Repeat hepatic resections for metastatic colorectal cancer

Limited Effect of Perioperative Systemic Therapy in Patients Selected for Repeat Local Treatment of Recurrent Colorectal Cancer Liver Metastases

Objectives

The aim of this study was to determine the potential benefit of perioperative systemic therapy on overall and progression-free survival after repeat local treatment in patients suffering from recurrent colorectal cancer liver metastasis (CRLM).

Background

The optimal treatment strategy in patients with recurrent CRLM needs to be clarified, in particular for those suffering from early recurrence of CRLM.

Methods

In this multicenter observational cohort study, consecutive patients diagnosed with recurrent CRLM between 2009 and 2019 were retrospectively identified in 4 academic liver surgery centers. Disease-free interval after initial local treatment of CRLM was categorized into recurrence within 6, between 6 and 12, and after 12 months. Perioperative systemic therapy consisted of induction, (neo)adjuvant, or combined regimens. Overall and progression-free survival after repeat local treatment of CRLM were analyzed by multivariable Cox regression analyses, resulting in adjusted hazard ratios (aHRs).

Results

Out of 303 patients included for analysis, 90 patients received perioperative systemic therapy for recurrent CRLM. Favorable overall (aHR, 0.45; 95% confidence interval [CI], 0.26-0.75) and progression-free (aHR, 0.53; 95% CI, 0.35-0.78) survival were observed in patients with a disease-free interval of more than 12 months. No significant difference in overall and progression-free survival was observed in patients receiving perioperative systemic therapy at repeat local treatment of CRLM, stratified for disease-free interval, previous exposure to chemotherapy, and RAS mutation status.

Conclusions

No benefit of perioperative systemic therapy was observed in overall and progression-free survival after repeat local treatment of recurrent CRLM.

Repeat hepatectomy justified in patients with early recurrence of colorectal cancer liver metastases: A systematic review and meta-analysis

BACKGROUND

The benefit of repeat hepatectomy in patients with early recurrence of colorectal cancer liver metastases (CRLM) is questioned, in particular in those suffering from recurrence within three to six months following initial hepatectomy. The aim of this review was therefore to assess whether disease-free interval was associated with overall survival in patients undergoing repeat hepatectomy for recurrent CRLM.

METHODS

A systematic review and meta-analysis was conducted, according to PRISMA guidelines. PubMed, Embase and Cochrane Library databases were searched from database inception to 6th June 2020. Observational studies describing results of repeat hepatectomy for recurrent CRLM, including (disease-free) interval between hepatic resections and overall survival were included. Patients undergoing repeat hepatectomy within three months or additional resection of extrahepatic disease were excluded from meta-analysis.

RESULTS

The initial search identified 2159 records, of which 28 were included for qualitative synthesis. A meta-analysis of 15 cohort studies was performed, comprising 1039 eligible patients. Median overall survival of 54.0 months [95 %-CI: 38.6-69.4] was observed after repeat hepatectomy in patients suffering from recurrent CRLM between three to six months compared to 53.0 months [95 %-CI: 44.3-61.6] for patients with recurrent CRLM between seven to twelve months (adjusted HR = 0.89, 95 %-CI: 0.66-1.18; p = 0.410), and 60.0 months [95 %-CI: 52.7-67.3] for patients with recurrent CRLM after twelve months (adjusted HR = 0.70, 95 %-CI: 0.53-0.92; p = 0.012).

CONCLUSIONS

Disease-free interval is considered a prognostic factor for overall survival, but should not be used as selection criterion per se for repeat hepatectomy in patients suffering from recurrent CRLM.

Prognostic Impact of Budding Grade in Patients With Residual Liver Recurrence of Colorectal Cancer After Initial Hepatectomy

BACKGROUND

Many patients undergoing hepatectomy for colorectal liver metastases (CRLM) experience recurrence. However, no criteria for screening candidates to undergo repeat hepatectomy (RH) for CRLM have been established. Budding, one form by which colorectal carcinoma malignancies are expressed, is a new pathologic index. This study aimed to analyze prognostic factors, including budding, and to provide criteria for screening candidates to undergo RH for recurrent CRLM.

METHODS

Data of 186 consecutive patients who underwent hepatectomy for CRLM between April 2008 and December 2015 were collected. Survival was calculated using the Kaplan-Meier method. Uni- and multivariate analyses were performed to determine factors significantly affecting mortality.

RESULTS

Of 186 patients, 131 experienced recurrence after hepatectomy, with 83 of the 131 patients showing recurrence in the liver, and 52 of these 83 patients undergoing primary surgery at the authors' institution and having information on budding grade. In the univariate analysis, preoperative chemotherapy, budding grade, extrahepatic metastases, and number of liver metastases at the time of recurrence were associated with overall survival (OS) for the 52 patients. In the multivariate analysis, budding grade and number of liver metastases at the time of recurrence were associated with OS.

CONCLUSION

The study examined simple prognostic factors that could help to screen patients better for RH. Repeat hepatectomy improved the prognosis for patients with recurrent CRLM. The independent prognostic factors for OS were number of liver metastases at recurrence as a conventional factor and budding grade as a new pathologic factor. With budding used as an index, patients who could benefit from hepatectomy can be screened more precisely.

Surgical Strategies in Colorectal Cancer Metastatic to the Liver

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

Resection of Colorectal Liver Metastases: Current Perspectives

BACKGROUND

Metastases to the liver is the leading cause of death in patients with colorectal cancer.

METHODS

The authors review the data on diagnosis and management of this clinical problem, and they discuss management options that can be considered.

RESULTS

Complete surgical resection of metastases from colorectal cancer that are localized to the liver results in 5-year survival rates ranging from 26% to 40%.

CONCLUSIONS

By adding modalities such as targeted systemic therapy and other "local" treatments for liver metastases, further gains in survival are anticipated.

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

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

Surgical management of hepatic metastases of colorectal cancer

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Repeat hepatectomy for recurrent colorectal metastases

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Repeat hepatectomy for liver metastases from colorectal primary cancer: a review of the literature

INTRODUCTION

After hepatectomy for metastases from colorectal cancer (CRC), approximately 50% to 70% of patients develop recurrent hepatic metastases. This recurrence is limited to the liver in about one-third of cases. The purpose of this study is to report a comprehensive review of the literature concerning the results of repeat hepatectomy for recurrent liver metastases from CRC.

METHODS

An electronic literature search was conducted to identify all medical articles published concerning repeat hepatectomy for liver metastases of colorectal origin during the period January 1990 to December 2010.

RESULTS

After a second hepatectomy, the mean mortality was 1.4% and the mean morbidity rate was 21.3%. The 5-year survival ranged from 16% to 55%. After a third or fourth hepatectomy, the mean mortality rate was 0% and the mean morbidity rate was 24.5%. After a third hepatectomy, the 5-year survival ranged from 23.8% to 37.9%. After a fourth hepatectomy, the 5-year survival was 9.3% to 36%.

