Resection of hepatic and pulmonary metastases in patients with colorectal carcinoma

Distant Lung Recurrence of Rectal Cancer 20 Years After Primary Surgery

A male patient in his 70s, who had undergone an abdominoperineal (A1) resection for rectal cancer 20 years prior, presented with hemoptysis. Imaging studies revealed distant lung recurrence, with no evidence of local recurrence. Biopsy revealed an adenocarcinoma, possibly of rectal origin. Immunohistochemical markers were suggestive of rectal cancer metastasis. However, carcinoembryonic antigen (CEA) levels were normal, and colonoscopy did not reveal any metachronous lesions. Curative left upper lobe resection was performed via posterolateral thoracotomy. The patient's recovery was uneventful.

Fat signal fraction assessed with MRI predicts hepatic recurrence following hepatic resection for colorectal liver metastases

PURPOSE

The effect of hepatic steatosis on the development of colorectal liver metastases (CRLM) remains unknown. This study evaluated the usefulness of fat signal fraction assessed with magnetic resonance imaging (MRI) and the effect of hepatic steatosis on hepatic recurrences following initial hepatectomy for CRLM.

METHODS

Between January 2013 and December 2019, 64 patients underwent initial hepatectomy for CRLM. The medical records of these patients were reviewed to evaluate the recurrence and survival outcomes.

RESULTS

The fat signal fraction was positively correlated with the nonalcoholic fatty liver disease activity score and liver-spleen ratio. Recurrence following the initial hepatectomy was observed in 48/64 patients, and hepatic recurrence was observed in 30/64 patients. The fat signal fraction was significantly higher in patients with hepatic recurrence after initial hepatectomy. The hepatic recurrence rate was 69.2% in patients with fat signal fraction ≥ 0.0258, which was significantly higher than that in patients with fat signal fraction < 0.0258. Hepatic recurrence-free survival rate was significantly higher in patients with fat signal fraction < 0.0258 than in those with fat signal fraction ≥ 0.0258. Multivariate analyses revealed that fat signal fraction ≥ 0.0258 was an independent risk factor for hepatic recurrence.

CONCLUSION

The fat signal fraction assessed with MRI was significantly associated with hepatic recurrence following initial hepatectomy for CRLM.

Transdiaphragmatic single-port video-assisted thoracoscopic surgery; a novel approach for pulmonary metastasectomy through laparotomy incision - case series

Background

Pulmonary metastasectomy was performed in the early twentieth century and ever since, it has evolved to be one of the main treatment options for certain metastatic malignancies. The advancement of minimally invasive procedures enabled new techniques to minimize morbidity and improve patient quality of care and overall outcome.

Cases presentation

Herein we present three patients, aged 53, 48, and 27 years, known to have sigmoid, rectal, and non-seminomatous germ cell tumors respectively. All patients were diagnosed to have metastatic lung nodules and underwent laparotomy to excise abdominal tumors followed by trans-diaphragmatic single-port video-assisted thoracoscopic pulmonary metastasectomy. All patients achieved complete surgical tumor excision, and none had pulmonary related complications on follow-up.

Conclusion

Our prescribed novel trans-diaphragmatic single-port video-assisted thoracoscopic surgery (VATS) technique for synchronous pulmonary metastasectomy and intra-abdominal tumor resection is safe and can achieve complete resection with negative margins.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01393-2.

Why recurrence was initially suspected during colorectal cancer postoperative surveillance?: A retrospective analysis

Routine postoperative surveillance is recommended for the patients with colorectal cancer (CRC). This study aimed to clarify the conditions indicate initial suspicion of CRC recurrence in different preoperative serum carcinoembryonic antigen (CEA) level groups, including positive physical signs/symptoms, elevated CEA level, positive radiologic studies results, and other elevated tumor markers.A total of 2268 patients with recurrence after curative surgery for CRC were enrolled in this study. The patients were classified into 3 groups according to preoperative serum CEA level (low, <2 ng/mL; intermediate, ≥2 and <5 ng/mL; and high, ≥5 ng/mL).Up to 63.6% of recurrence was suspected based on elevated CEA level in the high preoperative serum CEA level group. Patients in the low preoperative serum CEA level group had a higher rate of initial suspicion of recurrence based on positive physical signs or symptoms (36.7% vs 26.9% vs 20.4%, P < .001) and positive radiologic findings (51.4% vs 40.7% vs 29.5%, P < .001) than those in the intermediate and high preoperative serum CEA groups.Conditions indicate initial suspicion of recurrence varied in the different preoperative serum CEA level groups. In patients with low preoperative serum CEA level, the detection of recurrence depend on abnormal CEA level is less sensitive than intermediate and high preoperative serum CEA groups. We suggest that the strategy for CRC surveillance should not depend on serum CEA level alone. The signs or symptoms of patients, changes in postoperative serial CEA level, and ongoing radiologic or imaging findings must be cautiously monitored.

Oncological benefit of complete metastasectomy for simultaneous colorectal liver and lung metastases

BACKGROUND

The oncological benefit of complete metastasectomy for simultaneous colorectal liver and lung metastases (SLLM) have not been fully investigated.

METHODS

Patients undergoing initial hepatectomy for colorectal liver metastases (CLM) from 2005 to 2016 were divided into three groups: patients with isolated CLM undergoing complete resection (Group1, n = 317), SLLM undergoing complete metastasectomy (Group2, n = 33), and SLLM undergoing complete hepatectomy but incomplete lung resection (Group3, n = 20). A staged strategy (hepatectomy followed by lung resection) without interval chemotherapy was mainly applied for SLLM.

