==============================
Review Article
The Surgical Treatment of Hepatic Metastases in Colorectal Carcinoma
Neumann et al, 2010 -- not yet cited.
Background
Colorectal carcinoma with hepatic metastases was long considered an
incurable disease. Recent advances in surgical treatment have
substantially improved the affected patients' prognosis. At first,
surgery was only performed in patients whose hepatic tumor burden was
small (<4 nodes, <5 cm). Currently, however, the main issue is the
feasibility of curative resection of all metastases.
Conclusion
A multimodal approach to the treatment of hepatic metastases of
colorectal carcinoma has led to an increase in the number of
resections and to an improved long-term survival rate (currently more
than 40% at 5 years).
New criteria for resectability
Currently available data have led to a change in the indications for
resecting hepatic metastases of colorectal carcinoma. Previously, the
indication was based on tumor-biological and clinical
characteristics. The new criterion is the feasibility of complete
resection of both intra- and extrahepatic disease.
R0-resectable hepatic metastases, in patients without any extrahepatic
metastases, should be resected. As the determination of resectability
is becoming ever more complex, all patients with hepatic metastases of
colorectal carcinoma should be presented to an experienced
hepatobiliary surgeon before the beginning of treatment. Postoperative
hepatic function can be predicted more precisely with the aid of CT
volumetry. This technique enables prediction of the remaining volume
of hepatic tissue after surgery to within 10% of the actual value.
Metastases are considered resectable when the following criteria are met:
exclusion of a non-resectable extrahepatic tumor manifestation,
parenchymal involvement <75%,
<3 hepatic veins and <7 hepatic segments involved,
no hepatic insufficiency, no Child B or C cirrhosis,
no severe accompanying diseases.
Key Messages.
Hepatic resection is the standard treatment of resectable metastases
of colorectal carcinoma. 5 years after such procedures, 40% of
patients are still alive.
In view of the improved surgical, radiological, and oncological
treatments that are now available, all patients for whom a complete
resection is possible (even those with extrahepatic involvement)
should undergo resection.
Interdisciplinary treatment approaches can raise the percentage of
patients who are candidates for resection by approximately 10%.
==============================
Perioperative chemotherapy with FOLFOX4 and surgery versus surgery
alone for resectable liver metastases from colorectal cancer (EORTC
Intergroup trial 40983): a randomised controlled trial
Nordlinger, et al, 2008 -- cited by 45 other pubmed articles.
<= 4 nodes, apparently allows binodal.
pfs 3 yr ~40%, 5 yr ~30%
This trial was restricted to patients with four or fewer metastases to
reduce the proportion of patients that would be entered and later
found to have more metastases than were detected on imaging, some of
which would be unresectable. This restriction was not intended to
serve as a definition of unresectability, but to serve as a selection
criterion for the trial. These patients with a few metastases are
those with best prognosis after surgical resection. We believe that
the conclusions from this trial would probably also be valid for
patients at higher risk.
==============================
New Paradigm in the Management of Liver-Only Metastases From Colorectal Cancer
Donadon et al, 2007 -- cited by 2 2009 articles
Abstract
For patients with colorectal liver metastases, hepatic resection is
the treatment of choice, and the 5-year survival rate following
surgery now exceeds 50%. Timely multidisciplinary and multimodality
approaches that may include preoperative systemic chemotherapy,
preoperative portal vein embolization, extended hepatic resection, and
two-stage hepatectomy, have enabled a large proportion of patients to
undergo potentially curative treatment. The definition of
resectability has shifted from a focus on tumor characteristics, such
as tumor number and size, to determination of whether both
intrahepatic and extrahepatic disease can be completely resected and
whether such an approach is appropriate from an oncologic standpoint
for a given patient.
Table 2:Predictors of recurrence and long-term survival after resection for
colorectal liver metastases
lists 15 studies reporting 5 yr survival ranging from 23 to 58%
==============================
Five-Year Survival After Resection of Hepatic Metastases From
Colorectal Cancer in Patients Screened by Positron Emission Tomography
With F-18 Fluorodeoxyglucose (FDG-PET)
Fernandez et al, 2004 -- cited by 27 pmc articles.
Summary Background Data:
The 5-year overall survival after hepatic resection for colorectal
cancer metastases without preoperative FDG-PET has been established in
19 studies (6070 patients). The median 5-year overall survival rate in
these studies is 30% and has not improved over time. FDG-PET detects
unsuspected tumor in 25% of patients considered to have resectable
hepatic metastasis by conventional staging.
Methods:
From March 1995 to June 2002, all patients having hepatic resection
for colorectal cancer metastases had preoperative FDG-PET. A
prospective database was maintained.
Results:
One hundred patients (56 men, 44 women) were studied. Metastases were
synchronous in 52, single in 63, unilateral in 78, and <5 cm in
diameter in 60. Resections were major (>3 segments) in 75 and
resection margins were ≥1 cm in 52. Median follow up was 31 months,
with 12 actual greater than 5-year survivors. There was 1
postoperative death. The actuarial 5-year overall survival was 58%
(95% confidence interval, 46–72%). Primary tumor grade was the only
prognostic variable significantly correlated with overall survival.
Conclusions:
Screening by FDG-PET is associated with excellent postresection 5-year
overall survival for patients undergoing resection of hepatic
metastases from colorectal cancer. FDG-PET appears to define a new
cohort of patients in whom tumor grade is a very important prognostic
variable.