CONCLUSION

Repeat hepatectomy seems justified, since it may result in prolonged survival with acceptable rates of morbidity and mortality, results similar to those seen after initial hepatectomy.

Is laparoscopic repeat hepatectomy feasible? A tri-institutional analysis

BACKGROUND

A laparoscopic approach has not been advocated for repeat hepatectomy on a large scale. This report analyzes the experience of 3 institutions pioneering laparoscopic repeat liver resection (LRLR). The aim of this study was to evaluate the feasibility, safety, oncologic integrity, and outcomes of LRLR.

STUDY DESIGN

All patients undergoing LRLR were identified. Since 1997, 76 LRLRs have been attempted. Operative indications were metastasis (n = 63), hepatocellular carcinoma (n = 3), and benign tumors (n = 10). All patients had 1 or more earlier liver resections (28 open, 44 laparoscopic), including 16 major resections (en bloc removal of 3 or more Couinaud segments).

RESULTS

Eight conversions (11%) to open resections (n = 7) or radiofrequency ablation (n = 1) were required due to technical difficulties or hemorrhage. LRLRs included 49 wedge or segmental resections and 19 major hepatectomies. Median blood loss and operative time were 300 mL and 180 minutes. Patients with previous open liver resection (group B) experienced more intraoperative blood loss and transfusion requirements than those with earlier laparoscopic resections (group A) (p = 0.02; p = 0.01, respectively). R0 resection was achieved in 58 of 64 (91%) patients with malignant tumor. The incidence of postoperative complications and duration of hospital stay were not statistically different between the 2 groups. Bile leakages developed in 5 (6.6%) patients, including 1 requiring reoperation. There was no perioperative death. Median tumor size was 25 mm (range 5 to 125 mm) and the median number of tumors was 2 (range 1 to 7). Median follow-up was 23.5 months (range 0 to 86 months). There was no port-site metastasis. The 3- and 5-year actuarial survivals for patients with colorectal metastases were 83% and 55%, respectively.

CONCLUSIONS

Laparoscopic repeat hepatic resections can be performed safely and with good results, particularly in patients with earlier laparoscopic resections.

Outcomes of intensive surveillance after resection of hepatic colorectal metastases

BACKGROUND

The impact of computed tomography (CT)-based follow-up for the detection of resectable disease recurrence following surgery for colorectal liver metastases (CRLM) was evaluated.

METHODS

Some 705 patients undergoing resection of CRLM between January 1993 and March 2007 were included. Surveillance comprised 3-monthly CT (thorax, abdomen and pelvis) in the first 2 years after surgery, 6 monthly for 3 years and annually from years 6 to 10. Survival differences following recurrence between patients managed surgically and palliatively were determined, and the cost was calculated.

RESULTS

Five-year disease-free and overall survival rates were 28.3 and 32.3 per cent respectively. Of 402 patients who developed recurrence within 2 years, 88 were treated with liver resection alone and 36 with lung and/or liver resection. Their 5-year overall survival rates were 31 and 30 per cent respectively, compared with 3.9 per cent in 278 patients managed palliatively (P < 0.001). For each 3-month interval during the first year of follow-up, patients with recurrence treated surgically had better overall survival than those treated palliatively. The cost of surveillance that identified 124 patients amenable to further resection was 12,338 pounds per operated recurrence. Assuming that patients with recurrence gained 5 years' survival, the mean survival gain was 4.28 years per resection and the cost per life-year gained was 2883 pounds.

CONCLUSION

Intensive 3-monthly CT surveillance after liver resection for CRLM detects recurrence that is amenable to further resection in a considerable number of patients. These patients have significantly better survival with a reasonable cost per life-year gained.

Prognostic scores for colorectal liver metastasis: clinically important or an academic exercise?

OBJECTIVES

Over the last decade, various groups have proposed prognostic scoring systems for patients with colorectal liver metastasis (CLM) treated with hepatic resection. The aims of the current study were to evaluate the differences between and clinical importance of these prognostic scoring systems and to determine their clinical applicability.

METHODS

Relevant articles were reviewed from the published literature using the MEDLINE database. The search was performed using the keywords 'colorectal cancer', 'metastases', 'liver resection' and 'hepatectomy'.

RESULTS

Twelve prognostic scoring systems were identified from 1996 to 2009. Six of these originated from European institutions, three from Asian and three from North American centres. The median study sample was 288 patients (range 81-1568 patients) and median follow-up was 35 months (range 16-52 months). All studies were retrospective in nature and the numbers of groups proposed by the various scoring systems ranged from three to six. All the studies used the Cox proportional hazard model for multi-variable analysis.

CONCLUSIONS

There is no 'ideal' prognostic scoring system for the clinical management of patients with CLM for hepatic resection. These prognostic scoring systems are clinically relevant with respect to survival but have not been used for risk stratification in controversial areas such as the administration of chemotherapy or surveillance programmes.

Repeat curative intent liver surgery is safe and effective for recurrent colorectal liver metastasis: results from an international multi-institutional analysis

INTRODUCTION

Although 5-year survival approaches 55% following resection of colorectal liver metastasis, most patients develop recurrent disease that is often isolated to the liver. Although repeat curative intent surgery (CIS) is increasingly performed for recurrent colorectal liver metastasis, only small series have been reported. We sought to determine safety and efficacy of repeat CIS for recurrent colorectal liver metastasis as well as determine factors predictive of survival in a large multicenter cohort of patients.

METHODS

Between 1982 and 2008, 1,706 patients who underwent CIS--defined as curative intent hepatic resection/radiofrequency ablation (RFA)--for colorectal liver metastasis were identified from an international multi-institutional database. Two hundred forty-six (14.4%) patients underwent 301 repeat CIS. Data on clinico-pathologic factors, morbidity, and mortality were collected and analyzed.

RESULTS

Following initial CIS, 645 (37.8%) patients had recurrence within the liver. Of these, 246 patients underwent repeat CIS for recurrent disease. The majority had hepatic resection alone as initial therapy (n = 219; 89.0%). A subset of patients underwent third (n = 46) or fourth (n = 9) repeat CIS. Mean interval between surgeries was similar (first --> second, 19.1 months; second --> third, 21.5 months; third --> fourth, 11.3 months; P = 0.20). Extent of hepatic resection decreased with subsequent CIS (>or=hemihepatectomy: first CIS, 30.9% versus second CIS, 21.1% versus third/fourth CIS, 16.4%; P = 0.004). RFA was utilized in one quarter of patients undergoing repeat CIS (second CIS, 21.1% versus third/fourth CIS, 25.5%). Mortality and morbidity were similar following second, third, and fourth CIS, respectively (all P > 0.05). Five-year survival was 47.1%, 32.6%, and 23.8% following the first, second, and third CIS, respectively. Presence of extra-hepatic disease was predictive of worse survival (HR = 2.26, P = 0.01).

