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

Is Surgical Treatment Effective or Contraindicated in Patients with Colorectal Cancer Liver Metastases Exhibiting Extrahepatic Metastasis?

BACKGROUND

Surgical resection for patients with hepatic and extrahepatic colorectal metastases remains controversial. This study aimed to determine the efficacy of curative resection of distant extrahepatic metastatic lesions in patients with colorectal liver metastases (CRLM).

METHODS

From 2007 to 2019, 377 patients with CRLM were treated; of these, 323 patients underwent hepatectomy, and 54 patients with extrahepatic metastases (EHM) had received only chemotherapy. Survival and recurrence were compared between patients with and without EHM. Variables potentially associated with survival were analyzed in univariate and multivariate analyses.

RESULTS

Among patients who underwent hepatectomy, the median, 3-, and 5-year overall survival rates for patients with EHM (n = 60) were 32 months, 47%, and 28%, respectively, while those for patients without EHM (n = 263) were 115 months, 79%, and 66%, respectively (p < 0.001). Furthermore, outcomes were similar in R2 patients with EHM and those with unresectable tumors. However, outcomes were significantly better in the R0/1 group than in the R2 and unresectable groups (p < 0.001). Among patients with EHM, multivariate analysis revealed that higher clinical risk score, incomplete resection of all EHM, extrahepatic disease detected intraoperatively, and previous treatment with neoadjuvant chemotherapy were independently associated with worse survival.

CONCLUSIONS

In patients with CRLM with EHM (liver + one organ), gross curative resection is necessary when surgical treatment is contemplated, and resection of liver metastases should be performed in patients with CRLM with smaller and fewer tumors (e.g., H1).

New Frontiers in Management of Early and Advanced Rectal Cancer

It is important to understand advances in treatment options for rectal cancer. We attempt to highlight advances in rectal cancer treatment in the form of a systematic review. Early-stage rectal cancer focuses on minimally invasive endoluminal surgery, with importance placed on patient selection as the driving factor for improved outcomes. To achieve a complete pathologic response, various neoadjuvant chemoradiation regimens have been employed. Short-course radiation therapy, total neoadjuvant chemotherapy, and others provide unique advantages with select patient populations best suited for each. With a clinical complete response, a "watch and wait" non-operative surveillance has been introduced with preliminary equivalency to radical resection. Various modalities for total mesorectal excision, such as robotic or transanal, have advantages and can be utilized in select patient populations. Tumors demonstrating solid organ or peritoneal spread, traditionally defined as unresectable lesions conveying a terminal diagnosis, have recently undergone advances in hepatic and pulmonary metastasectomy. Hepatic and pulmonary metastasectomy has demonstrated clear advantages in 5-year survival over standard chemotherapy. With the peritoneal spread of colorectal cancer, HIPEC with cytoreductive therapy has emerged as the preferred treatment. Understanding the various therapeutic interventions will pave the way for improved patient outcomes.

The Assessment of Prognostic Factors for Lung Metastasectomy in Colorectal Cancer Patients With Previously Resected Liver Metastases

The purpose of this study is to investigate the prognostic factors of lung metastasectomy in patients with previously resected liver metastases. Thirty-three patients underwent complete resection of lung metastases after previous liver metastasectomy from colorectal cancer between January 2004 and December 2013. In univariate analyses, all cumulative survival curves were estimated using the Kaplan-Meier method, and differences in variables were evaluated using the log-rank test. Multivariate analyses were performed using the Cox proportional hazards regression model. The 5-year survival rate of all 33 patients after lung metastasectomy was 31%. Univariate analysis identified 2 significant prognostic factors: preoperative serum carcinoembryonic antigen level (P = 0.035) and maximum tumor size (P = 0.029). Subgroup analysis with a combination of these 2 independent prognostic factors revealed 2-year survival rates of 100%, 92.3%, and 0% for patients with 0, 1, and 2 risk factors, respectively. We identified 2 independent poor prognostic factors for pulmonary metastasectomy in patients with previously resected liver metastases: high serum carcinoembryonic antigen level before lung metastasectomy, and maximum size of lung metastases. When these 2 factors are combined, higher- and lower-risk subgroups can be identified, which may help select patients with previously resected liver metastases who benefit most from lung metastasectomy.

Long-term outcome of liver resection for colorectal metastases in the presence of extrahepatic disease: A multi-institutional Japanese study

BACKGROUND/PURPOSE

The purpose of the present study was to assess long-term outcomes following liver resection for colorectal liver metastases (CRLM) with concurrent extrahepatic disease and to identify the preoperative prognostic factors for selection of operative candidates.

METHODS

In this retrospective, multi-institutional study, 3820 patients diagnosed with CRLM during 2005-2007 were identified using nationwide survey data. Data of identified patients with concurrent extrahepatic lesions were analyzed to estimate the impact of liver resection on overall survival (OS) and to identify preoperative, prognostic indicators.

RESULTS

Three- and 5-year OS rates after liver resection in 251 CRLM patients with extrahepatic disease (lung, n = 116; lymph node, n = 51; peritoneal, n = 37; multiple sites, n = 23) were 50.2% and 32.0%, respectively. Multivariate analysis revealed that a primary tumor in the right colon, lymph node metastasis from the primary tumor, serum carbohydrate antigen (CA) 19-9 level >37 UI/mL, the site of extrahepatic disease, and residual liver tumor after hepatectomy were associated with higher mortality. We proposed a preoperative risk scoring system based on these factors that adequately discriminated 5-year OS after liver resection in training and validation datasets.

CONCLUSIONS

Performing R0 liver resection for colorectal liver metastases with treatable extrahepatic disease may prolong survival. Our proposed scoring system may help select appropriate candidates for liver resection.

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.

Outcomes and prognostic factors after pulmonary metastasectomy in patients with colorectal cancer with previously resected hepatic metastases

OBJECTIVES

Outcomes and prognostic factors remain obscure in patients with colorectal cancer after pulmonary metastasectomy who had previously received a curative hepatic metastasectomy.

METHODS

We collected data of 757 patients with pulmonary metastasis from colorectal cancer who underwent curative metastasectomy between 2004 and 2008 from 46 Japanese institutions, from which we extracted data on patients who previously received curative hepatic metastasectomy. Disease-free survival, overall survival, and prognostic factors were analyzed.

