The lack of selection criteria for surgery in patients with non-colorectal non-neuroendocrine liver metastases

Abstract

Background: The benefit of surgery in patients with non-colorectal non-neuroendocrine liver metastases (NCRNNELM) remains controversial. At the population level, several statistical prognostic factors and scores have been proposed but inconsistently verified. At the patient level, no selection criteria have been demonstrated to guide individual therapeutic decision making. We aimed to evaluate potential individual selection criteria to predict the benefit of surgery in patients undergoing treatment for NCRNNELM.Methods: Data for 114 patients undergoing surgery for NCRNNELM were reviewed. In this population, we identified an early relapse group (ER), defined as patients with unresectable recurrence <1 year postoperatively who did not benefit from surgery (N=28), and a long-term survival group (LTS), defined as patients who were recurrence-free ≥5-years postoperatively and benefited from surgery (N=20). Clinicopathologic parameters, the Association Française de Chirurgie (AFC) score, and a modified 4-point Clinical Risk Score (mCRS) (excluding CEA level) were analyzed and compared between LTS and ER groups.Results: The majority of patients were female and a majority had an ASA score ≤2 at the time of liver surgery. Median age was 55 years. Almost half of the patients (46%) presented with a single liver metastasis. Intermediate- and low-risk AFC scores represented 40% and 60% of the population, respectively. Five- and ten-year overall survival (OS) and disease-free survival (DFS) rates were 56% and 27%, and 30% and 12%, respectively. Negative prognostic factors were size of liver metastases >50 mm and delay between primary and NCRNNELM <24 months for OS and DFS, respectively. AFC score was not prognostic while high-risk mCRS (score 3-4) was predictive for poorer OS. The clinicopathologic parameters were similar in the ER and LTS groups, except the presence of N+ primary tumor and the size of liver metastases were significantly higher in the ER group. Conclusion: In patients with resectable NCRNNELM, no predictive factors or scores were found to accurately preoperatively differentiate individual cases in whom surgery would be futile from those in whom surgery could be associated with a significant oncological benefit.

Surgical treatment of liver metastases from non-colorectal non-neuroendocrine carcinomas

“…Multiple liver metastases were the third factor having a negative impact on 5-year survival. In our study, 41% of patients had solitary liver metastases; in the literature, the percentage varies between 46 and 62% (Bohlok et al 2020;Hoffmann et al 2015;Lendoire et al 2007;Sano et al 2018;Takemura et al 2013;Yedibela et al 2005).…”

“…A short interval between diagnosis of the primary tumor and liver metastases also resulted independently in poorer 5-year survival. We saw in 65% of patients a tumor free interval of less than 24 months, others saw 50% or 51% (Bohlok et al 2020;Holzner et al 2018;Slotta et al 2014).…”

“…These differences are mainly due to case mix in the studies. Patients with breast cancer were included in 5% (Sano et al (2018) to 61% (Bohlok et al (2020), but most studies do not provide detailed information on tumor sites. Some studies combine primaries of ovary, kidney, urinary bladder, ureter, testis, and prostate to "genitourinary cancer" (Bohlok et al 2020;Lendoire et al 2007;Schiergens et al 2016;Takemura et al 2013;Yedibela et al 2005).…”

Development and validation of prognostic nomograms for patients with colon neuroendocrine neoplasms

“…Patients have a slightly better prognosis if they do not have metastatic disease, if they have an adenocarcinoma component within the tumor, or if they respond to chemotherapy [ 23 ]. Unlike patients with non-colorectal non-neuroendocrine liver metastases [ 24 – 26 ], surgery, especially in the presence of metastatic disease, may not provide any survival benefit for most patients [ 23 ]. Fields et al [ 27 ] demonstrated that the total number of positive lymph nodes was an independent predictor of survival in patients with colon NENs.…”

Editorial on “Uncommon indications for associating liver partition and portal vein ligation for staged hepatectomy: a systematic review”

“…Not surprisingly, as patients have shown favourable outcome after ALPPS for CRLM that other secondary malignant lesions may benefit from it as well (7). However, benefit of resecting non-colorectal secondary liver lesions at all is still under debate, and although some reports provide supportive evidence, a selection bias must be anticipated as particularly young and otherwise healthy patients are preferred for treatments outside the mainstream (8,9).…”