CONCLUSION

Repeat CIS for recurrent colorectal liver metastasis can be performed with low morbidity and near-zero mortality. Patients with no extra-hepatic disease are best candidates for repeat CIS. In these patients, repeat CIS can offer the chance of long-term survival.

Resection versus no intervention or other surgical interventions for colorectal cancer liver metastases

BACKGROUND

About one in four of patients with metastatic colorectal cancer have metastases isolated to the liver, of which 10% to 25% are eligible for ablation of the liver metastases, improving the five year survival rate. Treatments include hepatic resection and other modalities using cryosurgery and radiofrequency thermal ablation. Although new modalities allow safe ablation of liver metastases without the need for surgical intervention, there are still no clear guidelines on the appropriate management of patients with colorectal cancer and hepatic metastases.

OBJECTIVES

The primary objectives were to compare resection of liver metastases to no intervention and other modalities of intervention (including cryosurgery and radiofrequency ablation) in terms of the benefits and harms for each intervention.

SEARCH STRATEGY

Searches were conducted of the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE databases up to October 2006. In addition, references were scrutinized in identified eligible trials.

SELECTION CRITERIA

Only randomized controlled trials reporting patients (regardless of age and sex) who had had curative surgery for adenocarcinoma of the colon or rectum, had been diagnosed with liver metastases and who were eligible for liver resection (i.e. with no evidence of primary or metastatic cancer elsewhere) were considered.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data using a form designed for this review. Discrepancies were resolved by consensus.

MAIN RESULTS

Only one trial involving 123 people (87 male 36 female) was included. The data from this ten year prospective, randomized clinical trial suggest that hepatic cryosurgery is effective in the treatment of resectable and nonresectable liver metastases. The results show intra-operative tumor reduction (>/=90% or </= 97%) and extended higher survival in these patients. The study indicated a five year and ten year survival rate of 44% and 19% after cryosurgery, respectively. However, it was not possible to separate out and unravel the outcomes data that related only to the participants (66.6%) with liver metastases from colorectal cancer as opposed to those with liver metastases from other primary tumors.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to support a single approach, either surgical or non-surgical, for the management of colorectal liver metastases. Therefore, treatment decisions should continue to be based on individual circumstances and clinician's experience. The authors conclude that local ablative therapies are probably useful, but that they need to be further evaluated in a randomized controlled trial.

WITHDRAWN: Resection versus no intervention or other surgical interventions for colorectal cancer liver metastases

BACKGROUND

About one in four of patients with metastatic colorectal cancer have metastases isolated to the liver, of which 10-25% are eligible for ablation of the liver metastases, improving the 5-year survival rate. Treatments include hepatic resection and non-surgical tumor ablation using cryosurgery and radiofrequency thermal ablation. Although new modalities allow safe ablation of liver metastases without the need for surgical intervention, there are still no clear guidelines on the appropriate management of patients with colorectal cancer and hepatic metastases.

OBJECTIVES

The primary objectives were to compare resection of liver metastases to no intervention and other modalities of intervention (including cryosurgery and radiofrequency ablation), in terms of the benefits and harms for each intervention.

SEARCH STRATEGY

We identified randomized controlled trials from MEDLINE, Embase, and the Cochrane Controlled Trials Register up to October 2006, based upon the search strategy developed for MEDLINE, and revised appropriately for each database. In addition, references were scrutinized in identified eligible trials.

SELECTION CRITERIA

We only considered randomized controlled trials reporting patients of any age and sex, who have had curative surgery for adenocarcinoma of the colon or rectum, diagnosed with liver metastases that are candidates for liver resection, i.e., with no evidence of primary or metastatic cancer elsewhere.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality using a data-extraction form designed for this review. Discrepancies were resolved in consensus.

MAIN RESULTS

Only one trial fulfilled our inclusion criteria. The data of this 10-year prospective, randomized clinical trial suggest that hepatic cryosurgery is effective in the treatment of resectable and non-resectable liver metastases. The results show intra-operative tumor reduction (> or = 90% < or = 97%) and extended higher survival in these patients. The study indicated a 5-year and 10-year survival rate of 44% and 19% after cryosurgery, respectively. However, it was not possible to separate out and unravel the outcomes data that related only to the participants (66.6%) with liver metastases from colorectal cancer as opposed to those with liver metastases from other primary tumors.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to support a single approach, either surgical or non-surgical for the management of colorectal liver metastases. Therefore, treatment decisions should continue to be based on individual circumstances and clinician's experience. We concede that local ablative therapies are probably useful, but they need to be further evaluated in a randomized controlled trial.

Outcome following repeat liver resection for colorectal liver metastases

AIM

Our aim was to determine independent predictors of survival after second liver resection and to confirm whether the type of first resection influences survival after repeat resection.

METHODS

Fifty-four patients who underwent a second liver resection for colorectal liver metastases were analyzed. To find independent predictors of survival, possible prognostic factors regarding the primary tumor, and the first and second resections were used in the Cox regression analysis.

RESULTS

There were three postoperative deaths within 90 days of surgery. The 3- and 5-year overall survival rates were 53% and 46%, respectively. The size of the tumor (>50mm) (p=0.005), serum carcinoembryonic antigen level (>30microg/L) (p=0.002), and the presence of a positive surgical margin at the second resection (p=0.006) were independent predictors of poor survival following the second resection. The type of first resection was not associated with survival but was associated with the ability to achieve a histological negative surgical margin at the second liver resection (p=0.01).

CONCLUSION

Three independent predictors of survival were identified. Major initial liver resection was associated with a reduced ability to achieve surgical clearance at the second resection. For colorectal liver metastases, major resection should only be performed if a negative margin cannot be achieved by minor resection.

Prognostic influence of multiple hepatic metastases from colorectal cancer

AIMS

The aim of this study was to report the results of surgery for multiple colorectal liver metastases on patient outcome.

METHODS

This was a review of 484 consecutive patients who underwent liver resection for colorectal liver metastases between 1993 and 2003. The cohort was divided into 2 groups, those with 1-3 metastases and those with "multiple" metastases, namely 4 or more lesions. The later group was subdivided into those with less than 8 ("several") or 8 or more ("numerous") separate lesions.

MAIN OUTCOME MEASURES

the post-operative hospital stay was calculated and morbidity and mortality were assessed.

RESULTS

On multivariate analysis the presence of multiple metastases was the only predictor for both poorer overall survival (p=0.007) and disease-free survival (p=0.031). However, when patients with multiple metastases are analysed in detail this survival disadvantage appears to be only present in patients with numerous (8 or more) lesions.

CONCLUSION

Although patients with multiple metastases appear to have a poorer outcome, significant number of patients with multiple metastases survive to 5 years or more and should not be denied surgery. Patients with numerous (8 or more) metastases showed a poorer survival disadvantage. These patients need alternative treatment speculatives.

Systematic review on safety and efficacy of repeat hepatectomy for recurrent liver metastases from colorectal carcinoma

BACKGROUND

We critically appraised the quantity and quality of current clinical evidence to demonstrate the efficacy and safety of repeat hepatectomy for recurrent colorectal liver metastases (CRLM).