RESULTS

The subjects of this study were 160 patients, of whom 44% had primary rectal tumor, 73% had a single pulmonary metastasis, 11% had a bilateral pulmonary metastasis, and 39% had high (>5 ng/mL) serum carcinoembryonic antigen. Patients' median age was 66 years, and 58% were male. The median follow-up was 64 months. Five-year overall survival and disease-free survival were 65.2% (95% confidence interval, 56.8-72.5) and 33.5% (95% confidence interval, 26.1-41.0), respectively. In multivariable analyses, high prethoracotomy carcinoembryonic antigen level was an independent prognostic factor for overall survival (hazard ratio, 2.01; 95% confidence interval, 1.16-3.47) and disease-free survival (hazard ratio, 2.10; 95% confidence interval, 1.41-3.12). Five-year overall survival and disease-free survival of patients with normal prethoracotomy carcinoembryonic antigen level were 76.4% (95% confidence interval, 66.1-83.9) and 40.7% (95% confidence interval, 30.5-50.5), respectively.

CONCLUSIONS

After pulmonary metastasectomy, approximately two thirds of patients with colorectal cancer with a history of curative hepatic metastasectomy survived for 5 years-half of them disease-free. Our results indicate that patients with colorectal cancer with pulmonary metastasis and a history of curative hepatic metastasectomy may benefit from sequential pulmonary metastasectomy, especially if prethoracotomy serum carcinoembryonic antigen levels are within normal range.

Longterm effects of palliative local treatment of incurable metastatic lesions in colorectal cancer patients

We assessed the value of palliative local treatment of incurable metastatic lesions in colorectal cancer patients. Consecutive patients with metastatic colorectal cancer treated between 2003 and 2014 were retrospectively reviewed. Propensity score matching was used to create comparable palliative local treatment and chemotherapy alone groups (n = 272 in each group). The primary endpoint was overall survival, which was calculated using Kaplan-Meier survival analyses. Factors possibly influencing survival were evaluated by univariate and subsequently by multivariate analyses. Palliative local treatment prolonged survival as compared with chemotherapy alone (38.73 vs. 19.8 months, p < 0.01). Univariate and subsequent multivariate analyses showed that primary stage IV at initial diagnosis; high CA199 level and LDH at the time of diagnosis were independent factors for a poor prognosis. Palliative local treatment improved survival better than chemotherapy alone in patients with 0, 1, 2, or 3 of the prognostic factors (p < 0.01). Patients administered treatment for pulmonary metastases survived longer than those treated for metastases elsewhere (56.77 vs. 35.43 months, p = 0.01). Surgical treatment provided marginally longer survival than non-surgical treatment (44.87 vs. 35.43 months, p = 0.05). These findings suggest palliative local treatment has survival benefit for selected patients with incurable metastatic colorectal cancer.

[Liver and lung metastases of colorectal cancer. Long-term survival and prognostic factors]

INTRODUCTION

The resection of liver and lung metastases from colorectal cancer has not yet been completely investigated. The aim of this study was to investigate the overall survival and prognostic factors for patients with liver and lung metastases from colorectal cancer.

METHODS

A retrospective review of a prospective database of 52 patients with liver and lung metastases from colorectal cancer, undergoing metastasectomy with curative intent from 1999-2009 at a single institution was carried out.

RESULTS

The mean overall survival (OS) was 64 months. For synchronous liver and lung metastases the mean overall survival was 63 months (5-year survival 54 %) and for metachronous liver and lung metastases 74 months (5-year survival 58 %, p = 0.451). A poor prognostic outcome was observed in cases of localization of the primary tumor in the rectum (OS 81 vs. 38 months, p = 0.004), with multiple lung metastases (≥ 2 metastases, OS 74 vs. 59 months, p = 0.032) and with disease progression after premetastasectomy chemotherapy (OS 74 vs. 63 vs. 15 months, p < 0.001). No influence on overall survival was detected for bilateral lung metastases, thoracic lymph node metastases, disease recurrence and disease-free interval < 36 months.

CONCLUSION

Metastasectomy for liver and lung metastases of colorectal cancer is associated with a good overall survival in selected cases. Patients with liver and lung metastases should not be routinely excluded from metastasectomy and patients with thoracic lymph node metastases should also not be routinely excluded. Negative prognostic factors for survival are localization of the tumor in the rectum, multiple metastases and disease progression after premetastasectomy chemotherapy. Patients with disease progression after premetastasectomy chemotherapy should be excluded from metastasectomy.

Management of patients with colorectal liver metastasis in eleven questions and answers

INTRODUCTION

Colorectal liver metastasis (CRLM) is the most frequent indication for liver resection in many centers. Recent improvements in oncology, surgery, interventional radiology, pathology and anesthesiology allow curative treatment in a larger proportion of patients with CRLM. Areas covered: We illustrate the various aspects of the management of CRLM through 11 questions that summarize the topic, from the current obtained survival to future perspectives such as transplantation. The limits of a curative treatment are also presented from different angles, such as the benefits of pathology, the surgical options for extreme resections, the available chemotherapies and their efficacy, or the non-surgical ablative treatments. Expert commentary: Given the increasing therapeutic possibilities, we strengthen the importance to analyze the situation of each patient with CRLM in a dedicated multidisciplinary team, in order to offer the best individualized treatment combination.

Prognostic factors after pulmonary metastasectomy of colorectal cancers: influence of liver metastasis

Background

Our objective was to evaluate the influence of liver metastasis on survival after pulmonary metastasectomy in patients with colorectal cancer (CRC).

Methods

We retrospectively reviewed a total of 524 patients and were classified into two groups based on the presence of liver metastasis. Group HM + PM (n = 106) included patients who previously received a hepatic metastasectomy and then received pulmonary metastasectomy. Group PM (n = 418) included patients who only received pulmonary metastasectomy with no liver metastasis.

Results

There were more male patients (70 vs. 57 %; P = 0.02) and more patients with colon cancer (60 vs. 42 %, P = 0.001) in group HM + PM than in group PM. Otherwise, there was no significant difference between the two groups in clinicopathologic characteristics and extent of surgery. The 5-year overall survival (OS) and disease-free survival (DFS) rates were 58 and 31 %, respectively. There was no significant difference in OS (group HM + PM, 54 % vs. group PM, 59 %; P = 0.085) and in DFS (group HM + PM, 28 % vs. group PM, 32 %; P = 0.12). For the entire patient cohort, a multivariate analysis revealed that the presence of liver metastasis, CRC T and N stages, disease-free interval, and number and size of lung metastases were significantly associated with OS and DFS.

