Metastatic recurrence after complete resection of colorectal liver metastases: impact of surgery and chemotherapy on survival

Abstract

PurposeSurgery is the standard of care for resectable colorectal liver metastases (CRC-LM). Unfortunately, 60 % of patients develop secondary metastatic recurrence (SMR) after R0-resection of CRC-LM. We investigated the impact of surgical re-intervention and chemotherapy (Ctx) on survival in a consecutive series of patients with SMR.MethodsFrom 01/2001 to 11/2011, 104 out of 178 consecutive patients with R0-resection of CRC-LM developed SMR and were evaluated. The impact of surgical and Ctx re-interventions on recurrence free (RFS) and cancer-specific survival (CSS) was analyzed. Median follow-up was 28.0 (95 %CI: 19.4–37.4) months.ResultsSMR occurred in 81 patients at a single site (49× liver, 18× lung, 14× other) and in 23 patients at multiple sites. Forty-two patients were scheduled for primary surgery. Fifty-three patients were classified as non-resectable and treated with median 5.0 [IQR, 3.0–10.0] cycles of Ctx, combined with an EGFR/VEGF-antibody in 27 patients. Nine patients received best supportive care only. R0/R1 resection could be achieved in 35 patients primarily and even in 8 patients secondarily after Ctx. Surgical morbidity and mortality were 16 and 0 %, respectively. The 5-year RFS rates for patients with R0 versus R1-resection were 22 and 24 % (p = 0.948). The 5-year CSS rate for R0/R1-resected patients was 38 % versus 10 % for those patients treated by Ctx alone (p < 0.001).ConclusionIn SMR, surgical re-intervention is feasible and safe in a remarkable number of patients and offers significantly longer CSS compared to patients without resection.

Pathological factors and prognosis of resected liver metastases of colorectal carcinoma: implications and proposal for a pathological reporting protocol

“…Improvement of chemotherapy regimens was one of the pillars of increased resectability in CRLMs . The concept of ‘perioperative chemotherapy’ has become a reality in CRLM management, and many regimens have been adopted, most of them based on 5‐fluorouracil plus leucovorin associated with oxaliplatin or irinotecan, bevacizumab, cetuximab (for KRAS wild‐type tumours), and others . Preoperative chemotherapy is increasingly being used, especially among patients with advanced CRLMs, allowing tumours that were considered initially unresectable to be downsized allowing further surgery …”

“…8 The concept of 'perioperative chemotherapy' has become a reality in CRLM management, and many regimens have been adopted, most of them based on 5-fluorouracil plus leucovorin associated with oxaliplatin or irinotecan, bevacizumab, cetuximab (for KRAS wildtype tumours), and others. 8,11,30,[86][87][88][89] Preoperative chemotherapy is increasingly being used, especially among patients with advanced CRLMs, allowing tumours that were considered initially unresectable to be downsized allowing further surgery. 30,43 Five different methods for measuring tumour cell viability are available, all of which attempt to correlate pathological response with prognosis after liver resection.…”

“…Decision‐making regarding resection is based on improvements in imaging modalities, such as: hepatobiliary‐phase magnetic resonance imaging, leading to a better sensitivity of metastasis detection; and positron emission tomography with computed tomography, which adds value in the initial staging for detection of extrahepatic disease, and may improve survival by changing the target patients for surgery . However, approximately 60–76% of patients who undergo an R0 resection will develop recurrence, despite advances in staging, adjuvant therapy, and surgical approaches …”

“…10 However, approximately 60-76% of patients who undergo an R0 resection will develop recurrence, despite advances in staging, adjuvant therapy, and surgical approaches. 4,6,11 For a better understanding of the prognostic factors that determine recurrence, histopathological features have been identified in the primary tumour, such as pTNM staging, vascular invasion, lymphatic invasion, perineural invasion, tumour grade, tumour deposits, tumour budding, tumour border configuration, tumour perforation, histological type, and inflammatory infiltration. 12,13 Pathologists routinely report these criteria for the primary tumour, in order to guide oncologists in the decision-making regarding adjuvant systemic therapy.…”

Repeat liver surgery by laparoscopy for a malignant recurrence after previous open or laparoscopic resection

“…Recurrence rate for liver malignancy is estimated at 77-100% for HCC [12,13] and 60% for metastasis from colorectal carcinoma. [14] Nevertheless, current data report efficacy of repeat hepatectomies in the treatment of primary or secondary tumors of the liver. [1][2][3][4][5] At present, studies on laparoscopic hepatic re-interventions are limited.…”