Short-Term Outcomes after Combined Colon and Liver Resection for Synchronous Colon Cancer Liver Metastases: A Population Study
Department of Surgery, University of Minnesota, Minneapolis, MN, USA, . Annals of Surgical Oncology
(Impact Factor: 3.93).
07/2012; 20(1). DOI: 10.1245/s10434-012-2515-z
The timing of surgical resection for stage IV colon cancer with liver metastasis and the safety of simultaneous colon and liver resection remains controversial. The purpose of our study was to evaluate short-term outcomes after combined colon and liver resection (CCLR) versus colon resection (CR) or liver resection alone (LR) using a population database.
The National Inpatient Sample was used to select patients who had surgery for colon cancer from 2002 to 2006. We evaluated for in-hospital morbidity, mortality, and prolonged length of stay (PLOS). Our analysis was done using design-weighted unadjusted analysis and logistic regression.
We identified 361,096 patients during our study period (CCLR 3,625; CR 322,286; LR 35,185). CCLR was not associated with an increased risk of complications (odds ratio (OR) 1.12; 95% confidence interval (CI) 0.94-1.33; P=0.21) or PLOS (OR 1.19; 95% CI 0.99-1.4; P=0.06) compared with CR. In-hospital mortality occurred in 3.5% of patients who underwent CCLR and was not significantly associated with mortality compared with CR alone (OR 1.17; 95% CI 0.79-1.74; P=0.43). Liver lobectomy with CR was associated with a PLOS and a trend toward increased morbidity and mortality. Significant predictors of complications, mortality, and PLOS included: age>70 years, male gender, nonprivate health insurance, and Elixhauser score>1.
CCLR with limited liver resection can be performed with similar morbidity and mortality to colectomy alone. For patients who require hepatic lobectomy, however, strong consideration should be given to a staged approach.
Available from: Pingping Xu
- "Other large studies, including meta-analyses , , , , have also shown that simultaneous resections are not associated with increased rates of hepatic or colon complications compared with delayed resection. Finally, as demonstrated by some large studies and meta-analyses examining the timing of hepatectomy for patients with SCRLMs, long-term OS and DFS are similar between the simultaneous and delayed resection groups , , . In our study, the median overall survival was 49 months, the 5-year OS rate was 46%, and the 5-year DFS was 35%. "
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It remains unclear which patients can benefit from simultaneous resection of synchronous colorectal liver metastases (SCRLMs). This study aimed to examine the prognostic value of patient- and tumor-related factors in predicting long-term outcomes of patients undergoing simultaneous resection of SCRLMs and to help patients select a suitable therapeutic regimen and proper surveillance.
Clinicopathological and outcome data of 154 consecutive SCRLM patients who underwent simultaneous resection between July 2003 and July 2013 were collected from our prospectively established SCRLM data and analyzed with univariate and multivariate methods, and the prognostic index (PI) was formulated based on the regression coefficients (β) of the Cox model. The patients were classified into high- and low-risk groups according to the PI value; the cut-off point was the third quartile.
The 5-year overall survival rate was 46%, and the 5-year disease-free survival rate was 35%. Five factors were found to be independent predictors of poor overall survival (OS) by multivariate analysis: positive lymph node status, vascular invasion, BRAF mutation, the distribution of bilobar liver metastases (LMs) and non-R0 resection of LMs. Compared to low PI (≤5.978), high PI (>5.978) was highly predictive of shorter OS. Three factors were found to be independent predictors of poor disease-free survival (DFS) by multivariate analysis: tumor deposits, BRAF mutation and bilobar LM distribution. We also determined the PI for DFS. Compared to low PI (≤2.945), high PI (>2.945) was highly predictive of shorter DFS.
Simultaneous resection of SCRLM may lead to various long-term outcomes. Patients with low PI have longer OS and DFS, while those with high PI have shorter OS and DFS. Thus, patients with high PI may receive more aggressive treatment and intensive surveillance, This model needs further validation.
Available from: Hui-Fang Liang
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ABSTRACT: Transforming growth factor β (TGF-β)/Smad signaling is involved in colorectal carcinoma (CRC) development and progression. The frequent loss of SMAD4 is associated with liver metastasis and poor prognosis of CRC, but the underlying mechanism remains elusive. This study aimed to elucidate the role of Smad independent TGF-β signaling in CRC metastasis. Immunohistochemistry showed that Smad4 level was negatively correlated with TNM stage and phospho-ERK level in human CRCs and liver metastasis samples. Knockdown of Smad4 in CT26 and HCT116 cells activated ERK pathway, altered the expression of MMP2 and COX-2, promoted cell motility, migration and invasion in vitro, enhanced metastasis and shortened the survival of metastatic tumor-bearing mice. MEK inhibitor U0126 and GSK1120212 inhibited the motility, migration and invasion of Smad4 knockdown cells, inhibited metastasis and prolonged the survival of metastatic tumor-bearing mice. Furthermore, MEK inhibitor could reverse the changes of phospho-ERK, MMP2 and COX-2 levels. In conclusion, our results indicate that ERK pathway plays a key oncogenic role in CRC with SMAD4 inactivation mutations, and implicate ERK as a potential therapeutic target for CRC liver metastasis.
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ABSTRACT: It remains unclear whether primary colorectal cancer and synchronous liver metastases (SLMs) should be resected simultaneously or with a staged procedure.
We reviewed the short-term outcomes of 127 patients who underwent simultaneous resection of primary colorectal cancer and SLM at our institution from January 1993 to December 2011.
The proportion of simultaneous resections was 84.7% (127 of 150 patients). There was no postoperative mortality, and the postoperative complication rate was 61.4%. Major complications occurred in 23 (18.2%) patients, and anastomotic failure occurred in 2 (1.6%). The 3-, 5-, and 10-year overall survival rates were 74%, 64%, and 52%, respectively. The median recurrence-free survival period was 7.0 months (95% confidence interval, 4.5-9.5 months) and the 5-year recurrence-free survival rate was 17%.
Simultaneous resection can be performed safely in patients with colorectal cancer and SLM.
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