Outcomes After Surgical Treatment of Colorectal Cancer Liver Metastases

doi:10.1053/j.seminoncol.2005.06.011

Seminars in Oncology

Volume 32, Supplement 9, December 2005, Pages 109-111

https://doi.org/10.1053/j.seminoncol.2005.06.011 Get rights and content

Many patients with metastatic colorectal cancer present with liver-only disease that is amenable to surgical resection. While patients with more than three or four hepatic metastases have traditionally been considered poor candidates for surgical treatment, a review of extant data shows that a sizable proportion of these patients can have long-term survival with surgical intervention. Our group performed a prospective study in 418 patients with proven liver-only disease to determine outcomes with resection alone and with resection plus radiofrequency ablation (RFA) or RFA alone in patients with unresectable disease. Overall 5-year survival was significantly greater in patients receiving resection alone, but 4-year survival rates were substantial in patients receiving resection plus RFA or RFA alone (P <.0001); survival with the latter two approaches was significantly better than that with chemotherapy alone (P = .0017). Although the presence of more than three metastases was associated with a significantly increased risk of death compared with a solitary metastasis on multivariate analysis, patients with more than three metastases had a 5-year survival rate in excess of 50%. Surgical resection and ablation should be considered as part of a multimodality therapeutic approach to both primary and secondary hepatic malignancies.

Section snippets

Candidates for Hepatic Resection

Data from the Registry of Hepatic Metastases reported in 1986 by Hughes et al¹ were instrumental in helping to define which patients are considered to be good candidates for surgical resection of liver metastases. The Registry included data on consecutive patients from 24 institutions who had undergone hepatic resection for CRC metastases. This retrospective review of 859 patients showed that hepatic resection was associated with a 5-year overall survival rate of approximately 33% and a

Surgical Treatment of Patients With Multiple Metastases

Recent studies have shown that resection in patients with four or more hepatic metastases from CRC can achieve long-term survival. For example, Minagawa et al⁵ reported that while survival was improved in patients with a solitary metastasis compared with those with multiple metastases, those with multiple distant lesions, including some patients with up to 20, still achieved 10-year survival rates in excess of 20%. Our group has examined our prospective database at The University of Texas M. D.

Conclusion

The gold standard in the treatment of CRC liver metastases remains complete resection. If complete resection cannot be performed safely with low morbidity and mortality as well as low local recurrence rates, local hepatic-tumor ablation techniques do have a role in the treatment of patients with unresectable disease. Ablation, with or without resection, appears to provide long-term survival benefit in an appreciable proportion of patients who, on the basis of having multiple metastases, would

References (7)

K.S. Hughes et al.
Resection of the liver for colorectal carcinoma metastasesA multi-institutional study of patterns of recurrence
Surgery
(1986)
B. Nordlinger et al.
Surgical resection of colorectal carcinoma metastases to the liverA prognostic scoring system to improve case selection, based on 1568 patients
Cancer
(1996)
Y. Fong et al.
Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancerAnalysis of 1001 consecutive cases
Ann Surg
(1999)

There are more references available in the full text version of this article.

Cited by (33)