RESULTS

The 5-year overall survival rate of Group2 was significantly better than that of Group3 (71.7% vs. 10.2%, P < 0.001) and similar to that of Group1 (63.9%, P = 0.779). The 5-year disease-free survival rate was significantly worse in Group2 than Group1 (15.7% vs. 29.0%, P = 0.035). On multivariable analysis, CEA>200 ng/ml was the sole predictor of incomplete resection of lung metastases (odds ratio, 13.7; 95% confidence interval, 1.30-145; P = 0.011).

CONCLUSIONS

The prognosis in patients with SLLM who achieve complete metastasectomy is acceptable and might be improved by appropriate selection based on operative indications.

Local treatment of liver and lung metastases from colorectal cancer: a multicenter Tunisian study

Aim: Surgical treatment of hepatic or pulmonary metastases is the optimal therapeutic goal in metastatic colorectal cancer (CRC). Methods: Our retrospective study concerned 70 patients treated for CRC, collected from 2003 to 2015, presenting liver metastases (LM) in 61 cases and pulmonary metastases (PM) in nine cases, treated by surgery for their distant disease. We collected and compared their epidemiologic, anatomoclinical parameters and analyzed several prognostic factors. Results: Metastases were multiple (≥ 4) in 9/61 LM and in 5/9 PM. Patients had synchronous metastases in 32 cases (30 LM/2 PM) and metachronous metastases in 33 cases (32 LM and 11 PM). Surgery for LM consisted of metastasectomy (49/61), segmentectomy (5/61) and hepatectomy for the remaining seven patients; ten patients had also subsequent liver radiofrequency. LM were treated by wedge resection in 6/9 and lobectomy in two cases, radiofrequency was performed in five cases. 56/61 (80%) patients received chemotherapy, mostly FOLFOX protocol as the first-line treatment and targeted therapy in 55% of cases. For the overall population, median OS and PFS were, respectively, 44 and 32 months. We did not observe any significant difference in terms of OS (p = 0.659) and PFS (p = 0.318) between resected LM or/and PM. A better survival was found when there was disease-free interval between the occurrence of the primary and the metastases exceeded 18 months and in patients with less than four metastases. Conclusion: Resection of metastatic disease mostly in liver and lungs improves survival of patients with CRC. The patients with longer disease-free interval and less than four metastases had the best outcomes.

Surgical Strategies in Colorectal Cancer Metastatic to the Liver

Surgical resection remains a milestone in the treatment of colorectal metastases to the liver. There is a distinct subset of patients who benefit from surgical resection in terms of longer survival or definitive cure. The main effort of the surgical oncological regards the safety of the procedure and the adequacy of the recommendation. Many studies, some of them including multivariate analysis, have shown the presence of prognostic determinants of long-term survival and prognostic indexes of the outcome after hepatectomy. It is now accepted that liver resection should be done when the complete excision of all demonstrable tumor with clear resection margins is feasible. Major contra-indication is represented by the presence of extra-hepatic intra-abdominal disease or of unresectable lung metastatic deposits. There is a wide literature indicating that in very selected patients liver reresection and multiorgan synchronous or metachronous resections are beneficial. The role of neoadjuvant chemotherapy and especially postoperative adjuvant local (intra-hepatic) and systemic chemotherapy is promising and supported by recent multicenter randomised clinical trials.

Clinical outcomes of stage IV colorectal cancer after R0 resection: a multi-institutional retrospective analysis

BACKGROUND

We analyzed the treatment outcomes after curative surgery for stage IV colorectal cancer to develop outcome-based follow-up protocols and treatment strategies.

METHODS

This study was a multi-institutional retrospective analysis of treatment outcomes in patients who underwent R0 surgery for stage IV colorectal cancer.

RESULTS

A total of 1133 patients, of whom 837 had recurrence, were included in this study. Recurrence occurred within 12 and 24 months after R0 surgery in 452 (54.0 %) and 652 (77.9 %) patients, respectively. Surgical resection was performed less frequently for recurrence within 12 months of R0 surgery than for recurrence after more than 12 months (p = 0.003). Prognosis was significantly better in patients who had recurrence more than 24 months after R0 surgery than in those who had recurrence within 24 months; this was not only for all patients but also specifically for patients with resection for recurrent disease. Recurrence was less frequent in patients who received preoperative chemotherapy than in patients who did not receive preoperative chemotherapy (p = 0.04). Of significance, fewer patients who received preoperative chemotherapy (57.5 %) had recurrence within 24 months compared with patients who did not receive preoperative chemotherapy (79.8 %) (p = 0.00001).

CONCLUSIONS

Intensive follow-up for at least 24 months was considered appropriate for monitoring disease recurrence after R0 surgery for stage IV colorectal cancer. In addition, preoperative chemotherapy contributed to improved outcomes.

