Two-stage resection for bilobar colorectal liver metastases: R0 resection is the key.

Department of Surgery and Cancer, Imperial College, Hammersmith Hospital Campus, London, UK.
Annals of Surgical Oncology (Impact Factor: 3.94). 02/2011; 18(7):1939-46. DOI: 10.1245/s10434-010-1533-y
Source: PubMed

ABSTRACT Two-stage liver resection (2-SLR) is used clinically in conjunction with portal vein embolization for bilobar disease to increase the number of patients suitable for liver resection. The long-term outcomes after 2-SLR for multiple bilobar colorectal liver metastases (CLM) was examined.
Patients who sought care between November 2003 and April 2006 with multiple CLM considered suitable for 2-SLR were prospectively followed. Clinicopathological data were collected. Surgical outcomes were defined as complete clearance of tumor (R0/R1/R2), postoperative morbidity (within 3 months), 30 day mortality, disease-free survival (DFS), and overall survival (OS).
A total of 131 patients with CLM underwent liver resection during the study period, 38 of whom were planned for a 2-SLR for multiple bilobar disease. Only 33 (87%) completed the 2-SLR with a curative intent. Five patients did not undergo stage II resection because of disease progression. The postoperative morbidity was 11 and 33% after stage I and stage II liver resections, respectively. Five patients (13%) encountered postoperative complications specific to liver surgery. The median interval from stage II resection to disease recurrence in the R0 group was 18 months versus 3 months in the R1/R2 group (P < 0.001). R0 resection with curative intent versus R1/R2 noncurative resection has a significantly longer period of DFS (P < 0.001) and OS (P = 0.04).
The 2-SLR combined with portal vein embolization is an effective and safe method for resecting previously unresectable multiple bilobar CLM. However, a positive resection margin leads to poor DFS and OS.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Background To evaluate the feasibility and long-term results of two-stage hepatectomy (TSH) in patients with bilobar colorectal liver metastases (CRLM). Study Design Retrospective multicenter study including 4 Italian hepatobiliary surgery units. One hundred-thirty patients were selected for TSH between 2002 and 2011. Primary endpoint was feasibility of TSH and the analysis of factors associated with failure to complete the procedure. Secondary endpoint was the long-term survival analysis. Results Patients presented with synchronous CRLM in 80.8% of cases, with a mean number of 8.3 CRLM and with concomitant extrahepatic disease in 20.0% of cases. The rate of failure to complete TSH was 21.5% and tumor progression was the most frequent reason of failure (18.5% of cases). Primary tumor characteristics, type, number and distribution of CRLM were not associated with significantly different risk of disease progression. The multivariable logistic regression analysis showed that tumor progression during pre-hepatectomy chemotherapy was the only independent risk factor for failure to complete TSH. The 5- and 10-year overall survival rates for patients who completed TSH were 32.1% and 24.1% with a median survival of 43 months. Duration of pre-hepatectomy chemotherapy ≥6 cycles was found to be the only independent predictor of overall and disease-free survival. Conclusions This study showed that selection of patients by response to pre-hepatectomy chemotherapy may be extremely important before planning TSH, because tumor progression while receiving pre-hepatectomy chemotherapy was associated with significantly higher risk of failure to complete the second stage. For patients who completed the TSH strategy, long-term outcome can be achieved with results similar to those observed following a single-stage hepatectomy.
    Journal of the American College of Surgeons 08/2014; · 4.45 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Up to a quarter of patients with rectal cancer have synchronous liver metastases at the time of diagnosis. This is a predictor of poor outcome. There are no standardized guidelines for treatment. We reviewed the outcomes of our patients with synchronous rectal liver metastases treated with a curative intent by neo-adjuvant chemotherapy with or without chemoradiotherapy followed by resection of primary tumor and then liver metastases. Between 2004 and 2012, patients who presented with rectal cancer and synchronous liver metastasis were treated with curative intent with perioperative systemic chemotherapy as the 1(st) line of treatment. Responders to chemotherapy underwent resection of the primary tumor with or without preoperative chemoradiotherapy (CRT) followed by hepatic resection. Fifty-three rectal cancer patients with 152 synchronous liver lesions were identified. After a median follow-up of 29.6 months, the median survival was 41.4 months. Overall survival (OS) was 59.0% at 3 years and 39.0% at 5 years. Rectal resection before hepatic resection, combined with neoadjuvant chemotherapy is associated with promising clinical outcome. It allows down-staging of liver lesions and removal of the primary tumor before the progression of further micrometastases. Furthermore, patients that do not respond to chemotherapy can be identified and may avoid major surgical intervention. This article is protected by copyright. All rights reserved.
    Colorectal Disease 12/2013; · 2.02 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Colorectal cancer (CRC) is a major health concern in the United States (US) with over 140,000 new cases diagnosed in 2012. The most common site for CRC metastases is the liver. Hepatic resection is the treatment of choice for colorectal liver metastases (CLM), with a 5-year survival rate ranging from 35% to 58%. Unfortunately, only about 20% of patients are eligible for resection. There are a number of options for extending resection to more advanced patients including systemic chemotherapy, portal vein embolization (PVE), two stage hepatectomy, ablation and hepatic artery infusion (HAI). There are few phase III trials comparing these treatment modalities, and choosing the right treatment is patient dependent. Treating hepatic metastases requires a multidisciplinary approach and knowledge of all treatment options as there continues to be advances in management of CLM. If a patient can undergo a treatment modality in order to increase their potential for future resection this should be the primary goal. If the patient is still deemed unresectable then treatments that lengthen disease-free and overall-survival should be pursued. These include chemotherapy, ablation, HAI, chemoembolization, radioembolization (RE) and stereotactic radiotherapy.
    Journal of gastrointestinal oncology 10/2014; 5(5):374-387.