Radiofrequency ablation compared to surgical resection for curative treatment of patients with colorectal liver metastases – a meta-analysis
2017, HPB
Citation Excerpt :
Three studies were additionally downgraded because they did not provide a description of how different outcomes were assessed, leaving a grade of 5 in the scale.31,36,40 One study only had a grade of 3, because it was a seminar which only showed results without mentioning in detail the methods.28 Patients treated with RFA had smaller diameter of metastases (mean difference: −0.59; 95% CI −0.79 to −0.39; P = 0.001,24,25,27,29,30,32–36,38–40,42 showed increased ASA classification (mean difference: 0.21; 95% CI 0.04–0.38; P = 0.0124,25,36), received more often neoadjuvant chemotherapy compared to patients who received resection (respectively 319/374 patients and 208/376 patients; P = 0.00224,27,29) and less often adjuvant chemotherapy (respectively 281/565 (50%) patients and 292/481 (61%) patients; P = 0.00224,32,34,38,40–42).
Hepatic resection and ablative treatments, such as RFA are available treatment options for liver tumors. Advantages and disadvantages of these treatment options in patients with colorectal liver metastases need further evaluation. The purpose of this study was to systematically evaluate the role of radiofrequency ablation (RFA) compared to surgery in the curative treatment of patients with colorectal liver metastases (CRLM).
A systematic search was performed from MEDLINE, EMBASE and the Cochrane Library for studies directly comparing RFA with resection for CRLM, after which variables were evaluated.
RFA had significantly lower complication rates (OR = 0.44, 95% CI = 0.26–0.75, P = 0.002) compared to resection. However, RFA showed a higher rate of any recurrence (OR = 1.66, 95% CI = 1.15–2.40, P = 0.007), local recurrence (OR = 9.56, 95% CI = 6.85–13.35, P = 0.001), intrahepatic recurrence (OR = 1.96, 95% CI = 1.34–2.87, P = 0.001) and extrahepatic recurrence (OR = 1.21, 95% CI = 0.90–1.63, P = 0.22). Also, 5-year disease-free survival (OR = 2.20, 95% CI = 1.28–3.79, P = 0.005) and overall survival (OR = 2.35, 95% CI = 1.49–3.69, P = 0.001) were significantly lower in patients treated with RFA.
RFA showed a significantly lower rate of complications, but also a lower survival and a higher rate of recurrence as compared to surgical resection. All the included studies were subject to possible patient selection bias and therefore randomized clinical trials are needed to accurately evaluate these treatment modalities.
Impact of peri-operative bevacizumab on survival in patients with resected colorectal liver metastases: An analysis of the LiverMetSurvey
2014, HPB
Citation Excerpt :
Colorectal liver metastases (CRLM) develop in nearly half of patients with CRC, and approximately 80–90% of these will initially be unresectable.2,3 Complete resection of hepatic metastases is curative in selected patients,4 and 5-year survival rates vary from 25% to 40% after a hepatectomy.5-7 However, up to 60% of patients develop recurrent metastases within the first 2 years after a hepatic resection.8
Peri-operative chemotherapy is recommended for the management of colorectal liver metastases (CRLM). The aim of this study was to examine the impact of peri-operative bevacizumab on survival in patients with resected CRLM.
A multicentre retrospective cohort of patients with resected CRLM was analysed from the LiverMetSurvey Registry. Patients who received peri-operative FOLFOX (group A) were compared with those who received peri-operative FOLFOX and bevacizumab (group B).
In total, 501 patients were compared (A, n = 384; B, n = 117). Group A was older (68.3 versus 62.5 years, P < 0.01), had more rectal cancers (30.7 versus 18.8%, P < 0.01) and higher carcinoembryonic antigen (CEA) levels at diagnosis (17.0 versus 9.7 ng/ml, P = 0.043). No difference was observed regarding primary tumour stage, synchronicity and the number or size of metastases. Post-operative infections were more frequent in group B (4.7% versus 12.8%, P < 0.01). Peri-operative bevacizumab had no effect on 3-year overall survival (OS) (76.4% versus 79.8%, P = 0.334), or disease-free survival (DFS) (7.4% versus 7.9%, P = 0.082). DFS was negatively associated with primary tumour node positivity (P = 0.011) and synchronicity (P = 0.041).
The addition of bevacizumab to standard peri-operative chemotherapy does not appear to be associated with improved OS or DFS in patients with resected CRLM.
Integration of neoadjuvant and adjuvant chemotherapy in patients with resectable liver metastases from colorectal cancer
2009, Cancer Treatment Reviews
Citation Excerpt :
We integrated the issue of chemotherapy timing into the design of the ongoing phase III ‘‘MIROX’’ study conducted by the GERCOR group. This study is comparing 12 courses of the FOLFOX-4 regimen to an experimental schedule composed of 6 courses of FOLFOX-7 (in which the dose of oxaliplatin reaches 130 mg/m2) followed by 6 courses of FOLFIRI. This schedule may reduce the risk of oxaliplatin-related sensory neuropathy and may increase efficacy, given that there is no cross-resistance between oxaliplatin and irinotecan.
