Repeat hepatectomy for liver metastases from colorectal primary cancer: a review of the literature. J Visc Surg. 2012;149:e97-e103. [PMID: 22317931 DOI: 10.1016/j.jviscsurg.2012.01.001]

Outcomes after repeat hepatectomy for colorectal liver metastases from the colorectal liver operative metastasis international collaborative (COLOMIC)

BACKGROUND

Resection of colorectal liver metastasis (CLM) is beneficial when feasible. However, the benefit of second hepatectomy for hepatic recurrence in CLM remains unclear.

METHODS

The Colorectal Liver Operative Metastasis International Collaborative retrospectively examined 1004 CLM cases from 2000 to 2018 from a total of 953 patients. Hepatic recurrence after initial hepatectomy was identified in 218 patients. Kaplan-Meier analysis was performed for overall survival (OS) and recurrence-free survival (RFS). Propensity score matching (PSM) was performed to offset selection bias. Cox proportional-hazards regression was performed to identify risk factors associated with OS.

RESULTS

A total of 51 patients underwent second hepatectomy. Unadjusted median OS was 60.1 months in repeat-hepatectomy versus 38.3 months in the single-hepatectomy group (p = 0.015). In the PSM population, median OS remained significantly better in the repeat-hepatectomy group (60.1 vs. 33.1 months; p = 0.0023); median RFS was 12.4 months for the repeat-hepatectomy group, versus 9.8 months in the single-hepatectomy group (p = 0.0050). Repeat hepatectomy was associated with lower risk of death (hazard ratio: 0.283; p = 0.000012). Obesity, tobacco use, and high intraoperative blood loss were associated with significant risk of death (p < 0.05).

CONCLUSION

In CLM with hepatic recurrence, second hepatectomy was beneficial for OS. With PSM, the OS benefit of performing a second hepatectomy remained significant.

Reconsideration of indications for third hepatectomy for colorectal liver metastases

BACKGROUND

It is unclear which patients with recurrence after a second hepatectomy will benefit from a third hepatectomy.

METHODS

Patients who underwent hepatectomy for colorectal liver metastasis (CRLM) between April 2005 and July 2021 were included. Factors affecting recurrence after each hepatectomy were analyzed.

RESULTS

Sixty-four of the 167 patients who had recurrence after the first hepatectomy underwent a second hepatectomy. Then, 46 patients had recurrence and 18 patients did not have recurrence after the second hepatectomy. Sixteen patients who underwent a third hepatectomy had better overall survival (OS) than those who did not (52 vs. 31 months, p = 0.043). However, the multivariate analysis demonstrated that only tumor size (>5 cm) during the second hepatectomy (p = 0.022) and carbohydrate antigen 19-9 (CA 19-9) level (>50 U/ml) (p = 0.041) at recurrence after the second hepatectomy were poor prognostic factors for OS.

CONCLUSION

While a third hepatectomy can be performed if it is technically and oncologically appropriate, tumor size >5 cm and CA 19-9 >50 U/ml should be considered in terms of long-term outcomes before proceeding to surgery.

Child-Turcotte-Pugh Score as a Predictive Factor for Long-Term Survival After Repeat Hepatectomy for Recurrent Liver Metastases of Colorectal Cancer

Objective

We aimed to evaluate the changes in liver function after repeat hepatectomy and their relationship with survival of patient with colorectal cancer.

Summary of Background Data

Repeat hepatectomy has been accepted as an effective treatment for recurrent liver metastases; however, how repeat hepatectomy changes the liver function during the follow-up period is not well understood.

Methods

Data regarding patients underwent R0 resections at initial hepatectomy for colorectal cancer with liver metastasis from 2012 to 2017 were retrospectively reviewed. Patients were divided into groups according to the total number of hepatectomies. Overall survival and Child-Turcotte-Pugh score after hepatectomy were analyzed.

