Liver resection for colorectal liver metastases

The role of FDG-PET in the selection of patients with colorectal liver metastases

BACKGROUND

Selection of patients for hepatic resection of colorectal liver metastases is still limited. After conventional work up by computed tomography (CT) scan, 60% of patients will develop recurrent disease in the early years after resection. The aim of the present study was to evaluate whether an additional fluorine-18-deoxyglucose positron emission tomography (FDG-PET) improves patient selection and therefore adds value to select patients for curative liver resection.

METHODS

Data from 203 patients selected for surgical treatment of colorectal liver metastases between 1995 and 2003 were collected in a prospective database. Group A consisted of 100 consecutive patients selected for hepatic surgery by conventional diagnostic imaging (CT chest and abdomen) only. Group B consisted of 103 consecutive patients selected for hepatic surgery by conventional diagnostic methods plus an additional FDG-PET.

RESULTS

The number of patients with futile surgery, in which further treatment was considered inappropriate at laparotomy, was 28.0% in group A and 19.4% in group B. The reason for unresectable disease differed between groups. In group A, 10/100 (10.0%) patients showed extrahepatic abdominal disease versus 2/103 patients (1.9%) in group B (P = .017). In all other cases, resection was not performed because liver disease proved too extensive at laparotomy. For patients ultimately undergoing surgical treatment of the metastases, survival was comparable between groups. Overall survival at 3 years was 57.1% in group A versus 60.1% in group B. Disease-free survival at 3 years was 23.0% in group A and 31.4% in group B.

CONCLUSIONS

In patients with colorectal liver metastases, FDG-PET may reduce the number of negative laparotomies. However, the effect size on the selection of these patients seems not sufficient enough to affect the overall and disease-free survival after treatment.

Pre-hepatectomy prognostic staging to determine treatment strategy for colorectal cancer metastases to the liver

BACKGROUND

Attempts at identifying prognostic factors after hepatectomy in patients with colorectal liver metastases have not achieved consensus. We investigated prognostic factors ascertainable before hepatectomy for colorectal metastasis.

METHOD

Clinicopathological data for 149 consecutive patients with colorectal cancer who underwent curative resection of primary lesions and metastatic liver disease at one institution were subjected to multivariate analysis concerning metastatic status and the primary lesion.

RESULTS

Poorly differentiated adenocarcinoma or mucinous carcinoma as the primary tumor (Poor/muc; P=0.026), marked vascular invasion by the primary tumor (V; P=0.002), bi-lobar liver metastases ( P=0.048), and short doubling time (DT) of the liver tumor ( P=0.028) were characteristics assessable before hepatectomy that independently indicated poorer survival. A four-stage classification based on these factors was related to overall ( P<0.01) and disease-free ( P<0.01) survival rates. No pattern of recurrence site was evident in stage I (patients with no risk factor). Recurrence was usually extrahepatic in stage IV (patients with Poor/muc) but favored the remnant liver in stage II (patients with bi-lobar metastases or short DT) or III (patients with V; P=0.037). Stage III showed more multiple and early hepatic recurrences than stage II, and repeat hepatectomy was less frequent ( P<0.05).

CONCLUSION

Pre-hepatectomy prognostic staging should help to guide treatment of liver metastases.

Survival of patients evaluated by FDG-PET before hepatic resection for metastatic colorectal carcinoma: a prospective database study

OBJECTIVE

To present the survival results for patients with colorectal carcinoma metastases who have undergone liver resection after being staged by [(18)F] fluoro-2-deoxy-D-glucose-positron emission tomography (FDG-PET).

SUMMARY BACKGROUND DATA

Hepatic resection is standard therapy for colorectal metastases confined to the liver, but recurrence is common because of the presence of undetected cancer at the time of surgery. FDG-PET is a sensitive diagnostic tool that identifies tumors based on the increased uptake of glucose by tumor cells. To date, no survival results have been reported for patients who have actually had liver resection after being staged by FDG-PET.

METHODS

Forty-three patients with metastatic colorectal cancer were referred for hepatic resection after conventional tumor staging with computed tomography. FDG-PET was performed on all patients. Laparotomy was performed on patients not staged out by PET. Resection was performed at the time of laparotomy unless extrahepatic disease or unresectable hepatic tumors were found. Patients were examined at intervals in the preoperative period.

RESULTS

FDG-PET identified additional cancer not seen on computed tomography in 10 patients. Surgery was contraindicated in six of these patients because of the findings on FDG-PET. Laparotomy was performed in 37 patients. In all but two, liver resection was performed. Median follow-up in the 35 patients undergoing resection was 24 months. The Kaplan-Meier estimate of overall survival at 3 years was 77% and the lower 95% confidence limit of this estimate of survival was 60%. This figure is higher than 3-year estimate of survival found in previously published series. The 3-year disease-free survival rate was 40%.

