Resection of hepatic metastases from colorectal cancer. Biologic perspective

Department of Surgery, New England Deaconess Hospital, Harvard Medical School, Boston, Massachusetts 02215.
Annals of Surgery (Impact Factor: 8.33). 09/1989; 210(2):127-38. DOI: 10.1097/00000658-198908000-00001
Source: PubMed

ABSTRACT During the past decade the results of slightly fewer than 1000 resections of liver metastases from colorectal carcinoma have been analyzed, retrospectively reanalyzed, and reviewed. The following are confirmed conclusions: major liver resection can be performed safely (less than a 5% operative mortality rate); 20% to 25% of these patients are cured; no other regional therapy options have any curative potential. The following caveats are also obvious: most patients who are operated on are not cured; although predictors have been proposed to select patients most likely to benefit from surgery, none is discriminating in and of itself; most therapy questions in this group of patients have not been addressed in any formal way; surgery for isolated regionally recurrent colon and rectum carcinoma remains an important stopgap only until effective systemic therapy is discovered. This review of our own and other single and multi-institutional prospective and retrospective data will be framed by the following questions. (1) Does resection of liver metastases cure patients or simply select those who would have survived in the long-term without any therapy? (2) In the absence of any formalized, properly designed trial, how can one judge the benefit of resection? (3) Why do metastases recur only in the liver? (4) What new therapies should focus on the predominant secondary failure sites in the majority of patients who do not benefit from hepatic metastasis resection?

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    • "In this setting, targeted local therapies have procured significant long-term survival. Systematic reviews of the resection of hepatic metastases showed a 5 year survival of 25e30% [4] [5]. Similarly, a multinational registry of 5206 patients undergoing surgical resection of lung metastases showed a 5 year survival rate of 36%, with the median survival being 35 months [6]. "
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    ABSTRACT: To compare outcomes of single-fraction and multi-fraction stereotactic ablative body radiotherapy (SABR) for pulmonary metastases. A retrospective review from two academic institutions of patients with one to three pulmonary metastases staged with (18)F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) scans. For single-fraction SABR, 26Gy was prescribed for peripheral targets and 18Gy for central targets. In the multi-fraction cohort, 48Gy/4 or 50Gy/5 was prescribed for peripheral targets and 50Gy/5 was prescribed for central targets. Three-dimensional conformal radiotherapy (3D-CRT), intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT) plans were delivered using heterogeneity corrections. Conformity indices at an intermediate dose (R50%) and at a high dose (R100%) were used to assess a relationship with the planning target volume (PTV). Overall survival, local and distant progression and toxicity rates were analysed from the date of treatment completion. Between February 2010 and June 2013, 65 patients with 85 pulmonary metastases were reviewed. The median follow-up was 2.1 years. Metastases most commonly originated from colorectal cancer (31%), followed by non-small cell lung cancer (25%). 3D-CRT was used in 52 targets, IMRT in 21 and VMAT in 12. 3D-CRT showed a lower median R50% (P = 0.01), but a higher median R100% than IMRT/VMAT (P = 0.04). The R50% index was inversely correlated to the PTV with all techniques (P = 0.01). Overall survival at 1 and 2 years in all patients was 93% (95% confidence interval 87-100%) and 71% (95% confidence interval 58-86%), respectively. The 2 year freedom from local and distant progression was 93% (95% confidence interval 86-100%) and 38% (95% confidence interval 27-55%), respectively. There were no significant differences between overall survival (P = 0 .14), time to distant progression (P = 0.06) or toxicity rates (P = 0.75) between single- and multi-fraction cohorts. We report comparable local control, overall survival and toxicity rates between single-fraction and multi-fraction SABR treatments in patients with FDG-PET-staged pulmonary oligometastases. We propose a guideline for R50% conformity incorporating 3D-CRT/IMRT/VMAT techniques with heterogeneity corrected planning algorithms. Copyright © 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
    Clinical Oncology 02/2015; 27(6). DOI:10.1016/j.clon.2015.01.004 · 2.83 Impact Factor
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    • "Rectal cancer is the fourth most commonly diagnosed malignancy in the United States, with approximately onethird of all colorectal malignancies arising in the rectum, considered as the last 15 cm of the large bowel. Of the 150,000 new cases of colorectal cancer (CRC) diagnosed in the United States every year, about 50% develop hepatic metastases during the course of their disease, with 20–25% of these presenting with synchronous liver metastases [1] [2] [3]. This is even more important if we consider that in about a onethird of the patients with synchronous or metachronous liver metastases, the liver is the only site of metastatic disease, meaning that around 15,000 patients per year are candidates for therapy of these lesions [4]. "
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    ABSTRACT: In the last few decades there have been significant changes in the approach to rectal cancer management. A multimodality approach and advanced surgical techniques have led to an expansion of the treatment of metastatic disease, with improved survival. Hepatic metastases are present at one point or another in about 50% of patients with colorectal cancer, with surgical resection being the only chance for cure. As the use of multimodality treatment has allowed the tackling of more complicated cases, one of the main questions that remain unanswered is the management of patients with synchronous rectal cancer and hepatic metastatic lesions. The question is one of priority, with all possible options being explored. Specifically, these include the simultaneous rectal cancer and hepatic metastases resection, the rectal cancer followed by chemotherapy and then by the liver resection, and finally the "liver-first" option. This paper will review the three treatment options and attempt to dissect the indications for each. In addition, the role of laparoscopy in the synchronous resection of rectal cancer and hepatic metastases will be reviewed in order to identify future trends.
    06/2012; 2012:196908. DOI:10.1155/2012/196908
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    • "En 2010, 40 000 nouveaux cas de cancer colorectal ont été diagnostiqués en France, responsables de 17 400 décès. On peut estimer que la moitié des patients atteints de cancer colorectal développent des métastases hépatiques au cours de leur maladie [1]. Elles sont synchrones dans 15 à 25 % des cas [2] et métachrones dans 25 à 40 % des cas [3]. "
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    ABSTRACT: Half of patients with colorectal cancer have liver metastasis during their illness. Surgical resection of metastases represents the only curative treatment with prolonged survival in more than 50 % of patients. The aim of liver resection is complete excision of the lesions with histological negative margins while preserving sufficient functional liver parenchyma. In patients with diffuse liver disease, the radiofrequency ablation of metastases may be associated with surgical resection. The use of portal vein remobilization and neoadjuvant chemotherapy can also increase the number of patients for curative treatment. Despite this progress, from 50 to 60 % of patients relapse after complete resection of MHCCR. Surgical treatment of recurrent aggressive and effective chemotherapy allows the prolonged survival of these patients. The modern treatment of liver metastasis of colorectal cancers can be envisaged as part of a multidisciplinary approach to increase the number of patients for curative treatment.
    La Presse Médicale 12/2011; 41(1):58-67. · 1.17 Impact Factor
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