Conclusions

Our findings suggest that previous or present liver metastasis should not exclude a patient from pulmonary metastasectomy. When lung metastasis is detected in patients with a history of hepatic metastasectomy, pulmonary metastasectomy is still a viable treatment option especially in patients with a long disease-free interval and a small number of lung metastases.

[Surgery for metastases, anatomical and ethical limits. Special aspect: oligometastases]

The surgical resection of metastases is nowadays feasible in selected patients with multifocal metastatic disease due to the implementation of interdisciplinary multimodal therapeutic options. Anatomical limitations do not seem to represent obstacles which cannot be overcome because of the development of new surgical techniques. The cornerstone of the selection of patients is the correct staging diagnosis achieved through modern diagnostic tools; however, surgery alone does not always offer acceptable survival and recurrence-free rates. Furthermore, in every complex surgical procedure there is the risk of morbidity and mortality; therefore, parameters such as alternative therapeutic modalities, the individual situation of the patient and tumor biology have to be considered in order to make the correct selection of patients. This is one of the major future challenges and should never be driven by unfounded hopes and expectations of the patients. The same principle also applies for brain metastases, which represent the most common brain tumors. Approximately 70 % of patients with brain metastases have 1-3 lesions (oligometastases). Treatment is now individualized and the goal of therapy has shifted towards long-term survival (≥ 24 months) and improved quality of life. Under this aspect surgery is one of the important treatment options, particularly in patients with a single metastasis or oligometastases. Furthermore, approximately 20 % of patients who have recurrent brain metastases, successfully undergo a complete resection of tumors and with a Karnofsky performance status (KPS) score > 70 show a long-term survival of ≥ 24 months.

Surgical management of patients with colorectal cancer and simultaneous liver and lung metastases

Background

The management of patients with colorectal cancer and simultaneously diagnosed liver and lung metastases (SLLM) remains controversial.

Methods

The LiverMetSurvey registry was interrogated for patients treated between 2000 and 2012 to assess outcomes after resection of SLLM, and the factors associated with survival. SLLM was defined as liver and lung metastases diagnosed 3 months or less apart. Survival was compared between patients with resected isolated liver metastases (group 1, control), those with resected liver and lung metastases (group 2), and patients with resected liver metastases and unresected (or unresectable) lung metastases (group 3). An Akaike test was used to select variables for assessment of survival adjusted for confounding variables.

Results

Group 1 (isolated liver metastases, hepatic resection alone) included 9185 patients, group 2 (resection of liver and lung metastases) 149 patients, and group 3 (resection of liver metastases, no resection of lung metastases) 285 patients. Ten variables differed significantly between groups and seven were included in the model for adjusted survival (age, number of liver metastases, synchronicity of liver metastases with primary tumour, carcinoembryonic antigen level, node status of the primary tumour, initial resectability of liver metastases and inclusion in group 3). Adjusted overall 5-year survival was similar for groups 1 and 2 (51·5 and 44·5 per cent respectively), but worse for group 3 (14·3 per cent) (P = 0·001).

Conclusion

Patients who had resection of liver and lung metastases had similar overall survival to those who had undergone removal of isolated liver metastases.

Outcome after liver resection in patients presenting with simultaneous hepatopulmonary colorectal metastases

BACKGROUND

The most common sites of metastasis from colorectal cancer (CRC) are hepatic and pulmonary; they can present simultaneously (hepatic and pulmonary metastases) or sequentially (hepatic then pulmonary metastases, or vice versa). Simultaneous disease may be aggressive, and thus may be approached with caution by the clinician. The aim of this study was to determine the outcomes following hepatic and pulmonary resection for simultaneously presenting metastatic CRC.

METHODS

A retrospective review was undertaken of a prospectively maintained database to identify patients presenting with simultaneous hepatopulmonary disease who underwent hepatic resection. Patients' electronic records were used to identify clinicopathological variables. The log rank test was used to determine survival, and χ(2) analysis to determine predictors of failure of intended treatment.

RESULTS

Fifty-nine patients were identified and underwent hepatic resection; median survival was 45·4 months and the 5-year survival rate 38 per cent. Twenty-two patients (37 per cent) did not have the intended pulmonary intervention owing to progression or recurrence of disease. Thirty-seven patients who progressed to hepatopulmonary resection had a median survival of 54·2 months (5-year survival rate 43 per cent). Those who had hepatic resection alone had a median survival of 24·0 months (5-year survival rate 30 per cent). Failure to progress to pulmonary resection was predicted by heavy nodal burden of primary colorectal disease and bilobar hepatic metastases. Redo pulmonary surgery following pulmonary recurrence did not confer a survival benefit.

CONCLUSION

Selected patients with simultaneous hepatopulmonary CRC metastases should be considered for attempted curative resection, but some patients may not receive the intended treatment owing to progression of pulmonary disease after hepatic resection.

Minimally invasive surgery using the open magnetic resonance imaging system combined with video-assisted thoracoscopic surgery for synchronous hepatic and pulmonary metastases from colorectal cancer: report of four cases

Simultaneous resection of hepatic and pulmonary metastases (HPM) from colorectal cancer (CRC) has been reported to be effective, but it is also considered invasive. We report the preliminary results of performing minimally invasive surgery using the open magnetic resonance (MR) imaging system to resect synchronous HPM from CRC in four patients. All four patients were referred for thoracoscopy-assisted interventional MR-guided microwave coagulation therapy (T-IVMR-MCT) combined with video-assisted thoracoscopic surgery (VATS). The median diameters of the HPM were 18.2 and 23.2 mm, respectively. The median duration of VATS and T-IVMR-MCT was 82.5 and 139 min, respectively. All patients were discharged without any major postoperative complications. One patient was still free of disease at 24 months and the others died of disease progression 13, 36, and 47 months without evidence of recurrence in the treated area. Thus, simultaneous VATS + T-IVMR-MCT appears to be an effective option as a minimally invasive treatment for synchronous HPM from CRC.

Simultaneous lung resection via a transdiaphragmatic approach in patients undergoing liver resection for synchronous liver and lung metastases

BACKGROUND

For patients with synchronous liver and lung metastases from colorectal cancer, the invasiveness of adding thoracic to abdominal surgery is an obstacle to concurrent liver and lung metastasectomy. We developed a simple technique to resect lung lesions via a transdiaphragmatic approach without thoracic incision in patients undergoing liver metastasectomy.