Results

Fifty-three patients underwent single hepatectomy and 37 patients underwent repeat hepatectomy. There was no significant difference in the overall survival rates between the 2 groups. At 27 months after the initial hepatectomy, mean Child-Turcotte-Pugh scores of patients with repeat hepatectomy started to become statistically higher than those of patients with single hepatectomy. Overall survival of patients who survived after 27 months from the initial hepatectomy showed a statistical difference between the 2 groups. The total number of liver metastases ≥ 4 and Child-Turcotte-Pugh score ≥ 6 at 27 months after the initial hepatectomy were significant risk factors for overall survival of patient who survived after 27 months from the initial hepatectomy.

Conclusions

Liver function after repeat hepatectomy can be deteriorated after a long-term period. Careful approach and continuous assessment of the liver function after hepatectomy are necessary to maintain long-term survival after repeat hepatectomy.

Surgical and oncologic outcomes following repeat hepatic resection of colorectal liver metastasis: Who benefits?

BACKGROUND

Resected colorectal liver metastases (CRLM) frequently recur intrahepatically. Selection criteria for repeat hepatectomy of recurrent CRLM are ill-defined.

METHODS

We performed an institutional review of patients with recurrent CRLM undergoing repeat hepatectomy from 2003 to 19. Post-recurrence overall (rOS) and recurrence-free survival (RFS) were analyzed with Cox proportional hazards modeling.

RESULTS

n = 147 experienced recurrent CRLM; 11% (n = 38) received repeat hepatectomy of which there was one Clavien-Dindo IIIa complication. Median rOS was 41 months; median RFS was 9 months. Improved rOS and RFS were independently associated with additional post-operative chemotherapy after repeat hepatectomy (HR 0.35 and 0.34, respectively); poor rOS with recurrent CRLM >3 cm (HR 4.4) and <12 months from first hepatectomy to recurrence (HR 4.8); poor RFS with ≥3 recurrence liver metastases (HR 2.8) (All P < 0.05).

DISCUSSION

Repeat hepatectomy for recurrent CRLM can be performed safely. Worse survival following repeat hepatectomy is independently associated with >3 cm and ≥3 liver lesions at recurrence, and <12 months to recurrence. Additional post-operative chemotherapy after repeat hepatectomy is associated with improved outcomes.

Late recurrence of cancer stem cell-positive colorectal cancer liver metastases after 15 years

No cases of late recurrence of colorectal cancer liver metastasis (CRLM) over 10 years have been reported in the literature. A 72-year-old woman had a surgical history of sigmoid colectomy and partial hepatic resections for sigmoid colon cancer and multiple liver metastases 15 years previously. The patient had been postoperatively treated with chemotherapy for 6 months and was observed regularly with no recurrence. Computed tomography (CT) performed due to high carcinoembryonic antigen (CEA) revealed a tumor of 70 mm in diameter at the anterior segment of the liver and a 6-mm nodule at the left lateral segment. There was no other malignant finding. We performed central bisegmentectomy and partial resection of the liver. Pathological findings showed the tumors to be well to moderately differentiated adenocarcinoma, and positive cytokeratin 20 (CK20) and caudal-type homeobox transcription factor 2 (CDX2) expression with negative expression of cytokeratin 7 (CK7). In addition, the tumors showed cluster of differentiation 44 (CD44) and 133 (CD133) positive signified cancer stem cell immunohistochemically. The postoperative diagnosis was recurrence of hepatic metastasis of sigmoid colon cancer. We report a rare case of late recurrence of CRLM more than 15 years after the primary diagnosis.