The liver is the primary metastatic site in patients with colorectal cancer, and the only hope for a cure or prolonged survival in patients with liver metastases is provided by surgical resection. Advances obtained in non-resectable metastatic disease using new chemotherapeutic agents raise important questions about the use of neoadjuvant and adjuvant chemotherapy in patients with resectable liver metastases. Two major randomized studies have yielded positive results. First, a combined intra-arterial plus systemic fluoropyrimidine-based chemotherapy regimen demonstrated a relapse-free survival benefit when compared to systemic 5-fluorouracil–leucovorin therapy alone. This approach is still restricted to specialized centres, however, due to technical limitations and locoregional toxicities. Secondly, an EORTC trial demonstrated the superiority of peri-operative FOLFOX-4 chemotherapy in comparison to surgery alone. Oxaliplatin and irinotecan can induce substantial liver damage, especially steatohepatitis and vascular lesions, but the impact of these lesions on postoperative morbidity and survival remains unclear. Ongoing and planned trials will assess the addition of anti-angiogenic and anti-epidermal growth factor receptor agents to chemotherapy regimens.
Radiofrequency ablation of primary and metastatic liver tumors: a critical review of the literature
2008, American Journal of Surgery
Citation Excerpt :
RFA was performed for unresectable lesions. The overall complication rate from RFA plus resection was 19.8%, while overall mortality was 2.3%, falling within the range of mortality (0–3%) reported for hepatic resection alone; 2 of the 4 deaths were related to liver failure [1,27]. The local recurrence rate (8.2%) was comparable to other studies.
Surgical resection is the treatment of choice for hepatic tumors; however, for various reasons, the vast majority of patients are not operative candidates. As a result, several local ablative therapies have emerged as alternatives to resection or as adjuncts in total oncologic care. Presently, the most widely employed liver-directed treatment is radiofrequency thermal ablation.
To define the current status of radiofrequency ablation (RFA), the authors reviewed available safety and efficacy data from select studies on RFA. A MEDLINE search was performed using the keywords “tumor type” + “radiofrequency ablation” + “survival.” Only those studies containing long-term survival data on greater than 50 patients were included in this analysis.
Although RFA has been readily adopted into treatment paradigms, more rigorous trials are needed to solidify its place in the armamentarium of therapeutic strategies for hepatic malignancy.
Mid-term Outcome of Positron Emission Tomography/Computed Tomography-assisted Radiofrequency Ablation in Primary and Secondary Liver Tumours - A Single-centre Experience
2008, Clinical Oncology
Citation Excerpt :
Some studies considered local tumour ablation as an efficient approach to maintain local control, reporting similar survival times compared with surgery [5,6]. However, other investigators found survival rates to be lower than with surgery [7] and only slightly higher than after non-surgical treatment [8]. The inherent problem is the high rate of local tumour progression (LTP) after RFA.
To determine the mid-term results of percutaneous radiofrequency ablation (RFA) of malignant liver tumours when using FDG-positron emission tomography (FDG-PET)/computed tomography for tumour evaluation and follow-up.
Between January 2002 and June 2006, 55 patients (mean age 63 years) with 78 liver lesions (39 colorectal metastases, 39 hepatocellular carcinoma [HCC] nodules) were treated with RFA. All patients received PET/computed tomography before intervention. RFA was performed under computed tomography guidance with conscious sedation. Post-interventional PET/computed tomography was carried out in PET-positive patients 24 h after the ablation and was repeated at 1, 3 and 6 months and every 6 months after the intervention. PET-negative patients received contrast-enhanced computed tomography at the same time points. The rate of local tumour progression (LTP) and survival rates were assessed for the whole patient population.
The 78 lesions (mean size 2.3 cm, range 0.8–5 cm) were treated with 101 consecutive ablation procedures resulting in a technical success rate of 96%. The mean time of follow-up was 25 ± 12 months. Thirty-five of 78 tumours (45%) developed LTP. At the end of follow-up, LTP was found in 22 patients (40%), with intra- and extrahepatic recurrence in 11 patients. Twenty-two patients remained free of hepatic tumours. The 1-, 2- and 3-year survival rates were 85, 74 and 58%, respectively. Tumour entity, lesion size and localisation were significant risk factors for LTP.
Computed tomography-guided RFA of malignant liver tumours is effective, but shows a high rate of LTP. PET/computed tomography supports RFA by early identification of residual tumour or LTP.
Panomics reveals patient individuality as the major driver of colorectal cancer progression
2023, Journal of Translational Medicine

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: Dr Curley has no significant financial relationships to disclose.

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Outcomes After Surgical Treatment of Colorectal Cancer Liver Metastases

Section snippets

Candidates for Hepatic Resection

Surgical Treatment of Patients With Multiple Metastases

Conclusion

Resection of the liver for colorectal carcinoma metastasesA multi-institutional study of patterns of recurrence

Surgery

Surgical resection of colorectal carcinoma metastases to the liverA prognostic scoring system to improve case selection, based on 1568 patients

Cancer

Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancerAnalysis of 1001 consecutive cases

Ann Surg