receiving LH at our institution that had or had not previously undergone upper abdominal surgery. Of the 80 patients who underwent LH, 22 had prior abdominal surgeries, including hepatectomy (n = 12), pancreatectomy (n = 3), cholecystectomy and common bile duct excision (n = 1), splenectomy (n = 1), total gastrectomy (n = 1), colectomy with the involvement of transverse colon (n = 3), and extended hysterectomy with extensive lymph-node dissection up to the upper abdomen (n = 1). Clinical indicators including operating time, blood loss, hospital stay, and morbidity were compared among the groups.

RESULTS: Eighteen of the 22 patients who had undergone previous surgery had severe adhesions in the area around the liver. However, there were no conversions to laparotomy in this group. In the 58 patients without a history of upper abdominal surgery, the median operative time was 301 min and blood loss was 150 mL. In patients with upper abdominal surgical history or repeat hepatectomy, the operative times were 351 and 301 min, and blood loss was 100 and 50 mL, respectively. The median postoperative stay was 17, 13 and 12 d for patients with no history of upper abdominal surgery, patients with a history, and patients with repeat hepatectomy, respectively. There were five cases with complications in the group with no surgical history, compared to only one case in the group with a prior history. There were no statistically significant differences in the perioperative results between the groups with and without upper abdominal surgical history, or with repeat hepatectomy.

CONCLUSION: LH is feasible and safe in patients with a history of upper abdominal surgery or repeat hepatectomy.

Expression of phosphorylated extracellular signal-regulated kinase at the invasive front of hepatic colorectal metastasis

Raf-1 kinase inhibitory protein (RKIP), an endogenous inhibitor of the extracellular signal-regulated kinase (ERK) pathway, suppresses metastasis in a number of cancer types, including colorectal carcinoma (CRC); thus, RKIP downregulation significantly contributes to CRC invasiveness and metastatic potential. However, our previous study demonstrated that RKIP-positive tumors in CRC patients are predictive of hepatic colorectal metastases (HCMs). Based on the previous finding that the ERK pathway can be activated independently of RKIP, we hypothesized that RKIP-expressing HCMs may express significant levels of phosphorylated ERK (pERK). Thus, the present study evaluated the expression of RKIP and pERK in 68 HCM tissue samples using immunohistochemistry. RKIP expression was positive in 22 (32.4%) of the 68 samples, seven (31.8%) of which exhibited nuclear pERK immunoreactivity exclusively at the invasive tumor front. Furthermore, pERK expression at the invasive front was significantly associated with recurrent HCM following hepatic resection, and pERK expression observed at the invasive front of RKIP-expressing HCMs indicated that the activation of the ERK pathway may also be involved in the invasive process of these tumors, despite the presence of RKIP. A strong association between pERK expression and the presence of recurrent HCM may indicate that the ERK pathway is important in the metastatic recurrence of RKIP-positive HCM.

Outcomes of repeat laparoscopic liver resection compared to the primary resection

BACKGROUND

Repeat laparoscopic liver resection (R-LLR) can be technically challenging. Data on this topic are scarce and many investigators would question its feasibility and outcomes. The aim of the present study was to evaluate the safety, feasibility, oncological efficiency and outcomes of R-LLR.

METHODS

We reviewed a prospectively collected database of 403 patients undergoing 422 laparoscopic liver resections (LLRs) from August 2003 to August 2013. Data of 19 patients undergoing R-LLR were analyzed and compared to the primary resection (P-LLR) in these patients. Demographic and clinical data were studied. A subgroup analysis was done for minor resections.

RESULTS

Twenty R-LLRs were performed in 19 patients (female 58 %; mean age: 57.5 years; age range: 23-79 years). Colorectal liver metastases (CRLM) were the commonest indication for R-LLR (60 %), followed by neuroendocrine tumor liver metastases (NETLM) (20 %) and hepatocellular carcinoma (HCC) (10 %). The majority (90 %) of resections were for malignant disease (18/20). There were three conversions (15 %), and two patients developed complications (10 %). The operative time (p = 0.005) and blood loss (p = 0.03) were both significantly greater in R-LLR compared to P-LLR, whereas length of stay (median 4 days; p = 0.30) and complications (p = 0.58) did not differ between the groups. R0 resection rates for P-LLR and R-LLR were 95 and 90 %, respectively (p = 0.73).