Hepatic metastasis from colorectal cancer

Colorectal cancer (CRC) is one of the most common cancers in the world. About two third of patients with CRC will develop distant recurrence at some point in time. Liver is the most common site where distant metastasis takes place. While the overall survival (OS) of patients with metastatic CRC was poor about 3 decades ago, there has been tremendous improvement in this area in the recent years. With the advent of effective systemic chemotherapy and biologic agents and better understanding of the biological behaviour of the tumour, aggressive treatment strategies such as metastatectomy of the liver metastases (or lung metastases) are now acceptable. More importantly, it has transformed the way how stage IV CRCs are being managed. From predominantly palliative as the primary aim, a comprehensive multidisciplinary approach is now the mainstay of treatment with very successful outcomes. Combination of systemic therapies with liver resection has been shown to be effective in providing promising survival benefits. In addition, other adjunctive modalities in targeting the liver metastases such as ablation, combining resection and ablation, transarterial chemoembolization, stereotactic body radiotherapy (SBRT), hepatic artery perfusion, etc. have also been demonstrated variable outcome in treating colorectal liver metastasis (CRLM). Very recently, transplant oncologists have also explored using liver transplantation as a treatment modality for unresectable CRLM, which has demonstrated very good long-term survival in well selected cases. The new paradigm in the treatment of metastatic CRC has dawned.

Repeat hepatectomy for recurred colorectal liver metastasis: is it justified?

Purpose

Liver resection is considered the only curative treatment modality for colorectal liver metastasis. The recurrence rate after hepatectomy is >50%. Two or more hepatectomies are applied to treat recurred metastases. We assessed the efficiency and feasibility of repeat hepatectomy and analyzed the prognostic factors after a repeat hepatectomy.

Methods

In total, 248 patients were diagnosed with recurred liver metastasis between January 2003 and May 2016. Second and third hepatectomies were performed in 70 and 7 patients, respectively. The other 171 patients did not undergo a repeat hepatectomy. Clinical features were collected from the medical records. We analyzed survival rates of the repeat hepatectomy group and the nonrepeat hepatectomy group. We also investigated factors affecting overall and disease-free survival of patients who received a repeat hepatectomy using univariate and multivariate analyses.

Results

Median overall survival was significantly higher in the repeat hepatectomy group than in the nonrepeat group (83.0 months vs. 25.0 months, P < 0.001). The morbidity and mortality rates of repeat hepatectomy were 9.1% and 0%, respectively. Median overall and disease-free survival of the repeat hepatectomy group were 62.0 and 51.0 months, respectively. The number of recurred tumors was the only significant factor for disease-free survival (P = 0.029). None of the factors affected overall survival.

Conclusion

Repeat hepatectomy is necessary, effective, and safe for treating recurred colorectal liver metastasis. Repeat hepatectomy can be considered in patients with fewer than three recurred metastatic tumors.

Repeat procedures for recurrent colorectal liver metastases: analysis of long-term liver regeneration and outcome

Background and aim: Repeat hepatectomy is increasingly performed for the management of recurrent colorectal liver metastases (CRLM). The aim of this study was to evaluate long-term functional liver volume (FLV) after a second hepatic procedure and to measure survival outcome. Methods: In this retrospective cohort study, patients treated for recurrent CRLM in the years 2005-2015 at two liver centers were included. Total FLV was calculated before the first procedure and before and after the second procedure. Overall survival was calculated. Results: Eighty-two patients were identified. The median follow-up was 53 (40-71) months from the first procedure. The median interval between first and second procedure was 13 (8-22) months. The initial FLV was 1584 (1313-1927) mL. The FLV was 1438 (1204-1896) mL after the first procedure and 1470 (1172-1699) mL after the second procedure (P<0.001). After the second procedure, a total of ten patients (12%) had a residual liver volume of less than 75% of the initial liver volume. The 5-year overall survival was 37 (26-54)% after the second procedure. Conclusion: Small changes in FLV were found after two hepatic procedures but with considerable inter-individual variation. Patients selected for a repeated hepatic procedure for recurrent CRLM had an acceptable survival.

Impact of Preoperative Hepatitis B Virus Levels on Prognosis After Primary and Repeat Hepatectomies for Hepatocellular Carcinoma Patients-a Retrospective Study

BACKGROUND

Chronic HBV plays an important role in hepatocellular carcinoma pathogenesis. Previously, most studies have been focusing on HBV DNA levels before the primary curative hepatectomy. However, the association of virus level before repeat hepatectomy with the degrees of inflammation and fibrosis on histopathology and prognosis has not been surveyed.