METHODS

Electronic searches for relevant studies published in peer-reviewed medical journals on repeat hepatectomy for recurrent CRLM before January 2007 were performed on six databases. The quality of each included study was independently assessed. Clinical effectiveness was synthesized through a narrative review with full tabulation of results of all included studies.

RESULTS

Seventeen studies with more than 20 patients were included for quality appraisal and data extraction. All 17 included articles were observational cases series. The overall perioperative morbidity rate ranged from 7% to 30% and mortality rate varied from 0% to 5%. The overall median survival since the repeat hepatectomy ranged from 23 to 56 months, with 3- and 5-year survival of 24% to 68% and 21% to 49%, respectively. The median disease-free survival ranged from 9 to 52 months, with 3- and 5-year disease-free survival of 16% to 68% and 16% to 48%, respectively.

CONCLUSIONS

The current literature suggests that repeat hepatectomy is associated with a prolonged survival for recurrent CRLM and is justified in selected patients because there is a lack of evidence for effective alternative treatments.

Repeat liver resection for recurrent liver metastases from colorectal cancer

AIMS

Numerous patients suffer from recurrence after resection of liver metastases from colorectal cancer. Recurrence is frequently restricted to the liver and repeat liver resection may offer a curative option in these patients. This study was conducted to clarify safety and effectiveness of this treatment and to identify prognostic factors of a favourable outcome after repeat hepatectomy.

METHODS

Between January 1988 and March 2006 in our institution 811 patients underwent 841 liver resections for metastases from colorectal cancer. Among these, 94 patients underwent a repeat hepatectomy. Patients were identified from a prospective database and retrospectively reviewed. Results of different time periods were assessed and prognostic factors for a favourable outcome were determined.

RESULTS

The perioperative morbidity and mortality was 24% (23 of 94) and 3% (3 of 94), respectively. The one-, three-, five- and ten-year survival for all patients in this series was 89%, 55%, 38% and 23%, respectively. In the univariate analysis, pT-stage of the primary, diameter of the largest metastases, surgical radicality, period of resection and distribution of metastases showed statistically significant influence on survival. The multivariate analysis revealed only pT-stage of the primary tumour, surgical radicality and period of resection as independent prognostic factors.

CONCLUSIONS

Repeat hepatectomy is a safe and effective treatment for recurrent liver metastases from colorectal cancer. Perioperative risk and long-term survival were similar when compared to the results obtained during the initial resection. Achieving a curative resection is the most relevant prognostic factor for a favourable prognosis after repeat liver resection.

Impact of radiofrequency assisted hepatectomy for reduction of transfusion requirements

BACKGROUND

Liver parenchyma transection technique using heat coagulative necrosis induced by radiofrequency (RF) energy is evaluated in this series.

METHODS

Between January 2000 and October 2004, 156 consecutive patients underwent liver resection with the RF-assisted technique. Data were collected prospectively to assess the outcome, including intraoperative blood loss, blood transfusion requirement, and morbidity and mortality rates.

RESULTS

There were 30 major hepatectomies and 126 minor resections. While total operative time was 241 +/- 89 minutes, the actual resection time was 75 +/- 51 minutes. Intraoperative blood loss was 139 +/- 222 mL. Nine patients (5%) received blood transfusion, predominantly those receiving major hepatectomy (P = .006). Thirty-six patients (23%) developed postoperative complications, and the mortality rate was 3.2%. Mean hospital stay was 12 +/- 12 days.

CONCLUSION

The RF-assisted technique is associated with minimal blood loss, a low blood transfusion requirement, and reduced mortality and morbidity rates and can be used for both minor and major liver resections.

Meta-analysis of clinical outcome after first and second liver resection for colorectal metastases

BACKGROUND

The perioperative risk and long-term survival benefit of repeat hepatectomy for patients with liver metastases from colorectal cancer, compared with that of a first liver resection, has been reported with varying results in the literature.

METHODS

The literature was searched using Medline, Embase, Ovid, and Cochrane databases for all studies published from 1992 to 2006. Two authors independently extracted data using the following outcomes: postoperative complications and mortality; disease recurrence; and long-term survival. Trials were assessed using the modified Newcastle-Ottawa Score. Random-effect meta-analytical techniques were used for analysis.

RESULTS

Twenty-one studies met the inclusion criteria, comprising 3,741 patients. The use of adjuvant chemotherapy was similar in both groups (odds ratio [OR] = 0.97; 95% confidence interval [CI] = 0.54, 1.74; P = .92), as was the number of hepatic nodules present at the time of first or second resection (weighted mean difference [WMD] = 0.18; 95% CI = -0.22, 0.57; P = .380). Wedge resection was carried out less often at first hepatectomy (39% vs 46%; OR = 0.66; 95% CI = 0.44, 1.00; P = .05). There was significantly less blood loss in patients undergoing first versus second hepatectomy (WMD = 238 ml; 95% CI = 90, 385; P = .002). There was no difference in perioperative morbidity (OR = 1.01; 95% CI = 0.65, 1.55; P = .98), mortality (OR = 1.01; 95% CI = 0.18, 5.72; P = .99) or long-term survival (HR = 0.90; 95% CI = .66, 1.24; P = .530) between groups.

CONCLUSIONS

Repeat hepatectomy for patients with colorectal cancer metastases is safe and provides survival benefit equal to that of a first liver resection.

Second hepatectomy for recurrent colorectal liver metastasis: analysis of preoperative prognostic factors

BACKGROUND

Second hepatectomy is a potentially curative treatment for patients with hepatic recurrence of colorectal cancer. However, there is still no consensus about the patient selection criteria for second hepatectomy under these circumstances, and the factors affecting prognosis after second hepatectomy remain uncertain.

METHODS

Clinicopathologic data for 111 consecutive patients with colorectal liver metastasis who underwent second hepatectomy at a single institution between 1985 and 2004, and for whom complete clinicopathologic reports were available, were subjected to univariate and multivariate analyses.

RESULTS

The morbidity and mortality rates were 14% and 0%, respectively, and the overall 5-year survival rate was 41%. Multivariate analysis revealed that synchronous resection for the first liver metastasis (hazard ratio, 1.8), more than three tumors at the second hepatectomy (1.9), and histopathological involvement of the hepatic vein and/or portal vein by the first liver metastasis (1.7) were independently associated with poor survival. We used these three risk factors to devise a preoperative model for predicting survival. The 5-year survival rates of patients without any risk factors, and with one, two, or three risk factors, were 62%, 38%, 19%, and 0%, respectively.

CONCLUSIONS

Second hepatectomy is beneficial for patients without any risk factors. Before second hepatectomy, chemotherapy should be considered for patients with any of these risk factors, especially with two or three factors, in the adjuvant or neoadjuvant setting to prolong survival. These results need to be confirmed and validated in another data set or future prospective trial according to the scoring scheme we outline.