CONCLUSIONS

Repeat LLR is safe, feasible, and can be performed with minimal morbidity. It appears to be technically more challenging than P-LLR, but without any increase in complications or length of hospital stay.

Surgical outcomes and prognostic factors in patients with synchronous colorectal liver metastases

CONTEXT

Colorectal cancer is the second most prevalent cancer worldwide, and the liver is the most common site of metastases. Surgical resection of colorectal liver metastases provides the sole possibility of cure and the best odds of long-term survival. Objectives To describe surgical outcomes and identify features associated with disease prognosis in patients submitted to synchronous colorectal cancer liver metastasis resection.

METHODS

Retrospective study of 59 patients who underwent surgery for synchronous colorectal cancer liver metastasis. Actuarial survival and disease-free survival were assessed, depending on the prognostic variable of interest.

RESULTS

Postoperative mortality and morbidity rates were 3.38% and 30.50% respectively. Five-year disease-free survival was estimated at 23.96%, and 5-year overall survival, at 38.45%. Carcinoembryonic antigen levels ≥ 50 ng/mL and presence of three or more liver metastasis were limiting factors for disease-free survival, but did not affect late survival. No patient with liver metastases and extrahepatic disease had disease-free interval longer than 20 months, but this had no significance or impact on long-term survival. None of the prognostic factors assessed had an impact on late survival, although no patients with more than three liver metastases survived beyond 40 months.

CONCLUSIONS

Although Carcinoembryonic antigen levels and number of metastases are prognostic factors that limit disease-free survival, they had no impact on 5-year survival and, therefore, should not determine exclusion from surgical treatment. Resection is the best treatment option for synchronous colorectal liver metastases, and even for patients with multiple metastases, large tumors and extrahepatic disease, it can provide long-term survival rates over 38%.

Determinants of repeat curative intent surgery in colorectal liver metastasis

INTRODUCTION

Following curative intent surgery (CIS) for colorectal liver metastasis (CRLM), repeat CIS for recurrence improves survival. The factors associated with repeat CIS are not widely reported.

METHODS

An institutional database (January 2002-December 2012) was reviewed to evaluate factors influencing repeat CIS.

RESULTS

One hundred sixty-three patients with colorectal liver metastasis (CRLM) underwent successful CIS. Median follow-up and disease-free interval (DFI) was 33 and 16 months, respectively. After initial CIS, 102 patients (63%) recurred. Fifty-three patients (52%) underwent a repeat CIS. After repeat CIS, 33 patients (62%) developed a second recurrence, and in 13 patients (39%), a third CIS was possible. DFI decreased following initial CIS (first CIS vs. second CIS vs. third CIS [20 vs. 15 vs. 8.5 months], p < 0.001). Overall 5-year survival in all patients was 55%; patients who recurred had a 5-year survival of 67% if they underwent repeat CIS vs. 7.8% if they were managed palliatively. Second CIS was less likely with a postoperative complication, other/multifocal recurrence, or DFI <12 months.

CONCLUSION

Despite high recurrence and decreasing DFI, repeat CIS provides a survival benefit. Postoperative complications, DFI, number, and pattern of recurrence influence the decision to pursue repeat CIS.

Safety and Efficacy of Ultrasound-Guided Radiofrequency Ablation of Recurrent Colorectal Cancer Liver Metastases after Hepatectomy

INTRODUCTION

To assess the results and outcome of radiofrequency ablation in the treatment of recurrent colorectal liver metastases.

PATIENTS AND METHODS

Between January 2005 and September 2012, we treated 59 patients with recurrent colorectal metastases not amenable to surgery with 77 radiofrequency ablation procedures. Radiofrequency was indicated if oncologic resection was technically not possible or the patient was not fit for major surgery. A total of 91 lesions were treated. The mean number of liver tumors per patient was 1.5, and the mean tumor diameter was 2.3 cm. In 37.5% of the cases, lesions had a subcapsular location, and 34% were close to a vascular structure.

