Taking Colorectal Cancer Surgery to the Next Level: Resecting Pulmonary and Hepatic Metastases

ABSTRACT & COMMENTARY

Synopsis: In this series of 30 patients from Japan in whom primary, curative-intent surgery was followed by the development of metastases in both the liver and the lung, a surgical approach to these metastatic lesions was undertaken. Surgical morbidity was low and there were no surgical deaths. Survival was 30 months (range, 7-108 months) after metastatic disease resection and 48.5 months (range, 11-149 months) after excision of the primary colorectal tumor. These results compare favorably with other treatment modalities for metastatic colorectal cancer.

Source: Murata S, et al. Cancer 1998;83:1086-1093.

Approximately 40% of patients who undergo curative intent surgery for colorectal cancer will succumb to metastatic disease. The gradual drop in this percentage is the result of new and more aggressive surgical techniques and the aggressive use of adjuvant chemotherapy.1 However, when metastatic disease is recognized, long-term survival is uncommon, and this is especially true when the metastatic disease involves more than one site (e.g., liver and lung). In this series from the National Cancer Center Hospital in Tokyo, data from 30 patients who had undergone resection of both hepatic and pulmonary metastases from either colon (n = 15) or rectal (n = 15) cancer were evaluated.

The selection criteria for resection of hepatic and/or pulmonary metastases included original curative intent surgery (including patients who presented with hepatic metastases) and an assessment that additional resection would be well-tolerated. After original surgery, patients were followed carefully and were considered candidates when either hepatic or pulmonary (or both) metastases were recognized.

Thus, this was a series of 30 patients who were treated surgically for both hepatic and pulmonary metastases. All operations were well-tolerated and there were no surgical deaths. Median survival times were 30 months (range, 7-108 months) after resection of both hepatic and pulmonary metastases and 48.5 months (range, 11-149 months) after excision of the primary colorectal tumor. Actuarial one-, three-, and five-year survival after resection of both hepatic and pulmonary metastases was 86.7%, 49.3%, and 43.8%, respectively.

Murata and colleagues conclude that resection of metastatic disease may prove useful in prolonging the survival for selected patients with metastatic disease involving the liver and lungs.

COMMENTARY

It is difficult to find fault with Murata et al’s conclusions based upon the data presented. Granted, this was a non-randomized, descriptive report from a single institution, but it did not appear that patients were selected for any parameter that would favor optimal clinical outcomes. Thus, patients as old as 81 years were included, as were those with short disease-free intervals (< 1 year) after primary surgery. In fact, using a multivariate analysis, only two features independently influenced survival. These were the time of appearance of metastasis (patients with simultaneous liver and lung metastases fared worse than those with serial occurrences and operations) and patients with unilateral pulmonary metastases survived longer than those with bilateral disease. Of interest, age, disease-free interval, and the site of primary tumor were not significant independent factors.

This is an intriguing series. Recently, there has been increased enthusiasm for a surgical approach to hepatic metastases from previously resected colon cancers.2 Like axillary node metastases from primary breast cancers, the liver has been considered a regional site for metastatic disease and, hence, the rationale for curative intent resection. The appearance of pulmonary metastases has other biological implications, indicating the entrance of tumor cells into the systemic circulation. The survival data presented in this report compare favorably with the results observed in similarly staged patients receiving chemotherapy. Morbidity was minimal and mortality was non-existent. This, too, compares favorably with chemotherapy. In fact, in this series of 30 patients, all of whom had both hepatic and pulmonary metastases, only eight received chemotherapy. This is a fresh look at the management of metastatic disease and the results warrant further investigation.

References

1. O’Connell MJ, et al. J Clin Oncol 1998;16:295-300.

2. Goldberg RM, et al. Ann Intern Med 1998;129:27-35.