METHODS

Sixteen patients with synchronous liver and unilateral lung metastases underwent transdiaphragmatic wedge resection of lung lesions simultaneous with liver metastasectomy. Short-term operative outcomes were compared with those in 102 patients treated with conventional unilateral wedge resection for colorectal lung metastases.

RESULTS

Twenty peripheral (<3 cm from the pleura) lung lesions from various locations in the lung were resected via transdiaphragmatic approach. No conversions to conventional approach were required. The median tumor number and size were 1 (range, 1-3) and 8 mm (range, 3-30 mm), respectively. Transdiaphragmatic resection reduced median operative blood loss compared with conventional resection (0 mL vs 50 mL [P < .001]) and reduced median duration of hospital stay compared with staged liver and lung resection (6 days vs 11 days [P < .001]). Operative duration and rates of lung-related morbidity and positive surgical margin were similar between the transdiaphragmatic and conventional groups (104 minutes vs 105 minutes [P = .61], 13% vs 4% [P = .15], and 6% vs 5% [P = .73], respectively).

CONCLUSION

Simultaneous transdiaphragmatic resection of peripheral lung lesions is safe in patients undergoing liver resection. The low-invasive transdiaphragmatic approach facilitates aggressive operative treatment for synchronous liver and lung metastases.

Pulmonary metastasectomy for colorectal cancer: How many nodules, how many times?

Colorectal cancer (CRC) is one of the most common cancers worldwide, with 5%-15% of CRC patients eventually developing lung metastasis (LM). Despite doubts about the role of locoregional therapy in the management of systemic disease, many surgeons have performed pulmonary metastasectomy (PM) for CRC in properly selected patients. However, the use of pulmonary metastasectomy remains controversial due to the lack of randomized controlled studies. This article reviews the results of surgical treatment of pulmonary metastases for CRC, focusing on (1) current treatment guidelines and surgical techniques of PM in patients with LM from CRC; (2) outcomes of PM and its prognostic factors; and (3) controversial issues in PM, focusing on repeated metastasectomy, bilateral multiple metastases, and combined liver and lung metastasectomy.

Lung metastasectomy for postoperative colorectal cancer in patients with a history of hepatic metastasis

OBJECTIVES

Our objective was to evaluate the efficacy of pulmonary metastasectomy for postoperative colorectal cancer with hepatic metastasis, and to investigate the role of clinicopathological factors as predictors of outcome.

METHODS

Consecutive patients undergoing pulmonary metastasectomy for colorectal cancer with (group PH, n = 27) or without (group P, n = 46) a history of hepatic metastasis were included in the study. Clinicopathological variables, including sex, age, site, carcinoembryonic antigen in the primary tumor, disease-free interval, prior hepatic resection, timing of pulmonary metastases, preoperative chemotherapy, type of pulmonary resection, and number, size, and location of pulmonary metastases were retrospectively collected and investigated for prognostic significance.

RESULTS

Five-year survival rates were 59.5 and 70.0 % for patients with and without a history of hepatic metastasis, respectively; these values did not differ significantly. Among all investigated prognostic variables, sex and number of pulmonary metastases (1 vs. >1) were the most important factors affecting the outcome after colorectal and pulmonary resection. There was no significant difference in overall survival whether it was calculated from the time of resection of the primary colorectal cancer or of pulmonary metastases.

CONCLUSIONS

Pulmonary resection is not contraindicated in clinical practice. Significant factors indicating a good prognosis were female sex and the number of pulmonary metastases. Special attention should be paid to comparison of survival among studies.

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.

Analysis of treatment that includes both hepatic and pulmonary resections for colorectal metastases

PURPOSE

Hepatic or pulmonary resections for colorectal metastases are regarded as standard treatment worldwide; however, the clinical significance of both hepatic and pulmonary resections for colorectal metastases remains undefined. We reviewed our clinical experience to evaluate the benefit of this treatment.

METHODS

Between 1986 and 2010, 186 patients underwent potentially curative hepatic and/or pulmonary resections for colorectal metastases. Of these patients, 25 underwent both treatments (Group C), 100 underwent hepatic resections alone (Group H), and 61 underwent pulmonary resections alone (Group L). Univariate and multivariate analyses of the clinical and pathological variables in Group C and comparative survival analyses between Group C and Groups H-L were performed.

RESULTS

In Group C, the median survival after primary tumor resection, initial metastasectomy, and last metastasectomy were 97, 60, and 35 months, respectively, and the 5-year overall survival rates were 63, 54, and 38%, respectively. Multivariate analyses after initial metastasectomy revealed rectal tumors, multiple hepatic tumors, and simultaneous metastases as poor prognostic factors. Comparative survival analyses revealed no significant difference in overall survival between Group C and Groups H-L.

CONCLUSION

Hepatic and pulmonary resections for colorectal metastases improve survival and may even offer the potential for cure in selected patients.

Surgical outcomes after resection of both hepatic and pulmonary metastases from colorectal cancer

BACKGROUND

The efficacy and the indications of resection of synchronous or metachronous hepatic and pulmonary metastases from colorectal cancer (CRC) are controversial. This study retrospectively reviewed the cases of CRC patients who underwent both liver and lung resection to define the appropriate indications for surgical resection in patients with hepatic and pulmonary metastases.

METHODS

A total of 39 patients with both hepatic and pulmonary metastases from CRC underwent both liver and lung resection from January 1987 to December 2009. The relapse-free survival (RFS) and overall survival (OS) from the resection for the first metastasis were evaluated by a Kaplan-Meyer analysis. Prognostic factors were analyzed using the log-rank test and a Cox proportional hazards model.

RESULTS

The median RFS and the 5-year RFS rate of all patients were 12 months and 2.6 %, respectively. The median survival time (MST) and 5-year OS rate of all patients were 66 months and 48.3 %, respectively. The MST of the patients with a long (>1 year) disease-free interval (DFI) could not be calculated, but their 5-year OS rate was 73.7 %. In contrast, the MST and 5-year OS rate of the patients with a short (<1 year) DFI were 29 months and 37.5 %, respectively. The short DFI was the only prognostic factor in the multivariate analysis.