RESULTS

The morbidity rate was 18.7%, and there were no post-procedural deaths. Distant extrahepatic recurrence appeared in 50% of the patients. Local recurrence at the site of ablation appeared in 18% of the lesions. Local recurrence rate was 6% in lesions less than 3 cm and 52% in lesions larger than 3 cm. The size of the lesions (more than 3 cm) was an independent risk factor for local recurrence (p < 0.05). Survival rates at 1, 3, and 5 years were 94.5%, 65.3%, and 21.7%, respectively.

DISCUSSION

Radiofrequency ablation is a safe procedure and allows local tumor control in lesions less than 30 mm (local recurrence of 6%) and provides survival benefits in patients with recurrent colorectal liver metastases.

Selecting patients for a second hepatectomy for colorectal metastases: an systemic review and meta-analysis

BACKGROUND

Opinions on the suitability of repeat hepatectomy for patients with recurrent colorectal liver metastases (CRLMs) vary among studies. We conducted a meta-analysis to establish the criteria for selecting the best candidates for a second hepatectomy.

METHODS

Database and manual searches were performed to identify comparative or prognostic studies published up to October 2013. Outcomes of interest included disease characteristics, perioperative outcomes, and long-term survival after initial and second hepatectomies for patients with CRLM. Study quality was appraised using the Newcastle-Ottawa scale and a modified Hayden's score.

RESULTS

A total of 7226 patients from 27 studies were included. Recurrent CRLMs after initial hepatectomy were more likely to be solitary (RR = 0.86, P = 0.045), unilobar (RR = 0.60, P < 0.001), and smaller (WMD = -0.66, P < 0.001). Postoperative morbidity and mortality were comparable between initial and second hepatectomies (RR = 1.10, P = 0.191; RR = 0.78, P = 0.678, respectively). In high-quality studies, patients showed better survival after a second hepatectomy than those after a single hepatectomy (HR = 0.68, P = 0.022). Patients meeting the following six predictors survived longer after second hepatectomy: disease-free survival after initial hepatectomy >1 y (P = 0.034); solitary CRLM at second hepatectomy (P < 0.001); unilobar CRLM at second hepatectomy (P = 0.009); maximal size of CRLM at second hepatectomy ≤ 5 cm (P = 0.035); lack of extrahepatic metastases at second hepatectomy (P < 0.001); and R0 resection at second hepatectomy (P < 0.001).

CONCLUSIONS

Second hepatectomy is a safe and feasible procedure for patients with recurrent CRLM. In fact, in well-selected patients it improves overall survival. The established criteria can help clinicians to select the best candidates for second hepatectomy and to achieve better long-term outcomes after resection.

Repeat liver resection for recurrent colorectal metastases: a single-centre, 13-year experience

OBJECTIVES

Isolated intrahepatic recurrence is noted in up to 40% of patients following curative liver resection for colorectal liver metastases (CLM). The aims of this study were to analyse the outcomes of repeat hepatectomy for recurrent CLM and to identify factors predicting survival.

METHODS

Data for all liver resections for CLM carried out at one centre between 1998 and 2011 were analysed.

RESULTS

A total of 1027 liver resections were performed for CLM. Of these, 58 were repeat liver resections performed in 53 patients. Median time intervals were 10.5 months between the primary resection and first hepatectomy, and 15.4 months between the first and repeat hepatectomies. The median tumour size was 3.0 cm and the median number of tumours was one. Six patients had a positive margin (R1) resection following first hepatectomy. There were no perioperative deaths. Significant complications included transient liver dysfunction in one and bile leak in two patients. Rates of 1-, 3- and 5-year overall survival following repeat liver resection were 85%, 61% and 52%, respectively, at a median follow-up of 23 months. R1 resection at first hepatectomy (P = 0.002), a shorter time interval between the first and second hepatectomies (P = 0.02) and the presence of extrahepatic disease (P = 0.02) were associated with significantly worse overall survival.

CONCLUSIONS

Repeat resection of CLM is safe and can achieve longterm survival in carefully selected patients. A preoperative knowledge of poor prognostic factors helps to facilitate better patient selection.

Early recurrence after liver resection for colorectal metastases: risk factors, prognosis, and treatment. A LiverMetSurvey-based study of 6,025 patients

PURPOSE

The aims of this study were to assess the risk of early recurrence after liver resection for colorectal metastases (CRLM) and its prognostic value; identify early recurrence predictive factors; clarify the effect of perioperative chemotherapy on its occurrence; and elucidate the best early recurrence management.

