Follow-up and outcomes for resection of colorectal liver metastases in Edinburgh

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Abstract

Aim

The aim of this study was to assess the value of a defined follow-up protocol for patients undergoing potentially curative hepatic resection for colorectal hepatic metastases.

Methods

A standard protocol for the duration of the study consisted of clinical assessment, serum carcinoembryonic antigen (CEA) and computed tomography. Patterns of recurrence, method and timing of diagnosis and outcome were recorded.

Results

One hundred and ninety-one patients underwent potentially curative resection from 1989 to 2004 of whom 103 developed recurrence. The median (inter-quartile range) follow-up was 24.4 (6.5–42.3) months. The median (IQR) time to recurrence and overall survival was 25.0 (10 – not yet reached) and 45.2 (21–123) months, respectively. Seventeen patients (8.9%) underwent further surgery with curative intent. Fifty-five patients (57.9%) had recurrence diagnosed at routine follow-up with 71% (44/62) being diagnosed by CEA and CT. The CEA was elevated in 85.7% (72/84 patients) at the time of diagnosis of recurrence.

Conclusion

Although the detection of recurrent disease is common during follow-up after hepatic resection for colorectal metastases, few patients will be suitable for further intervention with curative intent. The exact nature of the follow-up protocol remains to be determined but if it is going to be performed it should be most intensive within the first 3 years.

Introduction

Hepatic resection for colorectal metastases offers the only chance of long-term survival. Five-year survival rates of 11–58% have been reported following resection1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 compared with a median survival of 6 months with no treatment and 20 months with chemotherapy.16, 17 Despite this increase in survival, up to 80%19, 20, 21, 22, 23 of patients who undergo hepatic resection with curative intent develop recurrent disease. Five-year disease free survival of 16–28% is reported.1, 6, 11, 13, 24 Importantly, repeat hepatic resection for recurrent disease has been shown to be both feasible and beneficial with survival rates similar to that achieved by the initial hepatic resection.9, 25 In a recent review of the literature, Metcalfe et al.26 demonstrated that although hepatic recurrence is relatively common (30%), the frequency of isolated hepatic recurrence is less commonly reported but estimated at 23%, with 9.6% of patients being suitable for repeat hepatic resection. The identification of patients suitable for re-resection of recurrent disease is therefore an important component of subsequent follow-up, yet it is not known whether earlier detection will increase resectability rates or benefit patients. However, it would allow for consideration of alternative modality therapy in those not suitable for further surgical intervention. To date, the ideal frequency and combination of investigations to select these patients have not been defined. The aim of this study was to review the value of a defined follow-up protocol for patients undergoing hepatic resection for colorectal metastases.

Section snippets

Data collection

All patients undergoing hepatic resection for colorectal hepatic metastases at the Royal Infirmary of Edinburgh from November 1989 to June 2004 were identified from a prospectively collected database and follow-up continued for a minimum of 6 months. Additional patient information was sought from pathology records. A retrospective case note review was performed to complete the data set. Survival data were updated from general practitioner records up to December 2004. Data collected included

Results

A total of 197 patients underwent hepatic resection for colorectal metastases, 6 of whom died in the immediate post-operative period leaving 191 for analysis. Eleven patients were considered for potential curative resection following neoadjuvant therapy. Characteristics of the primary colonic tumour and the treatment, pathology and CEA levels (pre- and post-hepatic resection) of the hepatic metastases are documented in Table 1.

Eleven patients have incomplete follow-up and were included until

Discussion

In the event of recurrent metastatic disease following hepatic resection for colorectal liver metastases, both palliative,16, 18, 27, 28 and curative options9, 25 may prolong survival and therefore early detection is deemed to be beneficial. For intensive follow-up regimens to be justified they must change the subsequent management and potential outcome for the patient in the event of detecting recurrent disease. A meta-analysis28 on the benefit of palliative chemotherapy in advanced colorectal

Acknowledgements

We would like to thank Mr K. Zarins, Mrs D. Thompson, Ms L. Kirkpatrick and Dr C.M. Sturgeon for their contribution to the data collection for this study.

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