METHODS

From January 2002 to December 2009, all patients who were seropositive for hepatitis B surface antigen (HBsAg) were enrolled and assigned into four groups based on their HBV DNA levels before the primary and repeat hepatectomies. The cancer prognoses of these four groups of patients after the first and second operations were assessed and compared. The disease-free survival and overall survival were estimated by the Kaplan-Meier method. Univariate and multivariate analyses were performed to identify risk factors for the primary and repeat hepatectomies.

RESULTS

For the 385 patients in this study, a low level of serum HBV DNA before repeat hepatectomy, but not primary hepatectomy, was significantly associated with improvement in prognosis, in terms of tumor recurrence, liver fibrosis, and liver-related mortality.

CONCLUSION

The levels of HBV DNA before hepatectomies were crucial prognostic risk factors of HBV-related hepatocellular carcinoma patients. Surveillance of serum HBV DNA levels at multiple time points, rather than at a single time point, and antiviral therapy to suppress the virus to a low level had beneficial effects for these patients.

Long-term outcome and quality of life after initial and repeat resection of colorectal liver metastasis: A retrospective analysis

BACKGROUND

Repeat hepatectomy is a widely accepted treatment for patients with recurrent colorectal liver metastasis (CRLM). The aim of this study was to compare initial and repeat hepatic resection concerning overall survival, prognostic factors and postoperative quality of life.

METHODS

Data on patients who underwent initial or repeat hepatic resection for CRLM between 2010 and 2016 were prospectively collected and retrospectively evaluated. Follow-up data, EORTC QLQ-C30 and QLQ-LMC21 questionnaire results for quality of life (QoL) evaluation were analyzed.

RESULTS

160 patients at a median age of 62.8 ± 11.8 years were analyzed. 122 were initially resected and 38 underwent a repeat hepatic resection. Disease-free survival (DSF) was superior in the initial resection group (p < 0.001), while there was no difference in overall survival (OS) (p = 0.288). BMI >30 (p = 0.012), extrahepatic tumor manifestation (p = 0.037), >1 CRLM manifestation (p = 0.009), and perioperative chemotherapy (p = 0.006) in the initial resection group and primary left colon tumor (p = 0.001) in the repeat resection group were identified as prognostic factors in multivariate Cox regression analysis. EORTC QLQ-LMC-21 module symptom score displayed an increased occurrence of a dry mouth in the initial hepatectomy group (p = 0.003). EORTC QLQ-C30 general functioning and symptom scores showed no difference.

CONCLUSION

Repeat hepatic resection for CRLM is as effective as primary surgical treatment in terms of OS and QoL. Patients should be selected carefully concerning prognostic factors as DFS is decreased after repeat hepatic resection.

Recurrence of liver metastases from colorectal cancer and repeat liver resection

OBJECTIVE

The purpose of this study was to assess the resectability and effectiveness of repeat hepatectomy for relapsing liver metastases of colorectal origin in terms of morbidity, mortality, overall survival, and disease-free survival.

METHODS

A retrospective study was performed on a prospective cohort of patients with colorectal liver metastases who underwent repeat surgery at Hospital Universitario San Cecilio, Granada (Spain), from March 2003 to June 2013. Primary outcome variables included survival and morbidity within 30 days post-surgery.

RESULTS

A total of 147 patients with colorectal liver metastases underwent surgical excision during the study period; 61 patients had liver recurrence, and 34 of these received repeat surgery. The overall survival rate at 5 and 10 years for resected patients (n=27/34) was 48% and 48%. Mean hospital stay was 8.9 ± 3.5 days, morbidity was 9%, and mortality was 0%.

CONCLUSION

Repeat liver resection for colorectal liver metastases is a safe, effective surgical procedure whose results are similar to those obtained after initial liver resection.