METHODS

Patients of the LiverMetSurvey registry who underwent complete liver resection (R0/R1) between 1998 and 2009 were reviewed. Early recurrence was defined as any recurrence that occurred within 6 months after resection.

RESULTS

A total of 6,025 patients were included; 2,734 (45.4 %) had recurrence, including 639 (10.6 %) early recurrences. Early recurrence was mainly hepatic (59.5 vs. 54.4 % for late recurrences; p = 0.023). Independent risk factors of early recurrence were: T3-4 primary tumor (p = 0.0002); synchronous CRLM (p = 0.0001); >3 CRLM (p < 0.0001); 0-mm margin liver resection (p = 0.003); and associated intraoperative radiofrequency ablation (p = 0.0005). Response to preoperative chemotherapy (complete/partial) and administration of adjuvant chemotherapy reduced early recurrence risk (p = 0.003 and p < 0.0001, respectively). Intraoperative ultrasonography reduced hepatic early recurrence rate (p = 0.025). Early recurrence negatively affected prognosis: 5-year survival 26.9 versus 49.4 % for the late recurrence group (p < 0.0001, median follow-up 34.4 months). Overall, 234 (36.6 %) patients with early recurrence underwent re-resection. These patients had survival rates higher than non-re-resected patients (5-year survival 47.2 vs. 8.9 %; p < 0.0001) and similar to re-resected patients for late recurrence (48.7 %). Chemotherapy before early recurrence resection improved later survival (5-year survival 61.5 vs. 43.7 %; p = 0.028).

CONCLUSIONS

Early recurrence risk is enhanced for extensive disease after poor preoperative disease control and inadequate surgical treatment, but is reduced after adjuvant chemotherapy. Although early recurrence negatively affects prognosis, re-resection may restore better survival. Chemotherapy before early recurrence resection is advocated.

[Neoadjuvant chemotherapy or primary surgery for colorectal liver metastases. Pro primary surgery]

Approximately 50 % of patients with colorectal cancer (CRC) develop liver metastases, with the liver being the only site of metastasis in the majority of patients. Liver resection is the standard treatment of CRC liver metastases as it achieves a 5-year survival of 36-51 %. The primary goal in the treatment of non-resectable liver metastases is to achieve resectability by preoperative chemotherapy as even secondary liver resection after down-sizing is associated with improved overall survival. Furthermore, resectability can be increased by two-stage surgical procedures; however, the assessment of resectability varies widely even among experts in the field. In cases of suspected non-resectability patients should therefore be liberally admitted for a second opinion to centers of liver surgery. Perioperative chemotherapy in primarily resectable cases has only demonstrated an improvement in recurrence-free survival in subgroup analyses. Moreover, modern potent chemotherapy regimens increase the surgical morbidity depending on the duration of treatment: the lower the histological response of the metastases and the more treatment cycles are applied, the higher is the parenchymal damage with related surgical morbidity. Therefore, perioperative chemotherapy of resectable liver metastases should be viewed with caution and should not be considered the standard of care.

Safety and outcomes following resection of colorectal liver metastases in the era of current perioperative chemotherapy

BACKGROUND

Preoperative chemotherapy is increasingly utilized in the treatment of colorectal liver metastases (CRLM). Although this strategy may improve resectability, long-term advantages of preoperative chemotherapy for resectable CRLM are less clear. The objective of this study is to report safety and outcomes when perioperative chemotherapy is routinely added to surgery for CRLM.

METHODS

A retrospective review of patients undergoing liver resections for CRLM during 2003-2011 in single academic oncology center. Demographic data, tumor characteristics, chemotherapy, surgical details, complications and survival were analyzed.

RESULTS

The study included 157 patients that underwent 168 liver operations. One hundred eighteen patients (70 %) underwent preoperative chemotherapy (75 % oxaliplatin-based). Preoperative portal vein embolization was utilized in 16 (10.1 %) patients. Overall survival (OS) was 89, 57, and 27 % at 1, 3, and 5 years, respectively (median survival-42.8 months). Eleven (7 %) patients had repeat resections for liver recurrence. Thirty-day mortality was 1.26 %, morbidity-24 % (6 %-liver related). Complications were not significantly different in patients that had preoperative chemotherapy. On a multivariate analysis advanced age and >3 lesions predicted poor OS, while advanced age, lesions >5 cm, synchronous lesions, margin-positivity and resection less than hepatectomy were associated with decreased DFS.