Management of intrahepatic recurrence after curative treatment of colorectal liver metastases

BACKGROUND

Management of intrahepatic recurrence after complete surgical treatment for colorectal liver metastases is not well defined. The aim of this study was to analyse the survival results of patients who had repeat liver resection for intrahepatic recurrence and to evaluate prognostic indicators for survival.

METHODS

Between 1991 and 2005, 55 patients had repeat liver resection for isolated intrahepatic recurrence. The long-term survival results were assessed. Univariable and multivariable analyses were used to identify prognostic indicators for survival after repeat hepatectomy.

RESULTS

The median survival was 53 (range 2-97) months and the 5-year survival rate was 49 per cent. In univariable analysis, size of largest initial liver metastasis, margin of initial liver surgery, carcinoembryonic antigen (CEA) level before and after initial liver surgery, liver disease-free survival, margin of repeat liver surgery, operation type of repeat surgery and CEA level before and after repeat surgery were significant prognostic factors. In multivariable analysis, largest initial liver metastasis 4 cm or less and CEA level 5 ng/ml or less after repeat liver surgery were independently associated with improved survival.

CONCLUSION

Repeat hepatectomy can achieve an acceptable survival in selected patients with isolated intrahepatic recurrence.

Short time to recurrence after hepatic resection correlates with poor prognosis in colorectal hepatic metastasis

BACKGROUND

Early recurrence is a major problem after hepatic resection of colorectal hepatic metastasis (CHM). Our aim was to investigate the relationship between time to recurrence after CHM resection and overall survival.

METHODS

A retrospective analysis was performed for 101 consecutive patients who underwent hepatic resection for CHM and have been followed more than 5 years.

RESULTS

Among 101 patients, 82 (81%) had a recurrence. Overall survival of patients with recurrence within 6 months after CHM resection was significantly worse than that of patients with recurrence after more than 6 months (P < 0.01). Overall survival was poorer when time to recurrence was shorter. One of the reasons for poor prognosis of patients with recurrence within 6 months was that only a few patients could undergo a second resection for recurrence after CHM resection. Histological type, including poorly differentiated signet ring cell or mucinous adenocarcinoma in the primary tumor, bilobar metastases, microscopic positive surgical margin and carcinoembryonic antigen (CEA) above 15 ng/ml had predictive value for decreased recurrence-free survival after CHM resection.

CONCLUSION

Short time to recurrence after CHM resection correlates with a poor prognosis. Histological type of poorly differentiated signet ring cell or mucinous adenocarcinoma in the primary tumor might be a predictor for early recurrence after CHM resection.

Repeat hepatectomy for recurrent colorectal liver metastases

PURPOSE

Liver resection represents the best and potentially curative treatment for metastatic colorectal cancer (MCC) to the liver. After resection, however, most patients develop recurrent disease, often isolated to the liver. The aim of this study was to determine the value of repeat liver resection for recurrent MCC and to analyze the factors that can predict survival.

PATIENTS AND METHODS

From January 1992 to October 2002, 42 patients from a group of 168 patients resected for MCC were submitted to 55 repeat hepatectomies (42 second, 11 third, and 2 fourth hepatectomies). Records were retrospectively reviewed. The primary tumor was carcinoma of the colon in 26 patients and carcinoma of the rectum in 16 patients. Liver metastases were synchronous in 24 patients (57.1%).

RESULTS

There were 25 men and 17 women with the mean age of 63.5 years (range: 34-80). There was no intraoperative or postoperative mortality. The morbidity rates were 9.5%, 14.3%, and 18.2% (P = 0.6) respectively after a first, second, or third hepatectomies. No patients needed reoperation. Operative duration was longer after a second or third hepatectomie than after a first hepatectomie without difference for operative bleeding. Overall 5-year survivals were 33%, 21%, and 36% respectively after a first, second, or third hepatectomies. Factors of prognostic value on univariate analysis included serum carcinoembryonic antigen levels (P = 0.01) during the first hepatectomy, the presence of extrahepatic disease (P = 0.05) and tumor size larger than 5 cm (P = 0.04) during the second hepatectomie.

CONCLUSIONS

Repeat hepatectomies can provide long-term survival rates similar to those of first hepatectomies.

Method of Presenting Oncology Treatment Outcomes Influences Patient Treatment Decision-Making in Metastatic Colorectal Cancer

BACKGROUND

The methods used to communicate relevant outcomes in oncology to patients will likely influence treatment decisions. The purpose of this study was to examine the influence of three different methods of describing the efficacy of therapy on treatment decisions regarding management of metastatic colorectal cancer.

METHODS

Participants reviewed a clinical scenario and randomly received one of three ways of describing efficacy of chemotherapy in metastatic colorectal cancer: (1) relative risk reduction, (2) tumor response rate, and (3) median overall survival. They received the same clinical scenario but were presented four treatment options: (1) observation and supportive care, (2) chemotherapy, (3) surgery, and (4) surgery and chemotherapy and the accompanying median overall survival estimate.

RESULTS

Participants included 102 preclinical medical students. In the first scenario, 85% chose chemotherapy in the relative risk reduction group, as did 88% of the tumor response rate group, but significantly fewer participants did so in the median overall survival group (35%; P < .001). In the second scenario, there was a significant difference in treatment preferences, with 4% of participants choosing observation/supportive care. None chose chemotherapy only, 19% chose surgery only, and 77% chose surgery plus chemotherapy (P < .001).

CONCLUSIONS

This study demonstrated that different methods of describing oncology treatment outcomes associated with therapy for metastatic colorectal cancer to the liver can have a dramatic effect on patient treatment decisions.

Management of hepatic metastases from colorectal cancer

The majority of hepatic metastases in the United States occur in patients with a primary colorectal malignancy. Advances in technology combined with increasing surgeon experience have broadened the treatment options available for hepatic metastases from colorectal cancer. Surgical resection is the most effective therapy for metastatic colorectal cancer isolated to the liver. The aim of this article is to discuss the role of locally aggressive treatment options including resection, ablation, and regional chemotherapy in the management of patients with metastases from colorectal cancer.

Surgical therapy for metastatic disease to the liver

The liver is a common site of hematogenous metastasis. In the past, patients with liver metastases were often deemed inoperable, and medical therapy conferred only minor survival benefit. However, advances in surgical techniques and chemotherapeutic agents during the past two decades have led to effective treatments for selected patients with metastases to the liver. Up to approximately 80% of the liver can be resected, and partial hepatectomy is now routinely performed with a perioperative mortality rate of <5%. Surgical resection of colorectal cancer metastatic to the liver results in a 5-year survival rate of 40%. These results are expected to improve even further with multimodality approaches that include newer chemotherapy regimens. Liver metastases from other primary tumors, such as neuroendocrine carcinoma and genitourinary tumors, are also treated effectively with liver resection. The indications for surgical treatment of liver metastases are broadening as a variety of novel therapies are being developed, including hepatic artery embolization, hepatic artery infusion of chemotherapy, and radiofrequency ablation.