Repeat hepatic resection in patients with colorectal liver metastases

AIM: To investigate the survival outcomes of secondary hepatectomy for recurrent colorectal liver metastases (CRLM).

METHODS: From October 1994 to December 2009, patients with CRLM who underwent surgical treatment with curative intent were investigated. Patients were divided into two groups: patients who underwent primary hepatectomy (Group 1) and those who underwent secondary hepatectomy for recurrent CRLM (Group 2).

RESULTS: Survival and prognostic factors were analyzed. A total of 461 patients were included: 406 patients in Group 1 and 55 patients in Group 2. After a median 39-mo (range, 3-195 mo) follow-up, there was a significant difference between Groups 1 and 2 in terms of disease-free survival (P = 0.029) although there was no significant difference in overall survival (P = 0.206). Secondary hepatectomy was less effective in patients with multiple recurrent CRLM than primary hepatectomy for initial CRLM (P = 0.008). Multiple CRLM and radiofrequency ablation therapy were poor prognostic factors of secondary hepatectomy in multivariate Cox regression analysis (P = 0.006, P = 0.004, respectively).

CONCLUSION: Secondary hepatectomy for single recurrent CRLM is as effective as primary surgical treatment for single recurrent CRLM. However, secondary hepatectomy for multiple recurrent CRLM is less effective than that for single recurrent CRLM.

Liver resection for colorectal metastases: results and prognostic factors with 10-year follow-up

PURPOSE

Actual 5-year survival rates after resection of colorectal liver metastases (CLM) are 25-45%, whereas 10-year survival rates are extrapolated from survival curves. Few studies have reported long-term survivors with 10 years of actual follow-up. Therefore, no recurrences occurring after 10-plus years have been reported. The aim of our study was to analyze actual 10-year survival rates and prognostic factors.

METHODS

Clinical data of patients with CLM who had undergone first liver resection in our center between January 1990 and December 2000 were retrospectively analyzed.

RESULTS

Eighty-nine patients of mean age 64 years were studied. Three patients were excluded from the study: one because of postoperative death, and two from being lost to follow-up. All other subjects had a potential 10-year follow-up. Only 33% patients received perioperative chemotherapy. The actual 10-year overall and disease-free survival rate were 22 and 19%, respectively. Poor prognostic factors were disease-free interval less than 1 year, wedge liver resection, clinical risk score>2, segment 1 CLM location, and peritumoral lymphangitis. Good prognostic factors were tumors having mucinous components in primary tumor and CLM located in the right lobe.

CONCLUSIONS

With actual long-term follow-up for 10 years, disease-free survival rate is 19% and mainly depends on surgical management. Recurrence continues to occur more than 5 years after liver resection for CLM; cure cannot be assumed at this time. Clinical risk score is a good predictor of cure and should be taken into account when choosing perioperative treatment.

Recurrence pattern depends on the location of colon cancer in the patients with synchronous colorectal liver metastasis

BACKGROUND

The veins from the lower rectum drain into the systemic venous system, while those from other parts of the colon drain into the portal venous system. The aim of this study was to investigate recurrence pattern and survival according to the anatomical differences in patients with colorectal liver metastases (CRLM).

METHODS

From October 1994 to December 2009, synchronous CRLM patients who underwent surgery were identified from our prospectively collected database. The patients were excluded if there had been extrahepatic metastases. The patients were divided into two groups according to the location of the primary colorectal cancer: lower rectal cancer (group 1) and upper rectal or colon cancer (group 2). The recurrence patterns and survival were investigated.

RESULTS

A total of 316 patients were included: 53 patients in group 1 and 263 patients in group 2. After a median follow-up of 37 months, the extrahepatic recurrence curve of group 1 was superior to that of group 2 (P < 0.001), although there was no difference between the hepatic recurrence curves (P = 0.93). The disease-free and overall survival curves of group 1 were inferior to those of group 2 (P = 0.004) (P < 0.001). Lower rectal cancer was a significant risk factor for extrahepatic recurrence in Cox proportional hazard model analysis (hazard ratio = 1.7, P = 0.04).