CONCLUSIONS

Our results suggest that even with chemotherapy and resection only a subset of patients remain disease-free after 5 years. However, even in a high-risk patient with multiple lesions, preoperative chemotherapy can be administered safely without apparent increase in postoperative complications. Perioperative chemotherapy should be considered particularly in patients with multifocal or large lesions, synchronous disease and short disease-free interval.

Methods of haemostasis during liver resection--a UK national survey

BACKGROUND

Although haemorrhage is a major cause of morbidity and mortality in liver surgery, there is very little available guidance on its management.

METHODS

The aim of this study was to identify current practice in the UK in this regard. An online survey was created and hepatobiliary (HPB) specialists who were members of a specialist society and others who were known practitioners were invited by e-mail to complete the survey anonymously.

RESULTS

Fifty-one percent responded (n = 36/70), and most of these respondents worked at large HPB centres (>100 liver resections/year; n = 24, 66%). Not all questionnaires were fully completed by the individual surgeons. Thirty-eight percent of the surgeons routinely used Pringle's manoeuvre. Most surgeons used ligation of the inflow vessels (n = 16, 44%) and stapled the outflow vessels (n = 15, 42%). The Cavitron ultrasonic surgical aspirator (CUSA; 54%, 13/24) was preferred for parenchymal transection. The majority routinely used haemostatic adjuncts (n = 22, 62%), whilst 33% (n = 12) used them occasionally. Twenty-three (64%) felt manufactured haemostatic adjuncts played a major role in maintaining haemostasis and 19 preferred fibrin-based products.

CONCLUSION

The Pringle manoeuvre is a popular technique amongst specialist UK liver surgeons and the CUSA is used by nearly half of the surgeons. Despite the absence of definitive evidence for their benefit, manufactured haemostatic adjuncts are still widely used, especially the fibrin-based adjuncts.

Surgery for colorectal liver metastases

Half of all patients with colorectal cancer develop metastatic disease. The liver is the principal site for metastases, and surgical resection is the only modality that offers the potential for long-term cure. Appropriate patient selection for surgery and improvements in perioperative care have resulted in low morbidity and mortality rates, resulting in this being the therapy of choice for suitable patients. Modern management of colorectal liver metastases is multimodal incorporating open and laparoscopic surgery, ablative therapies such as radiofrequency ablation or microwave ablation and (neo)adjuvant chemotherapy. The majority of patients with hepatic metastases should be considered for resectional surgery, if all disease can be resected, as this offers the only opportunity for prolonged survival.

Outcome after repeat resection of liver metastases from colorectal cancer

INTRODUCTION

Although advances in multimodal treatment have led to prolongation of survival in patients after resection of colorectal liver metastasis (CRC-LM), most patients develop recurrence, which is often confined to the liver. Repeat hepatic resection (RHR) may prolong survival or even provide cure in selected patients. We evaluated the perioperative and long-term outcomes after RHR for CRC-LM in a single institution series.

PATIENTS AND METHODS

Since 1999, 92 repeat hepatic resections (63% wedge/segmental, 37% hemihepatectomy or greater) for recurrent CRC-LM were performed in 80 patients. Median interval from initial liver resection to first RHR was 1.25 years. Any kind of chemotherapy (CTx) had been given in 88% before RHR. Neoadjuvant CTx was given in 38%.

RESULTS

Hepatic margin-negative resection was achieved in 79%. Mortality was 3.8%. Overall complication rates were 53%, including infection (17%), operative re-intervention (12%), and hepatic failure (5.4%). Overall 5-year survival after first RHR was 50.3%. Univariately, primary tumor stage, the extent of liver resection, postoperative complications, and the overall resection margin correlated with survival. By multivariate analysis, primary T stage, size of metastasis, and overall R0 resection influenced survival. Survival was not independently influenced by hepatic resection margins or (neoadjuvant) CTx.

CONCLUSIONS

Repeat hepatic resection for recurrent CRC-LM can be performed with low mortality and acceptable morbidity. Survival after repeat hepatic resection in this selected group of patients is encouraging and comparable to results after first liver resections.