CONCLUSIONS

Aggressive surgical resection of both hepatic and pulmonary metastases from CRC should be undertaken in selective patients, including those with a long DFI.

Combined resection of colorectal hepatic-pulmonary metastases shows improved outcome over chemotherapy alone

BACKGROUND

The objective of this retrospective study was to assess the survival of patients after resection of hepatic and pulmonary colorectal metastases to identify predictors of long-term survival.

METHODS

Patients receiving chemotherapy alone were compared to patients receiving surgery and chemotherapy in a matched-pair analysis with the following criteria: UICC stage, grading, and date of initial primary tumor occurrence.

RESULTS

A total of 30 patients with liver and lung metastases of colorectal carcinoma underwent resection. In 20 cases, complete resection was achieved (median survival, 67 months). Incomplete resection and preoperatively elevated carcinoembryonic antigen (CEA) levels are independent risk factors for reduced survival. Patients developing pulmonary metastases prior to hepatic metastases had the worst prognosis. Surgical resection significantly increased survival compared to chemotherapy alone in matched-pair analysis (65 vs. 30 months, p = 0.03).

CONCLUSIONS

Incomplete resection and elevated CEA levels are predictors of poor outcome. Matched-paired analysis confirmed that surgical resection in combination with chemotherapy appears to be superior to chemotherapy alone.

Outcome of strict patient selection for surgical treatment of hepatic and pulmonary metastases from colorectal cancer

BACKGROUND

Surgery is currently the only potentially curative treatment for hepatic or pulmonary metastases from colorectal cancer. However, the benefit of surgery and the criteria for the inclusion of patients developing hepatic and pulmonary metastases are not well defined.

OBJECTIVE

The aim of this study was to describe the outcome for patients who undergo surgery for both hepatic and pulmonary metastases from colorectal cancer, to present a set of preoperative criteria for use in patient selection, and to analyze potential prognostic factors related to survival.

DESIGN

This was an observational study with retrospective analysis of data collected with a prospective protocol.

SETTINGS

This investigation was conducted at a tertiary centre.

PATIENTS

Between January 1996 and January 2010, of 319 patients who underwent surgery for hepatic metastases from colorectal cancer, 44 also had resection of pulmonary metastases. A set of strict selection criteria established by a panel of liver surgeons, chest surgeons, oncologists, and radiologists was used.

MAIN OUTCOME MEASURES

Survival was estimated with the Kaplan-Meier method, and univariate analyses were performed to evaluate potential prognostic factors for survival, including variables related to patient, primary tumour, hepatic, and pulmonary metastases and chemotherapy.

RESULTS

The 44 patients received a total of 53 pulmonary resections: 36 patients had 1, 7 patients had 2, and 1 patient had 3 resections. There was no postoperative mortality and the morbidity rate after pulmonary resection was 1.8%. No patient was lost to follow-up. Overall survival was 93% at 1 year, 81% at 3 years, and 64% at 5 years. Factors related to poor prognosis in the univariate analysis were presence of more than 1 pulmonary metastasis (p = 0.04), invasion of the surgical margin (p = 0.006), and administration of neoadjuvant chemotherapy (p = 0.01 for hepatic metastases and p = 0.02 for pulmonary metastases).

LIMITATIONS

The study was limited by its observational nature and the relatively small number of patients.

CONCLUSION

In patients with hepatic and pulmonary metastases from colorectal cancer selected according to strict inclusion criteria, surgical treatment performed in a specialized center is a safe option that offers prolonged survival.

Hepatectomy and resection of concomitant extrahepatic disease for colorectal liver metastases--a systematic review

BACKGROUND

Recent data suggest that hepatectomy for patients with colorectal liver metastases (CLM) with concomitant extrahepatic disease (EHD) achieve encouraging survival result. The authors examine the clinical efficacy of this treatment approach through a systematic review of the published literature.

METHODS

Electronic search of the MEDLINE and PubMed databases (January 2000 to January 2011) to identify studies reporting outcomes of hepatectomy for CLM with resection of EHD was undertaken. Two reviewers independently appraised each study using a predetermined protocol. Clinical efficacy was synthesised through a narrative review with full tabulation of results of all included studies.

RESULTS

Twenty-two studies were examined. This comprised 1142 patients. The median disease-free survival was 12 (range, 4-22) months, median overall survival was 30 (range, 14-44) months and median 5-year survival rate was 19% (range, 0-42%). Median 5-year survival of patients with R0 hepatectomy with resection of EHD was 25% (range, 19-36%). Survival based on site of EHD include lung; median survival (M/S) was 41 (range, 32-46) months, porto-caval lymph node; M/S was 25 (range, 19-48) months, peritoneal metastases; M/S was 25 (range, 18-32) months.

CONCLUSION

In the era of effective systemic therapies, surgical resection of CLM and concomitant EHD in carefully selected patients may achieve survival results superior to non-surgically treated patients. This treatment strategy may be considered appropriate especially when a R0 hepatectomy and complete resection of EHD may be achieved.

Survival after lung metastasectomy for colorectal cancer: importance of previous liver metastasis as a prognostic factor

AIMS

To analyse patient survival after the resection of lung metastases from colorectal carcinoma and specifically to verify whether presence of liver metastasis prior to lung metastasectomy affects survival.

METHODS

All patients who, between 1998 and 2008, underwent lung metastasectomy due to colorectal cancer were included in the study. Kaplan-Meier survival analysis was performed with the log-rank test and Cox regression multivariate analysis.

RESULTS

During this period, 101 metastasectomies were performed on 84 patients. The median age of patients was 65.4 years, and 60% of patients were male. The 30-day mortality rate was 2%, and incidence of complications was 7%. The overall survival was 72 months, with 3-and 5-year survival rates of 70% and 54%, respectively. A total of 17 patients (20%) had previously undergone resection of liver metastasis. No significant differences were found in the distribution of what were supposed to be the main variables between patients with and without previous hepatic metastases. Multivariate analysis identified the following statistically significant factors affecting survival: previous liver metastasectomy (p = 0.03), tumour-infiltrated pulmonary lymph nodes (p = 0.04), disease-free interval ≥ 48 months (p = 0.03), and presence of more than one lung metastasis (p < 0.01). In patients with previous liver metastasis, the shorter the time between primary colorectal surgery and the hepatectomy, the lower the survival rate after pulmonary metastasectomy (p = 0.048).