Long-term outcome of adrenalectomy for metastasis resulting from colorectal cancer with other metastatic sites: A report of 3 cases

Metastasis to the adrenal glands is a relatively frequent observation at autopsy of patients that have succumbed to cancer. Long-term disease-free survival has been reported in patients following the resection of solitary adrenal metastasis resulting from colorectal cancer. In addition, following primary resection for colorectal cancer, solitary metastasis to the adrenal glands is rare, even in outpatients at routine follow-ups. Therefore, adrenal metastasis is usually detected in combination with multiple synchronous metastases at other sites in the terminal stages of cancer. Between 1998 and 2002, 3 patients with adrenal metastasis and other synchronous metastatic sites underwent surgery for adrenal metastasis at the Department of Gastroenterological Surgery at Osaka University. The other synchronous metastatic sites observed in the 3 patients consisted of lung and para-aortic lymph nodes. In total, 2 out of the 3 patients experienced long-term disease-free survival for >5 years following surgery and 1 patient underwent curative resection for recurrence of metastases in the liver and right adrenal gland 79 months subsequent to the initial resection for adrenal metastasis. All 3 patients survived for >90 months. In conclusion, aggressive surgical resection for adrenal metastasis and other metastatic sites resulting from colorectal cancer may result in a survival benefit in selected patients.

Surgical treatment of synchronous colorectal liver and lung metastases: the usefulness of thoracophrenolaparotomy for single stage resection

When suitable, surgery still remains the therapeutic option to be preferred for patients carrier of colorectal liver and lung metastases. Since thoracophrenolaparotomy should be helpful during liver resection for some of these patients, simultaneous removal of right lung metastases can be proposed through this approach. Eleven consecutive patients (median age of 53 years) carrier of colorectal liver and lung metastases, underwent single session surgical resection of both liver and right lung lesions by means of J-shaped thoracophrenolaparotomy. The median number of liver metastases removed was 5 (range 2-30) and of lung metastases removed was 2 (range 1-3). Lung metastases were located in the upper lobe in 1 patient, in the middle lobe in 2, in the lower lobe in 6, and in the upper and lower lobe in 2. Mortality and major morbidity were nil. Two patients had a minor morbidity: one had wound infection and bile leakage treated conservatively and the other had transient fever. Mean overall survival was 24.4 months. An aggressive surgical approach should be undertaken for colorectal metastases: in case of multifocal liver disease with complex presentations, J-shaped thoracophrenolaparotomy could be considered as safe approach for combined liver and right lung metastasectomies.

Survival Following Resection of Intra- and Extra-Hepatic Metastases from Colorectal Cancer: A Phase II Trial

PURPOSE

Metastasectomy for intrahepatic metastases (IHM) from colorectal cancer (CRC) provides excellent 5-year overall survival (OS). Presence of extrahepatic metastases (EHM) has been a historic contraindication to surgery. Due to improved safety of hepatectomy, there is growing interest in multisite metastasectomy for IHM and EHM. The objective of this study was to evaluate the results of metastasectomy for patients with IHM and EHM from CRC.

METHODS

A phase II study of metastasectomy for both IHM and EHM from CRC. Eligible patients with any number of IHM and up to three EHM foci, resectable with RO intent, were offered metastasectomy. Clinical, survival, and quality of life (QoL) data were analyzed using standard statistical methods.

RESULTS

Twenty-six patients were enrolled with a median age of 58 (range 32-84) years; 14/26 (54 %) presented with synchronous disease. The lung was the most common EHM site (13/26, 50 %). Protocol surgery was completed in 20/26 (77 %), including 12/26 (46 %) planned sequential resections. Major morbidity and perioperative mortality were 5/26 (19 %) and 1/26 (4 %), respectively. The QoL decline appeared to be transient. All QoL domains returned to baseline by 1-year posttreatment. The median recurrence-free survival (RFS) was 5 months by intent-to-treat analysis. The median OS from the time of CRC diagnosis and metastasectomy were 50 and 38 months (3-year OS 80 and 53 %), respectively.

CONCLUSIONS

Complete metastasectomy of multisite CRC is safe, but disease recurs in the majority of patients. Data suggest that aggressive multisite metastasectomy may provide OS benefit for selected patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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

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

Repeated liver resection for recurrence of colorectal cancer metastases

BACKGROUND

Resection of liver metastases is accepted as treatment for diverse tumours, implying a survival improvement. Metastases often recur after first hepatectomy and, very few would be potentially resectable.

MATERIALS AND METHODS

A retrospective study of 18 patients undergoing repeated hepatectomies (two or more liver resections in the same patient) due to metastases of colorectal cancer between 1988 and 2006 was performed.

RESULTS

Thirteen men and five women, mean age 57.55 years, participated. In all patients, repeated liver resection was performed due to recurrence of the metastases. Complications rate after first hepatectomy was 11.1% and after the second 16.6%. Mortality rate was 11.1% after second hepatectomy, and there was no mortality after third hepatectomy. Three- and 5-year survival after colectomy was 88.9% and 77.8%, respectively; after first hepatectomy 3- and 5-year survival was 88.9% and 61.1%, respectively; after second hepatectomy, 3- and 5-year survival was 83.3% and 61.1% respectively; and 3-year survival after third hepatectomy was 67%.

CONCLUSION

Repeated resections by expert surgeons for recurrent liver metastases can be safely performed, with low morbidity and mortality rates similar to first hepatectomies. Repeated resections of liver metastases of colorectal cancer improve global survival.

Usefulness of the CAD system for detecting pulmonary nodule in real clinical practice

Objective

We wanted to evaluate the usefulness of the computer-aided detection (CAD) system for detecting pulmonary nodules in real clinical practice by using the CT images.