The road to clinical use of high-intensity focused ultrasound for liver cancer: technical and clinical consensus

Clinical use of high-intensity focused ultrasound (HIFU) under ultrasound or MR guidance as a non-invasive method for treating tumors is rapidly increasing. Tens of thousands of patients have been treated for uterine fibroid, benign prostate hyperplasia, bone metastases, or prostate cancer. Despite the methods' clinical potential, the liver is a particularly challenging organ for HIFU treatment due to the combined effect of respiratory-induced liver motion, partial blocking by the rib cage, and high perfusion/flow. Several technical and clinical solutions have been developed by various groups during the past 15 years to compensate for these problems. A review of current unmet clinical needs is given here, as well as a consensus from a panel of experts about technical and clinical requirements for upcoming pilot and pivotal studies in order to accelerate the development and adoption of focused ultrasound for the treatment of primary and secondary liver cancer.

A systematic review of repeat hepatectomy for recurrent colorectal liver metastases

BACKGROUND

Selected patients with recurrent colorectal liver metastases (CLM) may be resectable by repeat hepatectomy approach. In this review, we aim to collate and evaluate the published evidence for repeat hepatectomy in patients with recurrent CLM.

METHODS

Searches of the Medline and Embase databases were undertaken to identify studies of repeat hepatectomy in patients with recurrent CLM focusing on the perioperative treatment regimen, operative strategy, morbidity, technical success and survival outcomes.

RESULTS

Twenty-two observational studies were reviewed. A total of 1,610 patients underwent second hepatectomy for recurrent CLM. The median percentage of extra-hepatic disease was 15 % (range, 0-39 %). Preoperative chemotherapy was reported in 5/22 studies. Major liver resection was undertaken in 25 % (range, 9-59 %) of patients and the R0 resection rate was 90 % (range, 77-96 %). Postoperative morbidity and mortality after the second hepatectomy were 23 % and 1.2 %, respectively. Recurrence rate after second hepatectomy was 63.9 % (range, 42-91 %) with a median follow-up period of 32 months (range, 19-59 months). Median overall survival was 35 months (range, 19-56 months). The 3-year and 5-year overall survival rates were 55 % (range, 11-82 %) and 42 % (range, 31-73 %), respectively.

CONCLUSION

Second hepatectomy is safe and feasible in selected patients with recurrent CLM and is associated with acceptable perioperative and survival outcomes. Future prospective studies are required to further define the patient selection criteria for repeat hepatectomy and the exact role of perioperative chemotherapy.

Repeat liver resection for colorectal metastases

BACKGROUND

Following resection of colorectal liver metastases (CLMs) up to 75 per cent of patients develop recurrent liver metastases. Although repeat resection remains the only curative therapy, data evaluating the outcome are deficient. This study analysed postoperative morbidity, mortality and independent predictors of survival following repeat resection of CLMs.

METHODS

Data on surgical treatment of primary and recurrent CLMs between 1994 and 2010 were collected retrospectively, and compared with those for single hepatic resections carried out during the same period. Independent predictors of survival were evaluated by means of univariable and multivariable Cox regression models.

RESULTS

In this interval 1026 primary resections of CLMs were performed and 94 patients underwent repeat CLM excision. Overall postoperative morbidity and mortality rates were low (15·8 and 1·3 per cent respectively), with no statistical difference in patients undergoing repeat surgery (P = 0·072). Compared with single liver resections, overall survival was improved in repeat resections (P = 0·003). Multivariable analysis revealed that size of primary CLM over 50 mm was an independent predictor of survival (hazard ratio (HR) 2·61; P = 0·008). Only major hepatic resection was associated with poorer outcome following repeat surgery (HR 2·62; P = 0·009). International Union Against Cancer stage, number of CLMs, age at surgery and need for intraoperative transfusion had no impact on survival after repeat resection.

CONCLUSION

Recurrent CLM surgery is feasible with similar morbidity and mortality rates to those of initial or single CLM resections.

