Actual 10-year survival after resection of colorectal liver Metastases defines cure
ABSTRACT Resection of colorectal liver metastases (CLM) in selected patients has evolved as the standard of care during the last 20 years. In the absence of prospective randomized clinical trials, a survival benefit has been deduced relative to historical controls based on actuarial data. There is now sufficient follow-up on a significant number of patients to address the curative intent of resecting CLM.
Retrospective review of a prospectively maintained database was performed on patients who underwent resection of CLM from 1985 to 1994. Postoperative deaths were excluded. Disease-specific survival (DSS) was calculated from the time of hepatectomy using the Kaplan-Meier method.
There were 612 consecutive patients identified with 10-year follow-up. Median DSS was 44 months. There were 102 actual 10-year survivors. Ninety-nine (97%) of the 102 were disease free at last follow-up. Only one patient experienced a disease-specific death after 10 years of survival. In contrast, 34% of the 5-year survivors suffered a cancer-related death. Previously identified poor prognostic factors found among the 102 actual 10-year survivors included 7% synchronous disease, 36% disease-free interval less than 12 months, 25% bilobar metastases, 50% node-positive primary, 39% more than one metastasis, and 35% tumor size more than 5 cm.
Patients who survive 10 years appear to be cured of their disease, whereas approximately one third of actual 5-year survivors succumb to a cancer-related death. In well-selected patients, there is at least a one in six chance of cure after hepatectomy for CLM. The presence of poor prognostic factors does not preclude the possibility of long-term survival and cure.
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ABSTRACT: Recently, the state of oligometastases has been spotlighted in the treatment strategy for metastases. Aggressive local treatment for oligometastases, including pulmonary resection, stereotactic body radiotherapy (SBRT), radiofrequency ablation, and cryoablation has been the subject of research. Among studies on the local treatment, those on SBRT more often evaluated local control as the primary outcome, and those on pulmonary metastasectomy more often evaluated overall survival as the primary outcome. Oligometastases is a disease concept that is defined by a state of limited systemic metastatic tumors for which local ablative therapy could be curative. By definition, the purpose of local treatment for oligometastases is cure, and the primary outcome to be analyzed should be disease-free survival. As systemic adjuvant therapy in addition to local treatment with complete ablation has some effect on micrometastases, in clinical research on oligometastases, the only treatment modality under evaluation should be local ablation. There are multiple discrete indications for the local treatment of metastatic lesions. The purposes of these indications are (a) the intent to cure oligometastases, (b) the intent to prolong survival as a part of multidisciplinary therapy, and (c) local control for palliative care. In order to appropriately evaluate the significance of local treatment, the outcomes should depend on the indication for treatment. The corresponding outcomes to consider are (a) disease-free survival, (b) overall survival, and (c) local control. Factorial analysis of each outcome corresponding to each indication for local therapy would yield information on each clinical presentation to help decide treatment.01/2015; 343. DOI:10.1016/j.ctrc.2015.01.001
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ABSTRACT: Background Surgical resection of colorectal liver metastases (CRLMs) is the standard of care when possible, although this strategy has not been compared with non-operative interventions in controlled trials. Although survival outcomes are clear, the cost-effectiveness of surgery is not. This study aimed to estimate the cost-effectiveness of resection for CRLMs compared with non-operative treatment (palliative care including chemotherapy).Methods Operative and non-operative cohorts were identified from a prospectively maintained database. Patients in the operative cohort had a minimum of 10 years of follow-up. A model-based cost–utility analysis was conducted to quantify the mean cost and quality-adjusted life-years (QALYs) over a lifetime time horizon. The analysis was conducted from a healthcare provider perspective (UK National Health Service) in a secondary care (hospital) setting.ResultsMedian survival was 41 and 21 months in the operative and non-operative cohorts respectively (P < 0·001). The operative strategy dominated non-operative treatments, being less costly (€22 200 versus €32 800) and more effective (4·017 versus 1·111 QALYs gained). The results of extensive sensitivity analysis showed that the operative strategy dominated non-operative treatment in every scenario.Conclusion Operative treatment of CRLMs yields greater survival than non-operative treatment, and is both more effective and less costly.British Journal of Surgery 01/2015; 102(4). DOI:10.1002/bjs.9761 · 5.21 Impact Factor
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ABSTRACT: In patients with colorectal cancer liver metastases (CRCLM), chemotherapy-induced hepatic injury is associated with increased splenic volume, thrombocytopenia, and decreased long-term survival. The current study investigates the relationship between change in splenic volume after preoperative chemotherapy and development of postoperative complications. The study group consisted of 80 patients who underwent resection of CRCLM; half received neoadjuvant chemotherapy for 6 months before resection (n = 40) and the other half did not (n = 40). The study group was compared with two control groups: a normal group composed of patients undergoing cholecystectomy for benign disease (n = 40) and a group of untreated, nonmetastatic colorectal cancer (CRC) patients (n = 40). Splenic volume was measured by CT/MRI volumetry. In the study group, the nontumoral liver was graded for steatosis and sinusoidal injury; operative and outcomes characteristics were also analyzed. Before chemotherapy, CRCLM patients had normalized spleen volumes of 3.2 ± 1.1 mL/kg, significantly higher than normal (2.5 ± 0.8 mL/kg; p < 0.001) and nonmetastatic CRC (2.6 ± 1.3 mL/kg; p < 0.05) patients, with higher splenic volume after 6 months of chemotherapy (4.2 ± 1.7 mL/kg; p < 0.01). After chemotherapy, splenic volume increase was associated with any perioperative complication (p < 0.01) and major complications (p < 0.05). Patients with ≥39% splenic volume increase (maximal chi-square test) were significantly more likely to have major complications (p < 0.01). Spleen volume changes were not correlated with change in platelet count (R(2) = 0.03; p = 0.301). In patients with CRCLM, the presence of liver metastases and chemotherapy are associated with higher splenic volume. Percent splenic volume increase after 6 months of chemotherapy can aid preoperative risk stratification, as it was an independent predictor of major postoperative complications. Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.Journal of the American College of Surgeons 12/2014; 220(3). DOI:10.1016/j.jamcollsurg.2014.12.008 · 4.45 Impact Factor