Materials and Methods

Our Institutional Review Board approved our retrospective study with a waiver of informed consent. This study included 166 CT examinations that were performed for the evaluation of pulmonary metastasis in 166 patients with colorectal cancer. All the CT examinations were interpreted by radiologists and they were also evaluated by the CAD system. All the nodules detected by the CAD system were evaluated with regard to whether or not they were true nodules, and they were classified into micronodules (MN, diameter < 4 mm) and significant nodules (SN, 4 ≤ diameter ≤ 10 mm). The radiologic reports and CAD results were compared.

Results

The CAD system helped detect 426 nodules; 115 (27%) of the 426 nodules were classified as true nodules and 35 (30%) of the 115 nodules were SNs, and 83 (72%) of the 115 were not mentioned in the radiologists' reports and three (4%) of the 83 nodules were non-calcified SNs. One of three non-calcified SNs was confirmed as a metastatic nodule. According to the radiologists' reports, 60 true nodules were detected, and 28 of the 60 were not detected by the CAD system.

Conclusion

Although the CAD system missed many SNs that are detected by radiologists, it helps detect additional nodules that are missed by the radiologists in real clinical practice. Therefore, the CAD system can be useful to support a radiologist's detection performance.

Intraductal papillary growth of liver metastasis originating from colon carcinoma in the bile duct: report of a case

Morphologically, liver metastases from colorectal carcinoma usually form as nodular tumor masses, whereas intraductal papillary growth in the bile duct is rare. A 65-year-old man underwent right hemicolectomy for advanced colon carcinoma, and histology of the primary carcinoma confirmed moderately differentiated adenocarcinoma with subserosal invasion, no vascular infiltration, and no lymph node metastasis. A liver tumor was found in the right paramedian Glisson pedicle and intraductal growth of cholangiocarcinoma was seen on imaging. We performed right hepatectomy and macroscopically, the resected specimen contained a growth in the bile duct lumen similar to cholangiocarcinoma. Histological examination revealed intraductal papillary proliferation of well-differentiated adenocarcinoma without vascular infiltration or lymph node metastasis in the hepatic hilum. Immunohistochemical staining revealed that the tumor cells were negative for cytokeratin-7 and positive for cytokeratin-20. Based on these findings, liver metastasis from colon carcinoma was diagnosed. Liver metastasis from colorectal carcinoma rarely arises as intraductal papillary growth in the bile duct, but the possibility of liver metastases with unusual morphology must be borne in mind for patients with a history of carcinoma in the digestive tract.

Prognostic value of perineural invasion in patients with stage II colorectal cancer

BACKGROUND

Perineural invasion (PNI) may influence the prognosis after resection of colorectal cancer (CRC); whether this is a definite prognostic factor remains controversial. This study determined the clinicopathologic factors associated with oncologic outcome after radical resection of stage II CRC, focusing on PNI.

MATERIALS AND METHODS

We retrospectively reviewed 341 consecutive patients who underwent curative surgery for stage II CRC between January 2001 and December 2006. Of these, 278 patients (81.5%) received postoperative 5-fluorouracil-based chemotherapy. The oncologic outcomes and the risk factors for recurrence were analyzed.

RESULTS

PNI was detected in 57 of 341 patients (16.7%) and was significantly associated with depth of tumor invasion (P = .035) and positive lymphovascular invasion (P < .001). Multivariate analyses revealed that PNI was a significant independent prognostic factor for disease-free survival, not for overall survival. With a median follow-up period of 57.6 months, the 5-year disease-free and overall survival rates of the patients were 80.2 and 82.6%, respectively. The 5-year disease-free survival of the PNI-negative group was significantly higher than that of the PNI-positive group (P < .001). Within the PNI-positive patients, those receiving chemotherapy had significantly higher 5-year disease-free survival than the others (P = .023).

CONCLUSION

This study illustrates the value of PNI as a prognostic factor for stage II CRC. Moreover, PNI-positive patients should be considered for postoperative chemotherapy.

Sequential surgical resection of hepatic and pulmonary metastases from colorectal cancer

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.

Long-term survivors of metastatic colorectal cancer treated with systemic chemotherapy alone: a North Central Cancer Treatment Group review of 3811 patients, N0144

BACKGROUND

Although systemic chemotherapy in patients with unresectable metastatic colorectal cancer (mCRC) is palliative in nature, some patients experience long-term remission beyond 5 years consequent to treatment with chemotherapy alone.

PATIENTS AND METHODS

We reviewed clinical data from 32 prospective North Central Cancer Treatment Group chemotherapy trials in mCRC that enrolled patients from 1972 to 1995. Metastatic CRC was verified histologically. Excluded from analyses were patients who withdrew consent to the study, enrolled in > 1 study, were ineligible, or had major protocol violations. We defined patients with survival beyond 5 years from the initiation of systemic treatment of mCRC as long-term survivors (LTS).

RESULTS

A total of 36 of 3407 (1.1%) patients were LTS. A total of 13 patients (0.4%) are without evidence of disease or disease progression > 5 years from cessation of last chemotherapy, with a median follow-up of 10.6 years (minimum, 7.6 years). Long-term survivors were more likely to have received 5-fluorouracil (5-FU)-based treatment (33 of 2503 [1.3%]) as opposed to other, less effective therapy (3 of 904 [0.3%]), suggesting that the chemotherapy played an important role among LTS (P = .01). Clinical characteristics of LTS were similar to the overall population in terms of age, sex, performance status, and tumor grade.