Aggressive treatment of patients with metastatic colorectal cancer increases survival: a scandinavian single-center experience

Background. We examined overall and disease-free survivals in a cohort of patients subjected to resection of liver metastasis from colorectal cancer (CRLM) in a 10-year period when new treatment strategies were implemented. Methods. Data from 239 consecutive patients selected for liver resection of CRLM during the period from 2002 to 2011 at a single center were used to estimate overall and disease-free survival. The results were assessed against new treatment strategies and established risk factors. Results. The 5-year cumulative overall and disease-free survivals were 46 and 24%. The overall survival was the same after reresection, independently of the number of prior resections and irrespectively of the location of the recurrent disease. The time intervals between each recurrence were similar (11 ± 1 months). Patients with high tumor load given neoadjuvant chemotherapy had comparable survival to those with less extensive disease without neoadjuvant chemotherapy. Positive resection margin or resectable extrahepatic disease did not affect overall survival. Conclusion. Our data support that one still, and perhaps to an even greater extent, should seek an aggressive therapeutic strategy to achieve resectable status for recurrent hepatic and extrahepatic metastases. The data should be viewed in the context of recent advances in the understanding of cancer biology and the metastatic process.

New hepatectomy-induced postoperative adhesion model in rats, and evaluation of the efficacy of anti-adhesion materials

PURPOSE

Repeated hepatic resections are not uncommon during the surgical management of liver tumors. Postoperative adhesions induced by hepatectomies can have a significant negative impact on subsequent surgeries. We recently developed a new hepatectomy-induced postoperative adhesion animal model to evaluate the anti-adhesion efficacy of commercially available sheet materials (Seprafilm(®) and Interceed(®)) and the recently reported hyaluronan-based in situ cross-linkable hydrogels.

METHODS

The median lobe (ML) and the left lateral lobe (LLL) of the liver (approximately 70 % of the total liver) of 43 male Sprague-Dawley rats were resected based on the classical procedure; anti-adhesion materials were then applied. A relaparotomy was performed 1 week later to evaluate the adhesions and histopathological findings.

RESULTS

The rats without the application of anti-adhesion materials (n = 14) showed the most severe adhesions (grade 3) between the cut surface of the liver and the small bowel or omentum. All the barrier materials produced slight anti-adhesion effects. Adhesions between the liver surface and the diaphragm and adhesions around the hepatic hilum were less severe, but were not remarkably reduced, by the anti-adhesion materials.

CONCLUSION

We successfully established a new hepatectomy-induced animal adhesion model, which may be useful for the development of new anti-adhesion materials.

Repeat hepatectomy for recurrent colorectal metastases

BACKGROUND

The oncological benefit of repeat hepatectomy for patients with recurrent colorectal metastases is not yet proven. This study assessed the value of repeat hepatectomy for these patients within current multidisciplinary treatment.

METHODS

Consecutive patients treated by repeat hepatectomy for colorectal metastases between January 1990 and January 2010 were included. Patients undergoing two-stage hepatectomy were excluded. Postoperative outcome was analysed and compared with that of patients who had only a single hepatectomy.

RESULTS

A total of 1036 patients underwent 1454 hepatectomies for colorectal metastases. Of these, 288 patients had 362 repeat hepatectomies for recurrent metastases. Some 225 patients (78·1 per cent) had two hepatectomies, 52 (18·1 per cent) had three hepatectomies, and 11 patients (3·8 per cent) had a fourth hepatectomy. Postoperative morbidity following repeat hepatectomy was similar to that after initial liver resection (27·1 per cent after first, 34·4 per cent after second and 33·3 per cent after third hepatectomy) (P = 0·069). The postoperative mortality rate was 3·1 per cent after repeat hepatectomy versus 1·6 per cent after first hepatectomy. Three- and 5-year overall survival rates following first hepatectomy in patients who underwent repeat hepatectomy were 76 and 54 per cent respectively, compared with 58 and 45 per cent in patients who had only one hepatectomy (P = 0·003). In multivariable analysis, repeat hepatectomy performed between 2000 and 2010 was the sole independent factor associated with longer overall survival.

CONCLUSION

Repeat hepatectomy for recurrent colorectal metastases offers long-term survival in selected patients.

Metastatic recurrence after complete resection of colorectal liver metastases: impact of surgery and chemotherapy on survival

PURPOSE

Surgery is the standard of care for resectable colorectal liver metastases (CRC-LM). Unfortunately, 60% of patients develop secondary metastatic recurrence (SMR) after R0-resection of CRC-LM. We investigated the impact of surgical re-intervention and chemotherapy (Ctx) on survival in a consecutive series of patients with SMR.