In-contiguity and non-anatomical extension of right hepatic trisectionectomy for liver metastases

Background

In some patients undergoing right hepatic trisectionectomy for metastases, extension of the resection beyond the falciform ligament is necessary to achieve tumour clearance. The aim of the present study was to assess the early and long-term outcomes and hepatic function in patients who underwent extensive liver resection beyond right trisectionectomy.

Methods

Thirty-eight patients who had extension of a right trisectionectomy, either in contiguity (IC) or in a non-anatomical (NA) fashion, for liver metastases were included in the study. In-hospital mortality, hepatic function and other morbidity were recorded. Survival outcomes were analysed for the subgroup of patients with colorectal liver metastases. The clinical risk score described by the Memorial Sloan–Kettering Cancer Center was applied to all patients with colorectal liver metastases.

Results

Sixteen patients had IC resection, 15 NA resection, and seven had both IC and NA procedures. There was one in-hospital death. Hepatic dysfunction was seen in 25 patients and two developed liver failure. Disease-free actuarial 3-year survival was 42 per cent for patients with colorectal liver metastases. Survival was significantly better in patients with a clinical risk score of 3 or less.

Conclusion

Extension of right trisectionectomy for liver metastases was associated with a low risk of death and hepatic failure.

Single and multiple resections of multiple hepatic metastases of colorectal origin

BACKGROUND

Indications for hepatectomy in patients with 4 or more hepatic colorectal metastases remain controversial.

METHODS

A retrospective cohort study was performed with data from 131 patients who underwent a total of 198 hepatectomies. Patients were grouped according to the number of metastases at the initial hepatectomy (analysis 1) or by the total number of metastases removed by multiple hepatectomies (analysis 2).

RESULTS

In analysis 1, the risk ratios for death of patients with 4 to 9 and 10 nodules to those with 1 to 3 nodules were 2.12 (95% CI, 0.99-4.23) and 7.32 (95% CI, 2.82-16.9), respectively. In analysis 2, the risk ratios for death were 1.32 (95% CI, 0.66-2.59) and 3.07 (95% CI, 1.41-6.36), respectively. These values in 106 patients with negative surgical margins were 1.52 (95% CI, 0.51-3.73) and 5.40 (95% CI, 1.25-16.5), and 1.06 (95% CI, 0.45-2.32) and 1.70 (95% CI, 0.49-4.61), respectively. In analysis 2, the 5-year survival rates of patients with 1 to 3, 4 to 9, and 10 or more nodules were 51%, 46%, and 25%, respectively.

CONCLUSION

Hepatic resection for patients with 4 to 9 nodules clearly is warranted. On the other hand, for patients with 10 or more tumor nodules, surgery cannot be ensured absolutely to be contraindicated in high volume centers at which the surgical mortality rate is nearly zero.

Procedures of Choice for Resection of Primary and Recurrent Liver Metastases from Colorectal Cancer

Although liver resection offers the only realistic chance of cure for patients with liver metastases from colorectal cancer, no consensus exists as to the procedure of choice for managing these tumors. Data from 193 patients who underwent hepatectomy for liver metastases from colorectal cancer and 26 of 193 patients who underwent repeat hepatectomy for recurrent metastases were collected. The suitability of resection was evaluated retrospectively based on known risk factors for recurrence and patterns of recurrence. On multivariate analysis, a positive surgical margin (SM+) was the only risk factor for recurrence after the initial resection (p < 0.01). SM+ (p < 0.01) and nonanatomic resection (p < 0.05) that was less than a sectionectomy (p < 0.05) were risk factors for recurrence after repeat hepatectomy. Multiple tumors (four or more) was the most common pattern of recurrence after initial hepatectomy, and recurrence close to the line of resection was most common after repeat hepatectomy. Based on tumor doubling times, recurrence after initial hepatectomy seemed to originate from the primary colorectal lesion, whereas recurrence after repeat hepatectomy was derived from a hepatic metastasis. Retrospective analysis suggests that hepatectomy with clear surgical margins is more important than anatomic resection for initial hepatectomy, and at least sectionectomy is necessary for repeat hepatectomy.

Metastatic tumor doubling time: most important prehepatectomy predictor of survival and nonrecurrence of hepatic colorectal cancer metastasis

We determined the relative value of the metastatic colorectal cancer doubling time as a predictor of recurrence and survival after hepatectomy in comparison with other established predictors. Consecutive patients who underwent hepatic resection ( n = 144) for colorectal cancer liver metastases were studied retrospectively to identify factors that influence overall survival and recurrence in the remnant liver. Overall 5-year survival and nonrecurrence rates were 49.8% and 50.8%, respectively. By multivariate analysis, large liver tumors ( p = 0.038), p53 expression by the liver tumor (p = 0.011), and a short liver metastasis doubling time (< or = 45 days, p = 0.013) negatively affected survival; doubling times > 45 days (adjusted relative risk 0.06; p < 0.001) positively influenced disease-free survival. In patients with remnant liver recurrence, a short doubling time was associated with short disease-free intervals (7.3 +/- 6.2 months), multiple metastases (63.6%), and fewer attempts at repeat hepatectomy (22.7%). The doubling time determines tumor size and reflects the patient's immune and nutritional status. A short doubling time is the most reliable risk factor for multiple metastases, early recurrence, and poor prognosis. Further studies with a larger number of patients are needed to confirm this conclusion.

Liver resection for colorectal metastases: the third hepatectomy

OBJECTIVE

To determine the risk, the benefit, and the main factors of prognosis of third liver resections for recurrent colorectal metastases.

SUMMARY BACKGROUND DATA

Recurrence following liver resection is frequent after a first as after a second hepatectomy. Second liver resections yield a similar survival to that obtained with first liver resection, but little is known about third hepatectomy.

METHODS

This study reports a retrospective analysis of 60 patients who underwent a third liver resection for colorectal metastases in a 16-year experience (1984-2000). Patients were identified from a prospective database that collected 615 consecutive patients who cumulated 883 hepatectomies (615 first, 199 second, 60 thirds, and 9 fourths). Third hepatic resections were compared with first and second procedures, in terms of risk and benefit for the patient. Prognostic factors of survival after third hepatic resection were determined by univariate and multivariate analysis.

RESULTS

A third hepatic resection was attempted in 68 of 115 of liver recurrences following a second hepatectomy (59%) and achieved in 88% of the cases (60 of 68). There was no intraoperative mortality or postoperative deaths within the 2 months. Fifteen patients developed postoperative complications (25%), a rate similar to that of first and second hepatectomies. Overall 5-year survival was 32% and disease-free survival was 17% after the third resection. Survival compared favorably to that of patients with recurrence following a second hepatectomy who could not be operated (5% at 3 years) or who failed to be resected (15% at 2 years, P = 0.0001). It also compared favorably to that of patients who underwent only two hepatectomies (5-year survival, 27%). When estimated from the time of first hepatectomy, survival was 65% at 5 years for the 60 patients who underwent three hepatic resections. Concomitant extrahepatic tumor was treated in 16 patients (27%) by 11 abdominal procedures and 5 pulmonary resections. By multivariate analysis, tumor size > 30 mm for first liver metastases, presence of extrahepatic tumor at second hepatectomy, and noncurative pattern of third liver resection were independent prognostic factors of reduced survival.