CONCLUSION

This study establishes a baseline for long-term outcomes of mCRC in the era when effective treatment was limited to 5-FU. With the development of improved systemic therapy for mCRC, cure without salvage surgery might be possible for a small, but important number of patients. Clinical trials should follow patients for > 5 years to document the long-term outcomes.

Staging of advanced colorectal cancer

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.

Treatment outcomes of hepatic and pulmonary metastases from colorectal carcinoma

BACKGROUND AND AIM

The resection of synchronous or metachronous pulmonary and liver metastasis is an aggressive treatment option for patients with stage IV colorectal cancer and has been shown to yield acceptable long-term survival. We reviewed our experience with colorectal cancer patients with both liver and lung resections to determine the efficacy of surgical resections.

METHODS

We performed a single institution, retrospective analysis of all patients who underwent surgical hepatic and pulmonary resection for metastatic colorectal cancer between 1995 and 2004.

RESULTS

A total of 32 patients underwent resection of both hepatic and pulmonary metastases secondary to colorectal cancer. The 5-year overall survival from initial operation was 60.8%. The disease-free interval was 44.3 months (95% confidence interval: 24.7 and 63.8, respectively). Neither the number of pulmonary lesions nor the time interval between the primary surgery and the metastasectomy had a significant impact on survival (P = 0.134).

CONCLUSION

An aggressive surgical treatment of selected colorectal cancer patients with lung and liver metastases resulted in prolonged survival. The 5-year survival rate of 60.8% with no perioperative mortality was observed in our study.

Surgical treatment of combined hepatic and pulmonary colorectal cancer metastases

AIMS

Surgical resection of combined hepatic and pulmonary metastases remains controversial in light of limited supportive evidence. This study aimed to audit our initial experience with this aggressive surgical strategy.

METHODS

Between 1997 and 2006 we assessed 19 patients with colorectal cancer metastases for combined liver and lung metastasectomy, of whom 16 patients underwent surgery. We retrospectively reviewed perioperative and survival data.

RESULTS

Synchronous liver metastases were present in three out of 16 patients at time of diagnosis of the primary tumour, and one out of 16 patients had synchronous lung and liver metastases with the primary tumour. Of those 12 patients who developed metachronous metastases five patients developed liver metastases first, one patient developed pulmonary metastases first, and six patients developed synchronous liver and lung metastases. Thirty nine operations were performed on 16 patients. The median hospital stay was 5.5 (2-10) days for the pulmonary and 7 (1-23) days for the hepatic resections. There were no in-hospital deaths. Chemotherapy was given to five patients prior to metastasectomy and nine received adjuvant chemotherapy following metastasectomy. Median survival from diagnosis of metastatic disease was 44 months (8-87 months). Estimated 1-year survival from diagnosis of metastatic disease was 94%, estimated 5-year survival was 20%.

CONCLUSION

We believe an aggressive but selective surgical approach to combined hepatic and pulmonary colorectal metastases is justified by limited resource requirements and encouraging survival.

Multiple resections for hepatic and pulmonary metastases of colorectal carcinoma

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.

Prognostic significance of depth of invasion, vascular invasion and numbers of lymph node retrievals in combination for patients with stage II colorectal cancer undergoing radical resection

BACKGROUND AND OBJECTIVES

To determine which aspects of tumor histology influenced the postoperative relapse and overall survival rates after radical resection of UICC stage II colorectal cancer (CRC).

METHODS

Data were collected on 259 patients with stage II CRC who underwent radical resection in Kaohsiung Medical University Hospital between January 2002 and December 2005.

RESULTS

A univariate analysis identified that the depth of invasion, the presence of vascular invasion, the presence of perineural invasion, and the number of examined lymph nodes were significant prognostic factors for postoperative relapse. A combination of depth, vascular invasion, and numbers of lymph node retrieval as predictors of postoperative relapse showed that the more predictors that are involved, the higher chance that postoperative relapse would occur. Furthermore, T4 depth of tumor invasion, the presence of vascular invasion, and the number of examined lymph nodes <12 were considerably correlated to the poorer overall survival rates by survival analyses.

CONCLUSIONS

This study has revealed that the depth of invasion, the presence of vascular invasion, and number of examined lymph nodes, may prominently affect the prognosis of stage II CRC patients after radical resection. The increasing risk of postoperative relapse is proportionate to numbers of these three parameters.

The role of surgery in the treatment of recurrent gastric cancer

BACKGROUND

The purpose of the current study was to determine the role of surgery in the treatment of recurrent gastric cancer.

METHODS

Of the 347 patients with recurrent gastric cancer, 61 patients (17.8%) who underwent surgery were evaluated retrospectively. The underlying causes and types of surgery, survival, and postoperative quality of life were analyzed.

RESULTS

The most common cause of surgery was intestinal obstruction due to carcinomatosis. Complete resection was possible in 15 patients (24.6 %), including 10 gastric remnant recurrences, and 2 hepatic and 3 ovarian metastases. The survival of patients who had complete resection was significantly longer than the other groups (52.2 months for complete resections, 13.1 months for palliative procedures, and 8.7 months for laparotomy alone, respectively) (P < .05). The median hospital-free survival (HFS) durations were 9.4, 2.9, and 2.2 months for incomplete resection, bypass/enterostomy, and laparotomy only, respectively (P < .05).

CONCLUSION

Surgical treatment in recurrent gastric cancer is rarely indicated; however, if complete resection could be accomplished, long-term survival can be expected. Bypass surgery for symptom palliation did not increase the HFS.