CONCLUSIONS

Preoperative FDG-PET lessens the recurrence rate in patients undergoing hepatic resection for colorectal metastases to the liver by detection of disease not found on conventional imaging.

Surgery for colorectal liver metastases with hepatic lymph node involvement: a systematic review

BACKGROUND

Liver resection for colorectal metastases is the only known treatment associated with long-term survival; extrahepatic disease is usually considered a contraindication to such treatment. However, some surgeons do not regard spread to the hepatic lymph nodes as a contraindication provided that these nodes can be excised adequately. A systematic review of the literature was undertaken to address this issue.

METHODS

An electronic search using Medline, Cancerlit and Embase databases was performed for studies reporting liver resection for colorectal metastases from 1964 to 1999. Data were extracted from papers reporting outcome for patients with positive hepatic nodes and analysed according to predetermined criteria.

RESULTS

Fifteen studies were identified that gave survival data on 145 node-positive patients. Five patients were reported to have survived 5 years after liver resection; one was disease free, two had recurrent disease and the disease status was not described in the remaining two. Five studies containing 83 patients specified a formal lymph node dissection as part of the surgical procedure and four of the five node-positive 5-year survivors were from these studies.

CONCLUSION

There are few 5-year survivors after liver resection, with or without lymph node dissection, for colorectal hepatic metastases involving the hepatic lymph nodes.

Long-term survival of patients with unresectable colorectal cancer liver metastases following infusional chemotherapy with 5-fluorouracil, leucovorin, oxaliplatin and surgery

CONTEXT

Long-term survival of patients with metastatic colorectal cancer has been achieved only in patients who underwent complete resection of metastases. Such surgery could be performed in a greater proportion of patients if effective chemotherapy could downstage previously unresectable metastases. This approach has been limited by the low tumor response rate achieved with conventional chemotherapy.

OBJECTIVE

We studied the outcome of patients with initially unresectable liver metastases from colorectal cancer treated with a three-drug chemotherapy regimen followed by liver metastases surgery whenever possible.

PATIENTS AND METHODS

From March 1988 to June 1994, 151 patients with colorectal liver metastases were considered initially unresectable because of large tumor size (> 5 cm), multinodular (> 4) or ill-located metastases. All patients received fully ambulatory chemotherapy with 5-fluorouracil, leucovorin and oxaliplatin (chronotherapy in 83% of them). They were periodically reassessed for surgery by a joint medico-surgical team.

RESULTS

In 151 patients, the size of liver metastases decreased by > 50% in 89 patients (59%) and median overall survival was 24 months (95% confidence interval (95% CI): 19-28 months), with 28% surviving at five years (20%-35%). Surgery with curative intent was attempted in 77 patients (51%), complete resection of liver metastases was achieved in 58 patients (38%). The median survival of the 77 operated patients was 48 months (25-71), with a five-year survival rate of 50% (38-61).

CONCLUSION

This new strategy of combining effective chemotherapy with surgery apparently altered the natural history of unresectable colorectal cancer metastases.

Management strategies for colorectal liver metastases--Part II

Liver metastases are relatively common in colorectal cancer and a small proportion of patients may benefit from resection of these liver metastases. In a selected subgroup of patients, 5-year survival rates of 25-35% may be achieved following liver resection. These survival figures compare favourably with those of patients with untreated liver secondaries. In the second part of this review the surgical and non-surgical treatment options for treating colorectal liver metastases are examined in detail.

[Resection of liver metastases of colorectal tumors. A uni- and multivariate analysis of prognostic factors]

Between September 1985 and December 1994, liver resections with curative intent were performed for liver metastases of colorectal primaries in 76 patients at the department for abdominal surgery of the university of Mainz. Perioperative morbidity and 30-day mortality rates were 30.3% and 6.6% respectively. The 3- and 5-year survival rate was 53% and 36% respectively. For patients with complete tumor removal (R0 resection), excluding perioperative mortality, the following factors were associated with more prolonged survival after hepatic resection in univariate analysis. N1 stage of the colorectal primary compared to N2 stage (in patients with positive mesenterial lymph nodes); diameter of the largest metastasis between 2.1 and 3.5 cm; postoperative normalized CEA level (in patients with CEA level elevated to more than 4 ng/dl preoperatively); and wedge resections compared to hemihepatectomies. Regarding disease-free survival, only N1 stage of the colorectal primary compared to N2 stage and diameter of the largest metastasis between 2.1 and 3.5 cm had a positive influence. In multivariate analysis, the diameter of the largest metastasis was the only factor associated with survival time, while disease-free survival was influenced by the largest diameter of the metastasis, patient sex and N stage of the colorectal primary. Whether adjuvant therapies (systemic or regional chemotherapy) after curative resection of colorectal liver metastases is associated with better survival times remains an open question. Some of the above-mentioned prognostic factors may be helpful in selecting patients for entry into adjuvant therapy protocols.