CONCLUSIONS

A previous history of liver metastasis shortens survival after lung metastasectomy. The time between hepatic resection and lung metastasectomy does not affect survival; however, patients with synchronous liver metastasis and colorectal neoplasia have poorer survival rates than those with metachronous disease.

Radiofrequency ablation of concomitant and recurrent pulmonary metastases after surgery for colorectal liver metastases

BACKGROUND

To evaluate our experience of radiofrequency ablation (RFA) of pulmonary metastases in patients with resected colorectal liver metastases who had concomitant or recurrent pulmonary metastases.

METHODS

Clinical and treatment variables of patients undergoing RFA were collected, and their association with survival was examined. Survival analysis was performed by the Kaplan-Meier method.

RESULTS

RFA was performed as concomitant sequential treatment of extrahepatic pulmonary metastases after hepatectomy in 19 patients (30%) and as salvage treatment for pulmonary recurrences after hepatectomy in 45 patients (70%). Patients undergoing sequential treatment had a median survival of 31 (95% confidence interval [CI] 21.8-40.6) months compared to 59 (95% CI 35.0-82.0) months in the salvage treatment group (P = 0.142). The disease-free survival (DFS) was 9 (95% CI 1.0-18.8) months in the sequential treatment group and 16 (95% CI 8.1-23.1) months in the salvage treatment group (P = 0.023). Liver metastases occurring within 12 months of the primary tumor negatively influenced overall survival (OS) and DFS in the sequential treatment group (P = 0.003 and P = 0.091). Poorly differentiated tumor (P = 0.001) was associated with a poorer OS, and prehepatectomy carcinoembryonic antigen > 200 ng/ml (P = 0.017) and bilateral pulmonary metastases (P = 0.030) were associated with a shorter DFS in the salvage treatment group.

CONCLUSIONS

The DFS and OS of patients undergoing sequential RFA of extrahepatic pulmonary metastases after hepatectomy appeared shorter when compared to patients who underwent RFA as salvage treatment for pulmonary recurrences after hepatectomy. It nonetheless remains better than the historical results of chemotherapy alone and thus supports the use of RFA as an ablative technology to achieve tumor control.

Management of stage IV rectal cancer: Palliative options

Approximately 30% of patients with rectal cancer present with metastatic disease. Many of these patients have symptoms of bleeding or obstruction. Several treatment options are available to deal with the various complications that may afflict these patients. Endorectal stenting, laser ablation, and operative resection are a few of the options available to the patient with a malignant large bowel obstruction. A thorough understanding of treatment options will ensure the patient is offered the most effective therapy with the least amount of associated morbidity. In this review, we describe various options for palliation of symptoms in patients with metastatic rectal cancer. Additionally, we briefly discuss treatment for asymptomatic patients with metastatic disease.

Surgical treatment of hepatic metastases from colorectal cancer

Colorectal carcinoma is one of the most frequent cancers in Western societies with an incidence of around 700 per million people. About half of the patients develop metastases from the primary tumor and liver is the primary metastatic site. Improved survival rates after hepatectomy for metastatic colorectal cancer have been reported in the last few years and these may be the result of a variety of factors, such as advances in systemic chemotherapy, radiographic imaging techniques that permit more accurate determination of the extent and location of the metastatic burden, local ablation methods, and in surgical techniques of hepatic resection. These have led to a more aggressive approach towards liver metastatic disease, resulting in longer survival. The goal of this paper is to review the role of various forms of surgery in the treatment of hepatic metastases from colorectal cancer.

Hepatic resection for colorectal liver metastases

Colorectal adenocarcinoma remains the third most common cause of cancer death in the United States, with an estimated 146,000 new cases and 50,000 deaths annually. Survival is stage dependent, and the presence of liver metastases is a primary determinant in patient survival. Approximately 25% of new cases will present with synchronous colorectal liver metastases (CLM), and up to one-half will develop CLM during the course of their disease. The importance of safe and effective therapies for CLM cannot be overstated. Safe and appropriately aggressive multimodality therapy for CLM can provide most patients with liver-dominant colorectal metastases with extended survival and an improved quality of life.

Early intrapulmonary recurrence after pulmonary metastasectomy related to colorectal cancer

BACKGROUND

Early intrapulmonary recurrence is a major problem after pulmonary metastasectomy related to colorectal cancer. However, the risk factors for early intrapulmonary recurrence are not clear.

METHODS

Between August 2001 and December 2007, 125 patients underwent pulmonary metastasectomy after colorectal cancer. The prognostic factors for overall survival were evaluated, including early (within 6 months) intrapulmonary recurrence. The factors related to early intrapulmonary recurrence were also analyzed.

RESULTS

Thirteen patients (10.4%) had early intrapulmonary recurrence. The median follow-up was 46 months (range, 21 to 99). Early intrapulmonary recurrence (hazard ratio 2.716; 95% confidence interval: 1.027 to 7.182; p = 0.044), extrapulmonary metastasectomy, metastatic hilar or mediastinal lymph nodes, and high prethoracotomy carcinoembryonic antigen levels were independent prognostic factors on multivariate analysis. Extrapulmonary metastasectomy (odds ratio 4.840; 95% confidence interval: 1.314 to 17.821; p = 0.018) and bilateral pulmonary metastasis (odds ratio 6.228; 95% confidence interval: 1.689 to 22.960; p = 0.006) were independent risk factors for early intrapulmonary recurrence.

CONCLUSIONS

Early intrapulmonary recurrence after pulmonary metastasectomy related to colorectal cancer is a prognostic factor for poor overall survival. Extrapulmonary metastasectomy and bilateral pulmonary metastasis are risk factors for early intrapulmonary recurrence. Pulmonary metastasectomy in patients with these risk factors should be considered carefully.

Indications and approach to surgical resection of lung metastases

Pulmonary metastasectomy is a curative option for selected patients with cancer spread to the lungs. Complete surgical removal of pulmonary metastases can improve survival and is recommended under certain criteria. Specific issues that require consideration in a multidisciplinary setting when planning pulmonary metastasectomy include: adherence to established indications for resection, the surgical strategy including the use of minimally invasive techniques, pulmonary parenchyma preservation, and the role of lymphadenectomy.

Oncological outcome of unresectable lung metastases without extrapulmonary metastases in colorectal cancer

AIM: To explore the oncological outcomes of unresectable lung metastases without extrapulmonary metastases in colorectal cancer.