Pulmonary resection of colorectal metastases in patients with or without a history of hepatic metastases

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.

Combined liver and lung metastasectomy through an exclusive transthoracic approach

BACKGROUND

In a very selected group of patients, resection of metachronous liver and lung metastases, prolongs survival despite the aggressive nature of these lesions. We present here our experience with metastasectomy in patients with metachronous liver and lung metastases in whom, an exclusive transthoracic approach was performed.

METHODS

Between 2002 and 2005, five patients with metachronous colorectal liver and right-lung metastases, underwent an exclusive transthoracic approach. There were three men and two women, with a median age of 68 years (range, 55-76 years). Liver resections performed included segmentectomy of segments VII, VIII, or both. Previous operations include colon resection, adhesiolysis, or ventral hernia repair were performed in all patients.

RESULTS

No mortality was documented. Morbidity included pleural effusion (n = 2) and post-operative pneumonia (n = 1) which responded to conservative management. Median hospital stay was 8 days (range 5-12 days). With a median follow-up of 26 months all patients are alive without recurrent disease.

CONCLUSION

An aggressive surgical approach should be undertaken for CRC metastases. An exclusive transthoracic approach is feasible for combined lung and subdiaphragmatic liver metastasectomy in selected cases with previous abdominal surgery.

Detection and management of extrahepatic colorectal cancer in patients with resectable liver metastases

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.

Establishment of a syngeneic model of hepatic colorectal oligometastases

BACKGROUND

Regional and systemic therapies aimed at improving the outcome for patients with colorectal hepatic metastases have met with modest yet tangible success. Currently, liver resection remains the only curative treatment, but only a minority of patients are candidates for surgery. Animal models are an ideal way to study new treatments for patients with metastatic colorectal cancer. We propose a syngeneic animal model of hepatic colorectal metastases that simulates oligometastases, which is a clinical state considered amenable to regional therapeutic strategies.

MATERIALS AND METHODS

BDIX (BD-9) rats underwent intrasplenic injection of DHD/K12/TRb (Prob/K12) cells to create hepatic metastases via the portal system. After injection of 5 x 10(6) cells, rats underwent laparotomy to determine metastatic burden. Histological analysis confirmed the presence of metastases from resected tumors.

RESULTS

Fifty-three animals were prospectively treated and observed for the development of oligometastases defined as between 1 and 10 hepatic lesions. Thirty-six (68%) of the animals developed detectable metastases while 32 (60%) developed oligometastases (average = 4.40 +/- 2.67). Four animals had overwhelming metastatic liver and peritoneal disease. All animals underwent peritoneal examination and thoracotomy to ensure localized disease. Histological analysis of five hepatectomy specimens confirmed the presence of metastatic cancer. Animals with oligometastases were healthy as evidenced by normal feeding and grooming behavior.

CONCLUSIONS

An animal model of oligometastatic colorectal cancer to the liver can reproducibly mimic the stage IV state in humans conducive to regional therapy and can be used reliably to test novel treatments and mechanisms of metastatic colorectal cancer.

The Treatment of Hepatic Metastases in Colorectal Carcinoma

Colorectal carcinoma is the third most common cause of cancer death in the United States, with 135,000 new cases and 55,000 deaths annually. Ultimately, two-thirds (99,000) of all patients with colorectal cancer will develop metastasis to the liver and other organs in their life span, making metastatic colorectal cancer the second leading cause of cancer-related death in North America. The optimal management of these patients has become increasingly complex with the myriad of treatment options that are available. Because the timing of any therapy (surgery, chemotherapy, or others) has become integral to the success of the treatment, a collaborative approach involving multiple specialties is needed for the best patient outcome. Defined clinical and pathologic determinants of outcome have been demonstrated to effect the overall and disease-free survival of patients with metastatic colorectal cancer. Understanding of these determinants remains essential to any treating physician and has lead to significant paradigm shifts in the management of patients with metastatic colorectal cancer.

Surgical resection of hepatic and pulmonary metastases from colorectal carcinoma

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.

Monocyte chemoattractant protein-1 gene delivery enhances antitumor effects of herpes simplex virus thymidine kinase/ganciclovir system in a model of colon cancer

Suicide gene therapy using the herpes simplex virus thymidine kinase/ganciclovir (HSV-tk/GCV) system is a well-characterized tool for cancer gene therapy; however, it does not yet exhibit sufficient efficacy to cure patients of malignancies. We have reported that adenovirally delivered monocyte chemoattractant protein (MCP)-1 augmented the antitumor effects of the HSV-tk/GCV system in an athymic nude mouse model. The current study, which uses an immunocompetent mouse model of colon cancer, was designed to evaluate the antitumor effects of MCP-1 gene delivery in conjunction with this suicide gene therapy system. Subcutaneous tumor foci were directly transduced with both recombinant adenoviruses (rAds) expressing an HSV-tk gene and either of the MCP-1, CD80 and LacZ genes, followed by GCV administration. The growth of tumors was markedly suppressed by codelivery of HSV-tk and MCP-1 genes, which was exclusively associated with the recruitment of monocytes/macrophages, T helper 1 (Th1) cytokine gene expression and cytotoxic activity of the splenocytes. Furthermore, the antitumor effects were more efficient than that obtained by the combination of HSV-tk and CD80 genes. These results suggest an immunomodulatory effect of MCP-1 in the context of suicide gene therapy of colon cancer via orchestration of innate and acquired immune responses.