CONCLUSIONS

Third hepatectomy is safe and provides an additional benefit of survival similar to that of first and second liver resections. It is worthwhile when curative and integrated into an intended multimodal strategy of tumoral eradication.

Analysis of surgical salvage after failure of primary therapy in rectal cancer: results from Intergroup Study 0114

PURPOSE

Intergroup Study 0114 was designed to study the effect of various chemotherapy regimens delivered after potentially curative surgical resection of T3, T4, and/or node-positive rectal cancer. A subset analysis was undertaken to investigate the prevalence and influence of salvage therapy among patients with recurrent disease.

PATIENTS AND METHODS

Adjuvant therapy consisted of two cycles of fluorouracil (FU)-based chemotherapy followed by pelvic irradiation with chemotherapy and two more cycles of chemotherapy after radiation therapy. A total of 1,792 patients were entered onto the study and 1,696 were assessable. After a median of 8.9 years of follow-up, 715 patients (42%) had disease recurrence, and an additional 10% died without evidence of disease. Five hundred patients with follow-up information available had a single organ or single site of first recurrence (73.5% of all recurrences).

RESULTS

A total of 171 patients (34% of those with a single organ or single site of recurrence) had a potentially curative resection of the metastatic or locally recurrent disease. Single-site first recurrences in the liver, lung, or pelvis occurred in 448 patients (90% of the single-site recurrences), with 159 (35%) of these undergoing surgical resection for attempted cure. Overall survival differed significantly between the resected and nonresected groups (P <.0001), with overall 5-year probabilities of.27 and.06, respectively. Controlling for worst performance status at the time of recurrence does not alter this relationship. Patients who underwent salvage surgery had significantly increased survival (P <.001) for each site.

CONCLUSION

Attempted surgical salvage of rectal cancer recurrence is performed commonly in the United States. The chance of a long-term cure with such intervention is approximately 27%.

Prognostic factors for poor survival after repeat hepatectomy in patients with colorectal liver metastases

BACKGROUND

The recurrence rate for colorectal liver metastases after repeat hepatic resection is high, and selection criteria for repeat hepatectomy are still controversial.

METHODS

Clinical data of patients undergoing repeat hepatectomy for metastatic colon cancer were reviewed retrospectively and compared with those of initial hepatectomy and other treatments to determine criteria for repeat hepatectomy and to confirm its efficacy.

RESULTS

For 22 patients who underwent repeat hepatectomy, no mortality and an 18% morbidity rate were observed. The 3-year survival rate after repeat hepatectomy was 49%. The only poor prognostic factor after repeat hepatectomy was a serum carcinoembryonic antigen level greater than 50 ng/mL before initial hepatectomy. The prognosis for patients who underwent repeat hepatectomy and had shown high carcinoembryonic antigen levels before initial hepatectomy was approximately equal to that for the patients who received systemic chemotherapy or hepatic arterial infusion for unresectable tumors in the remnant liver.

CONCLUSION

Repeat hepatectomy for colorectal liver metastases can be performed safely and appears to be as effective as initial hepatectomy. However, for patients with a carcinoembryonic antigen level greater than 50 ng/mL before the initial hepatectomy, repeat hepatic resection alone may not be as effective, and a new strategy is needed.

Thermal ablative therapy for malignant liver tumors: a critical appraisal

The management of primary and secondary malignant liver tumors poses a great challenge to clinicians. Although surgical resection is the gold-standard treatment, most patients have unresectable malignant liver tumors. Over the past decade, various modalities of loco-regional therapy have gained much interest. Among them, thermal ablative therapy, including cryotherapy, microwave coagulation, interstitial laser therapy, and radiofrequency ablation (RFA), have been proven to be safe and effective. Despite the effective tumor eradication achieved within cryotherapy, the underlying freeze/thaw mechanism has resulted in serious complications that include bleeding from liver cracking and the 'cryoshock' phenomenon. Thermal ablation using microwave and laser therapy for malignant liver tumors is curative and is associated with minimal complications. However, this treatment modality is effective only for tumors <3 cm diameter. Radiofrequency ablation seems to be the most promising form of thermal ablative therapy in terms of a lower complication rate and a larger volume of ablation. However, its use is restricted by the difficulty encountered when using imaging studies to monitor the areas of ablation during and after the procedure. Moreover, the techniques of RFA need to be refined in order to achieve the same oncological radicality of malignant liver tumors as achieved by surgical resection. As each of the loco-regional therapies has its own advantages and limitations, a multidisciplinary approach using a combination of therapies will be the future trend for the management of malignant liver tumors.

Surgical and ablative modalities for the treatment of colorectal cancer metastatic to the liver

Colorectal cancer is the second leading cause of mortality from cancer in the United States. Death from colorectal cancer usually results from metastatic disease to the liver. Complete surgical resection is the only potentially curative treatment option for metastatic colorectal cancer to the liver, with a five-year survival rate of approximately 30%-40%. The addition of adjuvant systemic or hepatic intra-arterial pump chemotherapy appears to improve survival. Treatment options for unresectable disease in the liver are cryosurgery (intraoperative freezing of tumors), radiofrequency ablation (intraoperative or percutaneous heating of tumors), hepatic intra-arterial infusion pump chemotherapy (regional chemotherapy), and systemic chemotherapy. This article describes metastatic colorectal cancer disease presentation, extent of disease evaluation, and nonchemotherapeutic treatment options, including surgical and ablative therapies. The nurse's role in caring for this population also will be discussed.

Management of colorectal liver metastases

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

Isolated pulmonary recurrence after resection of colorectal hepatic metastases--is resection indicated?

BACKGROUND

Resection of colorectal hepatic metastases is an accepted treatment modality for stage IV colorectal cancer. Concurrent or sequential pulmonary metastasectomy continues to be a controversial strategy. We analyzed factors that predicted pulmonary recurrence in patients with resected hepatic metastases and examined the efficacy of these combined interventions in the treatment of metastatic colorectal cancer.

METHODS

A retrospective review of a database of patients who underwent resection of colorectal hepatic metastases was performed to identify patients who either had synchronous pulmonary metastases (defined as pulmonary recurrence at the time of or within 3 months of hepatic metastasectomy) or subsequently experienced pulmonary metastases. Patient demographics, operative interventions, and overall survival were analyzed. Statistical methods included unpaired Student's t-test, actuarial survival and log-rank analysis.

