Liver resection for colorectal liver metastases in older patients
Introduction
Life expectancy has increased dramatically over the last 100 years, and is now 75–77 years for men and 80–81 years for women in western society [1]. The demographics of these changes have important consequences for health care professionals in oncology. Currently, over half of all cancers are diagnosed in elderly patients, and 76% of all colorectal cancer patients are diagnosed between 65 and 85 years old [2], [3]. Although the prevalence of colorectal cancer in elderly patients is increasing, survival in this patient category has not improved accordingly. Age standardised survival rates are lower for elderly patients with colorectal cancer compared to younger ones, especially during the first year after diagnosis [2]. Elderly patients are less likely to undergo curative surgery, and less likely to be offered the option of metastasectomy when liver metastases are present [4].
Synchronous liver metastases are present in about 20% of patients found to have carcinoma of the colon and rectum [5], and metachronous liver metastases will subsequently appear in approximately 20–50% of patients [6], [7], [8], [9]. Hepatic resection is the only treatment offering long-term survival for these patients [8], [10], [11]. However, in studies reporting resection of colorectal liver metastases, only 8–20% [11], [12] of the patients are older than 70 years [13]. When balancing the benefits of surgical resection of liver metastases against the potential risks of surgery, many clinicians are still reluctant to advise in favour of surgical treatment in the elderly. Although such a minimalist approach might seem unacceptable, it is likely that concerns about postoperative morbidity and mortality in the elderly may have influenced the decision to not offer surgery to these patients.
Recent improvements in techniques of hepatic resection and anaesthetic interventions have evolved dramatically. Postoperative mortality has decreased over the past decades, and nowadays peri-operative care has improved with mortality rates varying between 0% and 11%, even for procedures combining colon resection with metastasectomy [14]. In addition, neoadjuvant chemotherapy is being used increasingly with the intention of improving disease-free survival post-liver resection, and also to bring patients with initially unresectable liver disease to potentially curative surgery. This study was therefore conducted to investigate the feasibility, short- and long-term outcomes of liver resection for colorectal liver metastases in patients over the age of 70.
Section snippets
Methods
Out of a consecutive series of 654 liver resections for colorectal metastases collected between August 1990 and April 2007 at our Unit, all patients over 70 years old were included in this study. Preoperative radiological investigations and clinical details of all patients were discussed at the hepatobiliary (HB) multidisciplinary team (MDT) meeting before proceeding to surgery data were collected prospectively, including: age, sex, site and staging of primary tumour, administration of
Results
Within the 17-year study period 181 liver resections were performed in 178 consecutive patients. The American Association of Anesthesiologists (ASA) grade was less than IV for all patients included. The median age of patients was 74 years (range 70–82 years). Patient characteristics are shown in Table 1.
Thirty-four patients (18.8%) received neoadjuvant chemotherapy prior to liver surgery. No patients received neoadjuvant chemotherapy prior to 2000, and all of those who received it thereafter
Discussion
Even with the recent advances in chemotherapy, 5-year survival in patients with colorectal liver metastases receiving only palliative chemotherapy is 0–4% and none are cured [16], [17]. The active treatment of elderly patients with metastatic colorectal cancer disease, with the intention of increasing life expectancy, presents us with a dilemma between the benefits and risks of surgery. Most studies reporting outcome after hepatic resection in the elderly deal with mixed caseloads (including a
Conflict of interest statement
No funding sources have been employed and there is no conflict of interest to be declared.
Reviewers
Professor Nicolas Demartines, Head, Department of Visceral Surgery, Centre Hospitalier Universitaire Vaudois CHUV, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland.
Nicola de Liguori Carino, M.D., Degree in Medicine and Surgery at University of Tor Vergata in Rome. Currently Surgical Senior Clinical Fellow in HPB and Transplant at St. James University Hospital, Leeds, UK.
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2020, HPBCitation Excerpt :There are conflicting accounts of the impact of age as an independent risk factor for PHLF. Many studies report no increased risk for over 70-year olds developing PHLF,5–10 despite increased mortality, and others demonstrated no risk for long term outcome11,12 on liver cancer resection, ascribing their reduced patient survival to co-morbidities in older populations. These studies did not solely consider patients having major liver resection, but also included minor resections.
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Nicola de Liguori Carino, M.D., Degree in Medicine and Surgery at University of Tor Vergata in Rome. Currently Surgical Senior Clinical Fellow in HPB and Transplant at St. James University Hospital, Leeds, UK.