METHODS

From 01/2001 to 11/2011, 104 out of 178 consecutive patients with R0-resection of CRC-LM developed SMR and were evaluated. The impact of surgical and Ctx re-interventions on recurrence free (RFS) and cancer-specific survival (CSS) was analyzed. Median follow-up was 28.0 (95%CI: 19.4-37.4) months.

RESULTS

SMR occurred in 81 patients at a single site (49× liver, 18× lung, 14× other) and in 23 patients at multiple sites. Forty-two patients were scheduled for primary surgery. Fifty-three patients were classified as non-resectable and treated with median 5.0 [IQR, 3.0-10.0] cycles of Ctx, combined with an EGFR/VEGF-antibody in 27 patients. Nine patients received best supportive care only. R0/R1 resection could be achieved in 35 patients primarily and even in 8 patients secondarily after Ctx. Surgical morbidity and mortality were 16 and 0%, respectively. The 5-year RFS rates for patients with R0 versus R1-resection were 22 and 24% (p = 0.948). The 5-year CSS rate for R0/R1-resected patients was 38% versus 10% for those patients treated by Ctx alone (p < 0.001).

CONCLUSION

In SMR, surgical re-intervention is feasible and safe in a remarkable number of patients and offers significantly longer CSS compared to patients without resection.

Repeat hepatic resection for colorectal liver metastases

BACKGROUND

Some 75-80 per cent of patients undergoing liver resection for colorectal liver metastases develop intrahepatic recurrence. A significant number of these can be considered for repeat liver surgery. This study examined the outcomes of repeat liver resection for the treatment of recurrent colorectal metastases confined to the liver.

METHODS

Patients who underwent repeat liver resection in a single tertiary referral hepatobiliary centre were identified from a database. Clinicopathological variables were analysed to assess factors predictive of survival.

RESULTS

A total of 195 patients underwent repeat resection between 1993 and 2010. Median age was 63 years, and the median interval between first and repeat resection was 13·8 months. Thirty-three patients (16·9 per cent) underwent completion hemihepatectomy or extended hemihepatectomy and the remainder had non-anatomical or segmental resection. The 30-day mortality rate was 1·5 per cent, and the overall 30-day morbidity rate was 20·0 per cent. Overall 1-, 3- and 5-year survival rates were 91·2, 44·3 and 29·4 per cent respectively. Tumour size 5 cm or greater was the only independent predictor of overall survival (relative risk 1·71, 95 per cent confidence interval 1·08 to 2·70; P = 0·021). Neoadjuvant chemotherapy before resection, perioperative blood transfusion, bilobar disease, R1 resection margin and multiple metastases were among factors that did not significantly influence survival.

CONCLUSION

Repeat hepatic resection remains the only curative option for patients presenting with recurrent colorectal liver metastases.

Second surgery or chemotherapy for relapse after radical resection of colorectal cancer metastases

PURPOSE

Limited data suggest that second resections for colorectal cancer metastases may improve survival, but no study has compared surgery with chemotherapy in this setting. Therefore, we retrospectively compared the clinical outcome of potentially resectable patients who received a second metastasectomy with those who did not in our single-centre experience.

METHODS

We retrospectively reviewed the clinical records of all patients treated for metastatic colorectal cancer in our centre over a period of 12 years. We selected patients who relapsed after radical resection of metastases from colorectal cancer and were deemed resectable again by our multidisciplinary team. We then compared the clinical outcome of those who received a second operation with those who refused surgery and also evaluated the role of prognostic factors.

RESULTS

We identified 60 patients fulfilling the inclusion criteria. Twenty-nine underwent a second resection and 31 refused surgery. Median overall survival rates were 58.7 and 24.0 months, median times to progression were 14.4 and 6.6 months. Patients who received surgery plus perioperatory chemotherapy (18/29) had a significantly better outcome; 4/29 achieved long-term disease-free survival.

CONCLUSIONS

Our study suggests that in highly selected metastatic colorectal cancer patients, a multimodal treatment plan, including a second resection, can achieve longer survival with respect to medical therapy.