Prognostic scores for colorectal liver metastasis: clinically important or an academic exercise?

Objectives:

Over the last decade, various groups have proposed prognostic scoring systems for patients with colorectal liver metastasis (CLM) treated with hepatic resection. The aims of the current study were to evaluate the differences between and clinical importance of these prognostic scoring systems and to determine their clinical applicability.

Methods:

Relevant articles were reviewed from the published literature using the MEDLINE database. The search was performed using the keywords ‘colorectal cancer’, ‘metastases’, ‘liver resection’ and ‘hepatectomy’.

Results:

Twelve prognostic scoring systems were identified from 1996 to 2009. Six of these originated from European institutions, three from Asian and three from North American centres. The median study sample was 288 patients (range 81–1568 patients) and median follow-up was 35 months (range 16–52 months). All studies were retrospective in nature and the numbers of groups proposed by the various scoring systems ranged from three to six. All the studies used the Cox proportional hazard model for multi-variable analysis.

Conclusions:

There is no ‘ideal’ prognostic scoring system for the clinical management of patients with CLM for hepatic resection. These prognostic scoring systems are clinically relevant with respect to survival but have not been used for risk stratification in controversial areas such as the administration of chemotherapy or surveillance programmes.     

What defines ‘cure’ after liver resection for colorectal metastases? Results after 10 years of follow-up

Background:

During the last two decades, resection of colorectal liver metastases (CLM) in selected patients has become the standard of care, with 5-year survival rates of 25–58%. Although a substantial number of actual 5-year survivors are reported after resection, 5-year survival rates may be inadequate to evaluate surgical outcomes because a significant number of patients experience a recurrence at some point.

Objectives:

This study aimed to analyse longterm results and prognostic factors in liver resection for CLM in patients with complete 10-year follow-up data.

Methods:

A total of 369 patients who underwent liver resection for CLM between 1985 and 1998 were identified from a bi-institutional database. Postoperative deaths and patients with extrahepatic disease were excluded. Clinicopathological prognostic factors were analysed using univariate and multivariate analyses.

Results:

The sample included 309 consecutive patients with complete 10-year follow-up data. Five- and 10-year overall survival rates were 32% and 23%, respectively. Overall, 93% of recurrences occurred within the first 5 years of follow-up, but 11% of patients who were disease-free at 5 years developed later recurrence. Multivariate analysis demonstrated four independent negative prognostic factors for survival: more than three metastases; a positive surgical margin; tumour size >5 cm, and a clinical risk score >2.

Conclusions:

Five-year survival rates are not adequate to evaluate surgical outcomes of patients with CLM. Approximately one-third of actual 5-year survivors suffer cancer-related death, whereas patients who survive 10 years appear to be cured of disease.     

Liver resection after chemotherapy and tumour downsizing in patients with initially unresectable colorectal cancer liver metastases

Objectives

Among patients with initially unresectable colorectal cancer liver metastases (CLM), a subset are rendered resectable following the administration of systemic chemotherapy. This study reports the results achieved in liver resections performed at a single hepatobiliary referral centre after downsizing chemotherapy in patients with initially unresectable CLM.

Methods

All liver resections for CLM performed over a 10-year period at the Toronto General Hospital were considered. Data on initially non-resectable patients who received systemic therapy and later underwent surgery were included for analysis.

Results

Between January 2002 and July 2012, 754 liver resections for CLM were performed. A total of 24 patients were found to meet the study inclusion criteria. Bilobar CLM were present in 23 of these 24 patients. The median number of tumours was seven (range: 2–15) and median tumour size was 7.0 cm (range: 1.0–12.8 cm) before systemic therapy. All patients received oxaliplatin-or irinotecan-based chemotherapy. Fourteen patients received combined treatment with bevacizumab. Negative margin (R0) resection was accomplished in 21 of 24 patients. There was no perioperative mortality. Ten patients suffered perioperative morbidity. Eighteen patients suffered recurrence of disease within 9 months. Rates of disease-free survival at 1, 2 and 3 years were 47.6% [95% confidence interval (CI) 30.4–74.6%], 23.8% (95% CI 11.1–51.2%) and 19.0% (95% CI 7.9–46.0%), respectively. Overall survival at 1, 2 and 3 years was 91.5% (95% CI 80.8–100%), 65.3% (95% CI 48.5–88.0%) and 55.2% (95% CI 37.7–80.7%), respectively.

Conclusions

Liver resection in initially unresectable CLM can be performed with low rates of morbidity and mortality in patients who respond to systemic chemotherapy, although these patients do experience a high frequency of disease recurrence.     