RESULTS

Twenty-one patients (19%) had pulmonary metastases after hepatic resection, of which 12/21(57%) underwent pulmonary resection. No differences were observed between the resection group, the nine patients with pulmonary metastases who did not undergo resection, and the 87 patients without pulmonary metastases with regard to age, sex, race, or extent of hepatic metastases. When comparing the resected versus the unresected pulmonary recurrences, the disease-free interval from hepatic resection to detection of pulmonary metastases was 21 +/- 20 months (range, 3-72 months) versus 16 +/- 8 months (range, 4-25 months), respectively. All patients with pulmonary recurrence who underwent pulmonary metastasectomy had unilateral disease. Seven of 12 (58%) underwent wedge/segmental resections, and the remaining five (42%) required lobectomy in order to obtain a complete resection. Four patients who underwent pulmonary resection had multiple lung metastases (two to four lesions), and eight had isolated metastasis. There were no perioperative deaths in the pulmonary metastasectomy group. Contraindications to pulmonary resection included extensive pulmonary disease and concurrent extrapulmonary disease. A survival benefit was noted at 3 years for the resected versus the unresected group (60% vs 31%). Survival was no different between the resected pulmonary recurrence patients and the resected hepatic metastases only patients (60% vs 54%).

CONCLUSIONS

Pulmonary metastasectomy can be performed safely and effectively in patients with recurrent disease after hepatic resection for colorectal metastases. Prolonged survival can be achieved with resection of isolated pulmonary recurrence after hepatic resection for colorectal cancer. Further studies that delineate selection criteria for pulmonary resection of colorectal metastases are warranted.

Radiofrequence ablation of liver cancers

Primary and secondary malignant liver cancers are some of most common malignant tumors in the world. Chemotherapy and radiotherapy are not very effective against them. Surgical resection has been considered the only potentially curtive option, but the majority of patients are not candidates for resection because of tumor size, location near major intrahepatic blood vessels and bile ducts, precluding a margin-negative resection, cirrhotic, hepatitis virus infection or multifocial. Radiofrequence ablation (RFA), which is a new evolving effective and minimally invasive technique, can produce coagulative necrosis of malignant tumors. RFA should be used percutaneously, laparscopically, or during the open laparotomy under the guidance of ultrasound, CT scan and MRI. RFA has lots of advantages superior to other local therapies including lower complications, reduced costs and hospital stays, and the possibility of repeated treatment. In general, RFA is a safe, effective treatment for unresectable malignant liver tumors less than 7.0 cm in diameter. We review the principle, mechanism, procedures and experience with RFA for treating malignant liver tumors.

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

OBJECTIVE

To determine the value of repeat liver resection for recurrent colorectal metastases to the liver.

SUMMARY BACKGROUND DATA

Liver resection represents the best and a potentially curative treatment for metastatic colorectal cancer to the liver. After resection, however, most patients develop recurrent disease, often isolated to the liver.

METHODS

This study reports the combined experience of repeat liver resection for recurrent liver metastases at an American and a European surgical oncology center. Patients were identified from prospective databases and records were retrospectively reviewed. A total of 126 patients (American n = 96, 1986-2001; European n = 30, 1985-1999) underwent repeat liver resection. Patient characteristics were similar in the two institutions. Median follow-up from first liver resection was 88 and 105 months, respectively.

RESULTS

Operations performed included 90 minor resections and 36 resections of a lobe or more. The 1-, 3-, and 5-year survival rates were 86%, 51%, and 34%. There were 19 actual 5-year survivors to date. By multivariate regression analysis (proportional hazard model), more than one lesion and tumor size larger than 5 cm were independent prognostic indicators of reduced survival. The interval between the first and second liver resection was not predictive of outcome.

CONCLUSIONS

Repeat liver resection for colorectal liver metastases is safe. Patients with a low tumor load are the best candidates for a repeat resection. In well-selected patients, further resection of the liver can provide prolonged survival after recurrence of colorectal liver metastases.

Follow-up of patients with colorectal cancer: numbers needed to test and treat

Follow-up after curative treatment of patients with colorectal cancer has as its main aims the quality assessment of the treatment given, patient support, and improved outcome by the early detection and treatment of cancer recurrence. How often, and to what extent, the final aim, improved survival, is indeed realised is so far unclear. A literature search was performed to provide quantitative estimates for the main determinants of the effectiveness of the follow-up. Data were extracted from a total of 267 articles and databases, and were aggregated using modern meta-analytic methods. In order to provide one more colorectal cancer patient with long-term survival through follow-up, 360 positive follow-up tests and 11 operations for colorectal cancer recurrence are needed. In the remaining 359 tests and 10 operations, either no gains are achieved or harm is done. As the third aim of colorectal cancer follow-up, improved survival, is realised in only few patients, follow-up should focus less on diagnosis and treatment of recurrences. It should be of limited intensity and duration (3 years), and the search for preclinical cancer recurrence should primarily be performed by carcino-embryonic antigen (CEA) testing and ultrasound (US). The focus of colorectal cancer follow-up should shift from the early detection of recurrence towards quality assessment and patient support. As support that is as good or even better can be provided by a patient's general practitioner (GP) or by specialised nursing personnel, there is no need for routine follow-up to be performed by the surgeon.

Surgical treatment of liver metastases

Approximately 50% to 60% of patients with colorectal cancer will develop hepatic metastases during the course of their illness, with 20% to 30% of patients having liver metastases at time of diagnosis. In nearly a quarter of these patients the liver is the only site of disease. Surgical resection of isolated hepatic metastases has been associated with a 27% to 37% 5-year survival and confers a survival advantage compared to patients not undergoing resection. Thorough preoperative and intraoperative evaluation is necessary to select appropriate surgical candidates who may benefit from resection. This article examines criteria useful in patient selection, and also reviews the management of recurrent hepatic metastases and the role of repeat hepatic resection.

Resection and local therapy for liver metastases

In 30-50% of patients the liver is a preferred site of distant disease for many malignant tumours. Due to the high incidence, most of the available data relate to metastases arising from colorectal primaries. Surgical resection is at present the only treatment offering potential cure. The achievable 5-year survival rate is 30%. However, only 10-15% of patients with colorectal liver metastases can undergo potentially curative liver resection. Therefore, accurate staging is an important prerequisite in selecting patients who would benefit from surgery. Recurrence of hepatic metastases after potentially curative resection occurs in up to 60% of the cases. Results demonstrate that re-resection of liver metastases can provide long-term survival rates in a carefully selected group of patients without extrahepatic disease. Because of the high rate of recurrences following an apparently curative resection several authors investigated the use of adjuvant chemotherapy (systemic, intraportal, and hepatic arterial infusion). Until recently none had shown effectiveness. Pre-operative chemotherapy seems to be a promising approach in patients with liver metastases initially considered unsuitable for radical surgery. Recently, neoadjuvant chemotherapy has been proposed as an alternative approach to conventional surgery as initial management with the aim of improving the results in resectable liver metastases. Interventional strategies (ethanol injection, cryosurgery, laser-induced thermotherapy, radio-frequency ablation) and combined modalities (surgical/interventional) are additive methods which may help to improve treatment results in the future.