Analysis of preoperative prognostic factors for long-term survival after hepatic resection of liver metastasis of colorectal carcinoma

Hepatic resection is the most effective therapy for liver metastasis of colorectal carcinoma. To clarify indications for this therapy, the clinicopathologic and follow-up data of 103 consecutive patients who underwent hepatic resection for metastases of colorectal carcinoma were analyzed. Factors influencing overall survival rate were investigated by multivariate analysis. Thereafter, patients who underwent resection were stratified according to the number of independent risk factors present, and their outcomes were compared with those of 14 nonresection patients with fewer than six liver tumors and without extrahepatic metastasis. The overall survival rate of the 103 resection patients was 43.1%. The clinicopathologic factors shown to affect on long-term survival after hepatic resection were the interval between colorectal and hepatic surgery (<12 months), preoperative carcinoembryonic antigen level (> or =10 ng/ml), and number of hepatic metastases (four or more). The 5-year overall survival rates were 75.0% with no risk factors (n=16), 53.6% with one risk factor (n=46), 23.0% with two risk factors (n=36), and 0% with three risk factors (n=5). Survival rates did not differ between resection patients with three risk factors and nonresection patients. Therefore, hepatic resection may be appropriate for patients with fewer than three risk factors.

Hepatic resection in stage IV colorectal cancer: prognostic predictors of outcome

BACKGROUND AND AIMS

Hepatic resection has been proposed as an effective way to treat metastatic colorectal carcinoma. The aim of the study was to determine if contemporary resection of intestinal primary tumor and hepatic metastases is effective in the treatment of patients with metastases that are recognized at the initial clinical presentation of the primary tumor.

METHODS

In a retrospective study, univariate and multivariate models were used to analyze the effect of patient demographics, tumor characteristics, and treatment factors on early and long-term outcome of patients submitted to synchronous intestinal and hepatic resection for colorectal liver metastases. From 1988 to 1999, 78 patients underwent surgical resection of primary colorectal tumor and hepatic metastases with curative intent. Criteria for study recruitment included primary tumor controllable, no extrahepatic disease detectable, and negative surgical margins of hepatic resection.

RESULTS

The univariate analysis disclosed as adverse predictors of the long-term outcome the numbers of metastases (</=3; >3), pre-operative CEA value >100 ng/ml, resection margin <10 mm, and portal nodal status. Multivariate analysis confirmed number of metastases, resection margin and portal nodal status as independent predictors.

CONCLUSIONS

Our findings confirm hepatic resection as an effective procedure when undertaking combined bowel and hepatic resection. The applicability and the outcome of this surgical strategy is definitively influenced by the chance of a radical resection of the primary tumor, the number of hepatic metastases, resection margin wider than 1 cm, positive portal nodes, and the absence of any extrahepatic metastatic disease.

Longterm results after resection of simultaneous and sequential lung and liver metastases from colorectal carcinoma

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.

A critical review of the major indicators of prognosis after resection of hepatic metastases from colorectal carcinoma

Hepatic resections for metastatic colorectal cancer have dramatically increased, and there is clear evidence of the effectiveness of this type of surgery. Controversy, however, persists regarding appropriate patient selection, extent and timing of liver resection, and adjuvant or alternative therapeutic options. This article reviews the authors' experience with more than 600 hepatic resections and the relevant literature is discussed. The results underscore the importance of macroscopically and histologically complete tumor clearance, a so-called "R0 resection."

Management of colorectal liver metastases

Hepatic metastases occur in 60% of patients following resection for colorectal cancer. Liver resection is the only curative option, with one third of resected patients alive at five years. In those developing recurrence in the liver following resection, further liver surgery may be curative, with similar 5 years survival rates of about 30%. Until recently surgery was feasible in only 15-25% of patients with colorectal liver metastases. New strategies, such as downstaging chemotherapy, portal vein embolization and two-stage hepatectomy, may increase the resectability rate by 15%. Earlier detection of liver metastases would increase resectability, although good follow-up trials are lacking. Once suspected, colorectal liver metastases are staged by spiral CT, CT portography and MRI, which have similar overall accuracies. Mortality following liver resection is less than 5% in major centres, with a morbidity rate of 20% to 50%. Prognostic scoring systems can be used to predict the likely cure rate with resection. Pulmonary metastases occur in 10-25% of patients with resected colorectal cancer, but are limited to the lung in only 2% of cases. In these selected cases surgery provides long-term survival in 20-40%, and repeat lung resection has shown similar rates. For patients with unresectable disease, chemotherapy and ablation techniques have been demonstrated to prolong survival, although chemotherapy alone has been shown to improve quality of life.

Resection of hepatic and pulmonary metastases in patients with colorectal cancer

The resection of liver and lung metastases is now regarded as valid therapy, although the surgical procedure of both metastatic sites has not been clearly defined. Nine consecutive patients who underwent resection of both liver and lung metastases from colorectal cancer (5 Dukes' stage B, 3 C, 1 D) between 1986 and 1999 were studied retrospectively. A total of 19 resections were performed: 8 hepatectomies, 2 liver wedge resections, and 9 lung lobectomies. No operative or hospital deaths occurred, and mean postoperative hospital stay per procedure was 12 days. Mean survival after resection of the primary colorectal tumor was 66.3 (range: 26-96) months. The median interval was 24.2 (range: 2-39) months from resection of the liver metastasis and 30.4 (range: 3-45) months from resection of the lung metastasis. At the last follow-up, 6 patients were still alive, 4 of whom were free of recurrence 59, 69, 74, and 76 months, respectively, after resections. Three patients died with metastases. Aggressive treatment of liver and lung secondaries from colorectal cancer was performed without hospital mortality and acceptable morbidity. Longer survival times warrant the use of this alternative therapy for selected patients. In association with new effective chemotherapies, it will be possible to select patients who will benefit from surgery.