METHODS: Patients with unresectable isolated lung metastases from colorectal cancer were prospectively collected in a single institution during a 5-year period. All patients received either the fluorouracil/leucovorin plus oxaliplatin, fluorouracil/leucovorin plus irinotecan or capecitabine plus oxaliplatin regimen as first-line treatment. The resectability after preoperative chemotherapy was evaluated. Patients’ outcome and predictive factors for overall survival were also investigated by univariate and multivariate analysis.

RESULTS: A total of 70 patients were included in the study. After standardized first-line chemotherapy, only 4 patients (5.7%) were converted to resectable disease. The median overall survival time in all patients was 19 mo (95% CI: 12.6-25.4), with a 2-year overall survival rate of 38.8%. No survival difference was found among different first-line chemotherapeutic regimens. Prognostic analysis demonstrated that only the first response assessment for first-line treatment was the independent factor for predicting overall survival. The median survival time in partial response, stable disease and progressive disease patients were 27 mo, 16 mo and 8 mo (P = 0.00001).

CONCLUSION: Pulmonary metastasectomy can only be performed in a small part of unresectable lung metastases patients after chemotherapy. Patients’ first response assessment is an important prognostic factor.

Metastasectomy for stage IV colorectal cancer

Metastatic colorectal cancer traditionally has been considered incurable. Over the past 3 decades, however, resection of low-volume hepatic disease has been recognized as beneficial in some cases. More recently, resection of isolated pulmonary metastases has been shown to offer long-term survival in carefully selected patients. Resection of metastases to more unusual sites (ovary, brain, peritoneal cavity) is more controversial; nevertheless, retrospective data suggest that a few patients may be cured with resection of these tumors. In this article, we review the history and current status of metastasectomy in stage IV colorectal cancer.

Long-term outcome after sequential resections of liver and lung metastases from colorectal carcinoma

BACKGROUND

Surgical resection of colorectal liver metastases (CLM) is an established form of treatment. Limited data exists on the value of sequential hepatic and pulmonary metastasectomy. We analysed patients who underwent sequential liver and lung resections for CLM.

METHODS

A total of 910 patients who underwent liver resection for CLM between January 2000 and December 2007, were analysed to identify patients with resectable pulmonary metastases (n= 43; 4.7%). Patient demographics, overall survival and survival difference between synchronous and metachronous pulmonary metastasectomy groups were compared. In addition, outcomes in the 'liver and lung resection' group were compared with a matched group of 'liver resection only' patients (matched for age, primary disease stage, interval to liver resection and liver disease stage).

RESULTS

Forty-three patients (median age 62, range 43-83 years, 22 males) underwent sequential liver and lung resection. A total of 36 patients underwent major hepatic resections, 18 patients had bilobar disease and the median number of liver lesions resected was 3 (range 1-5 lesions). Ten patients had synchronous liver and lung metastases. The median interval between liver and lung metastasectomy was 25 months (range 2-88 months). A total of two patients underwent major lobectomies, three patients had bilateral disease and the median number of lung lesions resected was one (range 1-3). The 1-, 3- and 5-year overall survival rates after first metastasectomy were 100%, 87.1% and 53.9%, respectively, with a median survival of 42 months.

PATIENTS

Undergoing metachronous pulmonary metastasectomy had better 1-, 3- and 5-year survival rates than those with synchronous disease (100%, 88.9% and 60.9% vs. 100%, 75% and 0%, respectively; P= 0.02, log rank test). There was no significant survival difference between the 'liver and lung resection' and the 'liver resection only' groups.

CONCLUSION

Sequential liver and lung resection for CLM is associated with good long-term survival in selected patients, except in those presenting with synchronous lung and liver metastases.

Liver resection for metastatic colorectal cancer in the presence of extrahepatic disease

Early studies of liver resection for colorectal cancer metastases identified patients with concomitant extrahepatic disease as a group with poor outcomes. These studies concluded that the presence of extrahepatic disease should be a contraindication to resection. This contraindication has more recently been challenged. In this paper, we review the published work on metastatic colorectal cancer, pertaining to the role of surgery in patients with liver metastases and concomitant extrahepatic disease. 5-year survival after resection is worse in patients with extrahepatic disease than in patients with liver-only disease, but is similar to that seen in patients who underwent resection in the era before the use of modern chemotherapy. Recurrence occurs in most patients. There is a role for surgery in highly selected patients with single sites of extrahepatic disease, although expectations should be different than those of patients with liver-only metastases. Further studies are necessary to define the patient group best suited for resection of hepatic metastases with extrahepatic disease.

Inoperable colorectal liver metastases: a declining entity?

BACKGROUND

Untreated colorectal liver metastases (CLMs) have a dismal prognosis. Surgery remains the gold standard of treatment, but many patients will have inoperable disease at presentation. Until recently, the outlook for such patients was bleak. The purpose of this review was to report on available options in the treatment CLMs, which would be considered unresectable by conventional evaluation.

METHODS

Inclusion criteria were articles published in English-language journals reporting on either retrospective or prospective cohorts of patients undergoing treatment for conventionally inoperable CLM. Main outcome measures were survival, resectability rates, morbidity and mortality following treatment of the patients' disease.

RESULTS

Improved chemotherapy regimes and other innovative treatments have opened up new options for such patients and may even render conventionally inoperable disease resectable. The aim of treatment should be down-staging of metastases to achieve resectability, however, other treatments such as ablation may be also be used (either alone or in conjunction with resection).

CONCLUSION

A nihilistic attitude to the patient with seemingly inoperable liver metastases should be discouraged. Discussion of such patients at multi-disciplinary meetings is essential in order to plan and monitor treatments.

Appraisal of 1 cm hepatectomy margins for intrahepatic micrometastases in patients with colorectal carcinoma liver metastasis

BACKGROUND

This study sought to clarify the distribution of intrahepatic micrometastases and elucidate an adequate hepatectomy margin for colorectal carcinoma liver metastases.

METHODS

Intrahepatic micrometastases in resected specimens from 90 patients who underwent hepatectomy for colorectal carcinoma liver metastases were examined retrospectively. Intrahepatic micrometastases were defined as microscopic lesions spatially separated from the gross tumor. Distances from these lesions to the hepatic tumor borders were measured histologically, and the density of intrahepatic micrometastases (number of lesions/mm(2)) calculated relative to the advancing tumor border in a zone <1 cm from the border (close) or >/=1 cm away (distant). Median follow-up time was 127 months.

