One-Stage Surgery for Patients with Colorectal Cancer Presenting with Liver Metastases

Abstract & Commentary

Synopsis: Approximately 20% of patients with colorectal cancer will have hepatic metastases at the time of original presentation. Partial hepatectomy has become increasingly used in the treatment of liver metastases, but the timing of this procedure for those who present with liver involvement remains an unsettled question. The current single-institution experience would suggest that for selected patients, a simultaneous, one-stage procedure offers a safe and effective treatment strategy.

Source: Tanaka K, et al. Surgery. 2004;136:650-659.

There has been increasing enthusiasm for a surgical approach to hepatic metastases from colorectal primary cancers. However, consensus has not been reached concerning the timing of hepatectomy in patients who at initial presentation are found to have liver involvement. Tanaka and colleagues from Yokohama City University Graduate School of Medicine retrospectively obtained data for 39 consecutive patients with synchronous colorectal cancer hepatic metastases who underwent curative-intent, simultaneous (one-stage) hepatectomy and resection of the colorectal primary. These patients were among 91 who presented to their institution with hepatic metastases and primary colorectal cancer during a 12-year period (1992-2003). Simultaneous resections were performed in those (of the 91) with a relatively small number of liver neoplasms considered to be completely removed by a relatively simple hepatectomy procedure, and were made on a patient-by-patient basis. Liver resection was considered contraindicated at the time of primary operation in 50 patients for the following reasons: poor performance status (4 patients), massive neoplasm (2 patients), unfavorably located neoplasm (2 patients), multicentricity (6 patients) and multiple, bilobar liver metastases (36 patients). Of the 41 who underwent simultaneous resection, 2 were excluded from analysis because of concomitant extrahepatic metastases, which could not be resected completely.

The data on the 39 patients who underwent simultaneous primary and hepatic metastases resection with curative intention were reviewed using both univariate and multivariate analyses with regard to success and safety outcomes.

Regarding safety, no patient died within 60 days of the operation. However, 11 patients (28%) had postoperative complications. Of several clinicopathologic factors, including age, primary site, TNM stage, histology of primary neoplasm, extent and number of liver nodules, maximum liver neoplasm size, resected liver volume, hepatectomy procedure used, duration of operation and intraoperative blood loss, only resected liver volume was significantly different between the groups with or without complications. The mean liver volume removed from those that were to develop postoperative complications was 350 grams (range, 80-870 grams) compared to 150g (range, 20-370 grams) from those that did not develop complications (P < .05).

Overall survival at 1, 3, and 5 years after simultaneous resection of colorectal cancer and hepatic metastases were 86%, 68% and 53% respectively. During follow-up, 28 patients (72%) developed recurrence (liver only, 16; liver plus extrahepatic, 4; extrahepatic only, 8). Disease-free survival rates at 1, 3, and 5 years were 64%, 20%, and 16%, respectively.

By univariate analysis, a number of potential variables on survival were examined, but only histological features of the primary neoplasm (P < 0.01) and age (P < 0.05) were identified as significant prognostic determinants. Survival was better in patients with well-to-moderately differentiated primary adenocarcinoma, and in younger patients (younger than 70 years of age). To identify independent prognostic determinants multivariate regression analysis using a proportional hazard method involving a Cox model was performed. This analysis indicated that the only independent factor adversely affecting survival was the histology of the primary neoplasm (specifically, poorly differentiated adenocarcinoma or mucinous carcinoma vs other types).

Comment by William B. Ershler, MD

Hepatic metastases are found in 15%-20% of patients undergoing an operation for colorectal cancer.1 New and more precise imaging techniques coupled with methods of hepatectomy have improved the outlook for patients with metastatic disease. Although there may be theoretical reasons for waiting and possibly performing two procedures for patients who present with metastatic disease, simultaneous resection would clearly be preferable from a patient’s perspective if safety and outcome data were comparable. Some researchers2,3 believe that the survival benefit from hepatic resection is determined by biological features of the neoplasm, rather than by early detection. Particularly for synchronous hepatic metastases, several investigators2-4 have recommended interval (ie, delayed) hepatic resection to assess the biological behavior of the metastatic disease. Scheele et al3 demonstrated poor prognosis in patients with synchronous metastases, attributing some of the poor outcome to failure to resect micrometastatic hepatic lesions in patients who underwent resection of the overt liver metastases as part of the primary procedure. This and similar reports have led to a policy in which resection of the primary neoplasm and of liver tissue known to contain metastases are to be separated by 3 to 6 months. Theoretically this period of time would allow those occult micrometastases to become evident. However, other surgical teams have demonstrated no decrement in 5-year survival when patients underwent a one-stage combined procedure.5,6

The current report adds useful perspective to this dialogue. It would seem that the outcome for selected patients may be at least as good with simultaneous resection of primary and hepatic lesions. Included would be those younger patients with more favorable histology and whose involvement in the liver would require a relatively small resection. These criteria, however, would restrict simultaneous resection to less than 50% of patients who present initially with liver metastases.

William B. Ershler, MD, INOVA Fairfax Hospital Cancer Center, Fairfax, VA, Director, Institute for Advanced Studies in Aging, Washington, DC, is Editor of Clinical Oncology Alert.

References

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2. Cady B, Stone MD. Semin Oncol. 1991;18:399-406.

3. Scheele J. Br J Surg. 1993;80:274-276.

4. Labert LA, et al. Arch Surg. 2000;135:473-480.

5. Vogt P, et al. World J Surg. 1991;15:62-67.

6. Delva E, et al. Ann Surg. 1989;209:211-218.