Hydronephrosis associated with colorectal carcinoma: treatment and outcome

AIM

Obstruction of the upper urinary tract, hydronephrosis, is not uncommon in the context of primary or recurrent colorectal cancer (CRC). Its presence poses a therapeutic dilemma. This study focuses on the significance of hydronephrosis as a prognostic marker for CRC by analysing the resectability and survival rates of patients affected.

PATIENTS AND METHODS

Retrospective data of 52 patients with hydronephrosis were analysed. Ten had primary CRC at different sites and 42 developed hydronephrosis 1-84 months following resection of a primary CRC. Twenty eight had unilateral and 24 bilateral hydronephrosis.

RESULTS

In 10 patients with primary CRC and in 38 of those with a history of CRC, hydronephrosis was secondary to malignant obstruction. In four it was related to iatrogenic injury to the urinary tract. Complete surgical resection was possible in five patients (10%) with malignant obstruction. The remaining 90% underwent palliative or no surgical treatment due to diffuse metastasis or extensive local disease. No difference in survival was found between these two groups (6 vs 8 months) nor when comparing CEA levels, Duke's staging, or unilateral vs bilateral hydronephrosis. Patients with benign obstruction were treated by a ureteric stent, leading to resolution of hydronephrosis. All four are alive.

CONCLUSIONS

Malignant hydronephrosis, secondary to primary or recurrent CRC, represents local manifestation of a disseminated disease with almost no probability of long-term survival and cure. It would seem that patients with such disease do not benefit from aggressive operations.

Simultaneous detection of colorectal carcinoma liver and lung metastases does not warrant resection

BACKGROUND

Recent evidence suggests that metastasectomy is efficacious for selected patients with hepatic and pulmonary metastases from a colorectal primary. The aim of this study was to identify a subgroup of patients who best benefit from hepatic and pulmonary metastasectomy among those with colorectal carcinoma metastases.

STUDY DESIGN

We analyzed retrospectively a total of 136 patients who underwent resection of hepatic or pulmonary metastases of colorectal origin at Niigata University Medical Hospital between 1982 and 2000. The median follow-up period was 94 months. Eighty-four patients underwent hepatectomy alone, 25 underwent pulmonary resection alone, and 27 underwent both hepatic and pulmonary resection. The 27 patients undergoing hepatic and pulmonary resection were divided into two groups: 17 patients with sequentially detected hepatic and pulmonary metastases and 10 patients with simultaneously detected metastases. Survival time was determined from the date of initial metastasectomy. Differences in cumulative survival were evaluated using the log-rank test. Sixteen factors were assessed for their influence on the survival of the 27 patients undergoing resection of hepatic and pulmonary metastases; univariate and multivariate analyses were used in this evaluation.

RESULTS

Patient survival after hepatic and pulmonary resection was comparable with that after hepatectomy alone (p = 0.536) and that after pulmonary resection alone (p = 0.294). Among the 27 patients undergoing hepatic and pulmonary resection, the outcomes after resection were significantly better in patients with sequentially detected metastases (cumulative 5-year survival of 44%) than in those with simultaneously detected ones (cumulative 5-year survival of 0%) (p < 0.001). On multivariate analysis sequential detection of hepatic and pulmonary metastases was the strongest independent favorable prognostic factor (p <0.001).

CONCLUSIONS

Patients with sequentially detected hepatic and pulmonary metastases from a colorectal primary are good candidates for aggressive metastasectomy. Simultaneous detection of these metastases does not warrant resection.

Surgical treatment of hepatic and pulmonary metastases from colon cancer

BACKGROUND

Surgical resection of isolated hepatic or pulmonary metastases secondary to colorectal cancer has been shown to yield acceptable long-term survival. However, results are inconclusive for surgical resection of both hepatic and pulmonary metastases.

METHODS

We reviewed the records of all patients who underwent surgical resection of both hepatic and pulmonary metastases from colorectal cancer between 1980 and 1998.

RESULTS

A total of 58 patients underwent resection of both hepatic and pulmonary metastases secondary to colorectal cancer. All patients had local control of their primary cancer before metastasectomy. There were no operative deaths. Morbidity occurred in 12% of patients. Follow-up was complete in all patients, with a median duration of 62 months (range, 6 to 201 months). The 5- and 10-year survivals were 30% and 16%, respectively. A premetastasectomy carcinoembryonic antigen level greater than 5 ng/mL increased the risk of early death (p = 0.029). Neither the number of pulmonary lesions nor the time interval between the primary surgery and the metastasectomy had a significant impact on survival (p = 0.67). At 5 years, 55% of patients were free of disease. Four patients had lymph node involvement at the time of pulmonary resection and all 4 patients died within 22 months of their pulmonary metastasectomy.

CONCLUSIONS

Resection of both hepatic and pulmonary metastases secondary to colorectal cancer in highly selected patients is safe and results in long-term survival. Thoracic lymph node involvement and elevated carcinoembryonic antigen levels before pulmonary metastasectomy are associated with reduced survival.