CONCLUSIONS

The extrahepatic recurrence rate is high in lower rectal cancer patients after surgical treatment for synchronous CRLM.

Surgical management of colorectal peritoneal metastases: treatment and outcomes compared with hepatic metastases

PURPOSE

The liver and peritoneum are common sites of colorectal metastases. Hepatectomy for colorectal liver metastases (CLM) is considered gold standard treatment. We attempt to compare the survival outcomes for CLM patients after hepatectomy to that of patients with colorectal peritoneal metastases (CPM) who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

A retrospective review of patients with CPM and CLM who underwent surgery between January 2003 and May 2011 was performed. The overall (OS) and disease-free survivals (DFS) were compared.

RESULTS

There were 22 patients with CPM who underwent CRS and HIPEC and 186 patients who underwent hepatectomy for CLM. Patients with CPM had a 3-year OS of 39 % and DFS of 27.7 %. CLM patients showed a 3-year OS of 58.5 % and a DFS of 28.8 %. Most recurrences for CPM occurred within 2 years, while CLM patients continue to develop systemic recurrences over 3 years, showing a gradual decline in DFS and OS during this period of time.

CONCLUSION

Our results show that CRS and HIPEC for CPM confer good OS and DFS rates and that the DFS after CRS and HIPEC is comparable to that after hepatectomy for CLM.

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.

Recent advances and significance of intra-arterial infusion chemotherapy in non-resectable colorectal liver metastasis

In era of systemic chemotherapy for colorectal liver metastasis (CLM), role of hepatic intraarterial infusion chemotherapy (HAIC) remains important. We examined treatment effects of HAIC in 36 patients with non-resectable CLM using 5-FU or CPT-11. Tumor response was complete response (CR) in 4, partial response (PR) in 19, stable disease (SD) in 6, and progressive disease (PD) in 7. Tumor control rate was 81% and response rate was 64%. Six patients showed catheter-related complications. Median survival period was 62 months in CR, and 25 with PR. HAIC has a major impact in high chemotherapy response and prolonging survival.

Surgical management of colorectal cancer metastases to the liver: multimodality approach and a single institutional experience

Over the past 30 years, the treatment of metastatic colorectal cancer to the liver has undergone major changes. Once considered terminal and incurable, the prognosis of patients with colorectal hepatic metastases has seen dramatic improvements using modern multimodality therapy and now long-term survival and even cure are possible in some patients. Despite the advances seen in systemic therapy, hepatic resection offers the longest survival potential and remains the only curative option. Based on long-term outcomes and the improved safety of hepatic resection using modern operative techniques and critical care support, an aggressive locoregional approach to colorectal hepatic metastasis has become the standard of care. This article focuses on the management of colorectal hepatic metastases and highlights the importance of multimodality therapy. We also report our 18-year experience treating patients with hepatic resection for colorectal metastases.

Multimodal management of colorectal liver metastases and the effect on regeneration and outcome after liver resection

Management of colorectal liver metastases (CRLM) has dramatically changed during the last decade and has now become more multimodal and aggressive, including the use of downstaging chemotherapy, portal vein embolization to increase the function of the liver remnant or both in combination. Radiofrequency ablation is also an option in CRLM, potentially combined with surgical resection. Results are quite convincing concerning the safety of liver resection also when performed following neoadjuvant chemotherapy. Sparing liver parenchyma in patients with bilobar liver metastatic disease subjected to liver resection may be possible without endangering surgical radicality. Sparing liver parenchyma when using neoadjuvant chemotherapy, a chemotherapy-free period of 6 weeks or more seems to positively affect liver regeneration. There is still the possibility to reresect recurrent liver lesions, though there seems to be a tendency toward fewer reresections following the use of adjuvant chemotherapy.