RESULTS

A total of 294 intrahepatic micrometastases were detected in 52 (58%) patients; 95% of these occurred in the close zone. The density of intrahepatic micrometastases was significantly higher in the close zone (mean 74.8 x 10(-4 ) lesions/mm(2)) than in the distant zone (mean 7.4 x 10(-4 ) lesions/mm(2); P < 0.001). Hepatectomy margin status was positive by 0 cm in 10 patients or negative by <1 cm in 51, and by >/=1 cm in 29 patients. The median survival times were 18, 33, and 89 months in patients with hepatectomy margins 0 cm, <1 cm, and >/=1 cm, respectively. Hepatectomy margin status independently influenced survival (P < 0.001) and disease-free survival (P < 0.001).

CONCLUSION

The currently recommended >/=1 cm hepatectomy margin should remain the goal for resections of colorectal carcinoma liver metastases, based on the distribution of intrahepatic micrometastases and survival risk.

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.

Surgical treatment of metastatic disease to the lung

The presence of distant metastases usually implies disease not amenable to cure through surgical resection. In such cases, chemotherapy is the mainstay of treatment, with surgery or radiation reserved for palliative measures. However, metastases limited to the lung may be resected with resultant prolonged patient survival compared to unresectable, widely disseminated metastases. Isolated pulmonary metastases should therefore not be considered untreatable. In this review, we discuss the pathophysiology of pulmonary metastases. We outline prognostic factors associated with metastases, and propose criteria to help select patients for metastasectomy. Surgical approaches, including various open techniques and video-assisted thoracoscopy, are covered. Surgical issues, including the need for unilateral versus bilateral exploration, the extent of resection to achieve cure, the need for lymph node dissection, and the benefit of repeat operations, are discussed. Finally, we review some of the more common tumors that metastasize to the lungs, and the role of metastasectomy in their treatment. Resection of pulmonary metastases confers a survival benefit to a select group of patients so long as the primary tumor is controlled, metastases are limited to the lungs, the patient can tolerate the operation from a cardiopulmonary standpoint, and the metastases are completely resected.

Expanding criteria for resectability of colorectal liver metastases

Surgical resection is the treatment of choice in patients with colorectal liver metastases, with 5-year survival rates reported in the range of 40%-58%. Over the past 10 years, there has been an impetus to expand the criteria for defining resectability for patients with colorectal metastases. In the past, such features as the number of metastases (three to four), the size of the tumor lesion, and a mandatory 1-cm margin of resection dictated who was "resectable." More recently, the criteria for resectability have been expanded to include any patient in whom all disease can be removed with a negative margin and who has adequate hepatic volume/reserve. Specifically, instead of resectability being defined by what is removed, decisions concerning resectability now center around what will remain after resection. Under this new paradigm, the number of patients with resectable disease can be expanded by increasing/preserving hepatic reserve (e.g., portal vein embolization, two-stage hepatectomy), combining resection with ablation, and decreasing tumor size (preoperative chemotherapy). The criteria for resectability have also expanded to include patients with extrahepatic disease. Rather than being an absolute contraindication to surgery, patients with both intra- and extrahepatic disease should potentially be considered for resection based on strict selection criteria. The expansion of criteria for resectability of colorectal liver metastases requires a much more nuanced and sophisticated approach to the patient with advanced disease. A therapeutic approach that includes all aspects of multidisciplinary and multimodality care is required to select and treat this complex group of patients.

Intrahepatic lymphatic invasion independently predicts poor survival and recurrences after hepatectomy in patients with colorectal carcinoma liver metastases

BACKGROUND

D2-40 monoclonal antibody immunoreactivity is specific for lymphatic endothelium and therefore provides a marker of lymphatic invasion. We hypothesized that intrahepatic lymphatic invasion reflects the nodal status of colorectal carcinoma liver metastases and may function as an adverse prognostic factor.

METHODS

A retrospective analysis of 105 consecutive patients who underwent resection for colorectal carcinoma liver metastases was conducted. Intrahepatic lymphatic invasion was declared when either single tumor cells or cell clusters were clearly visible within vessels that showed immunoreactivity for D2-40 monoclonal antibody. The median follow-up time was 124 months.

RESULTS

Of 105 patients, 13 were classified as having intrahepatic lymphatic invasion. All tumor foci of intrahepatic lymphatic invasion were detected within the portal tracts. Intrahepatic lymphatic invasion was significantly associated with hepatic lymph node involvement (P = 0.039). Survival after resection was significantly worse in patients with intrahepatic lymphatic invasion (median survival time of 13 months; cumulative five-year survival rate of 0%) than in patients without (median survival time of 40 months; cumulative five-year survival rate of 41%; P < 0.0001). Patients with intrahepatic lymphatic invasion also showed decreased disease-free survival rates (P < 0.0001). Intrahepatic lymphatic invasion thus independently affected both survival (relative risk, 7.666; 95% confidence interval, 3.732-15.748; P < 0.001) and disease-free survival (relative risk, 4.112; 95% confidence interval, 2.185-7.738; P < 0.001).

CONCLUSIONS

Intrahepatic lymphatic invasion is associated with hepatic lymph node involvement and is an adverse prognostic factor in patients with colorectal carcinoma liver metastases.

Surgical therapy for colorectal metastases to the liver

Colorectal cancer is the fourth most common type of cancer in the West and the second leading cause of cancer-related deaths in the United States. Approximately 35 to 55% of patients with colorectal cancer develop hepatic metastases during the course of their disease. Surgical resection of colorectal liver metastases represents the only chance at potential cure, and long-term survival can be achieved in 35 to 58% of patients after resection. The goal of hepatic resection should be to resect all metastases with negative histologic margins while preserving sufficient functional hepatic parenchyma. In patients with extensive metastatic disease who would otherwise be unresectable, ablative approaches can be used instead of or combined with hepatic resection. The use of portal vein embolization and preoperative chemotherapy may also expand the population of patients who are candidates for surgical treatment. Despite these advances, many patients still experience a recurrence after hepatic resection. More active systemic chemotherapy agents are now available and are being increasingly employed as adjuvant therapy either before or after surgery. Modern treatment of colorectal liver metastasis requires a multidisciplinary approach in an effort to increase the number of patients who may benefit from surgical treatment of colorectal cancer liver metastasis.

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.