A systematic review of a liver-first approach in patients with colorectal cancer and synchronous colorectal liver metastases

Background: Since the liver metastases rather than the colorectal cancer itself is the main determinant of patient’s survival, the ‘Liver-First Approach (LFA)’ with upfront chemotherapy followed by a hepatic resection of colorectal liver metastases (CLM) and finally a colorectal cancer resection was proposed. The aim of this review was to analyse the evidence for LFA in patients with colorectal cancer and synchronous CLM.Methods: A literature search of databases (MEDLINE and EMBASE) to identify published studies of LFA in patients with colorectal cancer and synchronous CLM was undertaken focussing on the peri-operative regimens of LFA and survival outcomes.Results: Three observational studies and one retrospective cohort study were included for review. A total of 121 patients with colorectal cancer and synchronous CLM were selected for LFA. Pre-operative chemotherapy was used in 99% of patients. One hundred and twelve of the initial 121 patients (93%) underwent a hepatic resection of CLM. In total, 60% had a major liver resection and the R0 resection rate was 93%. Post-operative morbidity and mortality after the hepatic resection were 20% and 1%, respectively. Ultimately, 89 of the initial 121 (74%) patients underwent a colorectal cancer resection. Post-operative morbidity and mortality after a colorectal resection were 50% and 6%, respectively. The median overall survival was 40 months (range 19–50) with a recurrence rate of 52%.Conclusions: Current evidence suggests that LFA is safe and feasible in selected patients with colorectal cancer and synchronous CLM. Future studies are required to further define patient selection criteria for LFA and the exact role of LFA in the management of synchronous CLM.     

A systematic review of two-stage hepatectomy in patients with initially unresectable colorectal liver metastases

Objectives

Selected patients with unresectable colorectal liver metastases (CLM) may be rendered resectable using the two-stage hepatectomy (TSH) approach. This review was conducted with the aim of collating and evaluating published evidence for TSH in patients with initially unresectable CLM.

Methods

Searches of the MEDLINE and EMBASE databases were undertaken to identify studies of TSH in patients with initially unresectable CLM. Studies were required to focus on the perioperative treatment regimen, operative strategy, morbidity, technical success and survival outcomes.

Results

Ten observational studies were reviewed. A total of 459 patients with initially unresectable CLM were selected for the first stage of TSH. Preoperative chemotherapy was used in 88% of patients and achieved partial and stable response rates of 59% and 39%, respectively. Postoperative morbidity and mortality after the first stage of TSH were 17% and 0.5%, respectively. Portal vein embolization (PVE) was used in 76% of patients. Ultimately, 352 of the initial 459 (77%) patients underwent the second stage of TSH. Major liver resection was undertaken in 84% of patients; the negative margin (R0) resection rate was 75%. Postoperative morbidity and mortality after the second stage of TSH were 40% and 3%, respectively. Median overall survival was 37 months (range: 24–44 months) in patients who completed both stages of TSH. In patients who did not complete both stages of TSH, median survival was 16 months (range: 10–29 months). The 3-year disease-free survival rate was 20% (range: 6–27%).

Conclusions

Two-stage hepatectomy is safe and effective in selected patients with initially unresectable CLM. Further studies are required to better define patient selection criteria for TSH and the exact roles of PVE and preoperative and interval chemotherapy.     

Tumour biology of colorectal liver metastasis is a more important factor in survival than surgical margin clearance in the era of modern chemotherapy regimens

Background

The aim of the authors was to reassess the impact of a positive surgical margin (R1) after a liver resection for colorectal liver metastases (CLMs) on survival in the era of modern chemotherapy, through their own experience and a literature review.

Methods

Inclusion criteria were: R1 or R0 resection with no local treatment modalities, extra-hepatic metastases or other cancer.

Results

Among 337 patients operated between 2000 and 2010, 273 patients were eligible (214 R0/59 R1). The mean follow-up was 43 ± 29 months. Compared with a R0 resection, a R1 resection offered a lower 5-year overall (39.1% versus 54.2%, P = 0.010), disease-free (15.2% versus 31.1%, P = 0.021) and progression-free (i.e. time to the first non-curable recurrence; 33.1% versus 47.3%, P = 0.033) survival rates. Metastases in the R1 group were more numerous, larger and more frequently synchronous. Independent factors of poor survival were: number, size and short-time interval of CLM occurrence, N status, rectal primary, absence of adjuvant chemotherapy, but not a R1 resection. With the more-systematic administration of chemotherapy since 2005, the intergroup difference in progression-free survival disappeared (P = 0.264).

Conclusion

A R1 resection had no prognostic value per se but reflected a more severe disease. The recent change in the prognostic value of a R1 resection may be linked to the beneficial effect of chemotherapy.     

Complications following liver resection for colorectal metastases do not impact on longterm outcome

Background

It has been suggested that adverse postoperative outcomes may have a negative impact on longterm survival in patients with colorectal liver metastases.

Objectives

This study was conducted to evaluate the prognostic impact of postoperative complications in patients submitted to a potentially curative resection of colorectal liver metastases.

Methods

A retrospective analysis of outcomes in 199 patients submitted to hepatic resection with curative intent for metastatic colorectal cancer during 1999–2008 was conducted.

Results

The overall complication rate was 38% (n = 75). Of all complications, 79% were minor (Grades I or II). There were five deaths (3%). The median length of follow-up was 39 months. Rates of 5-year overall and disease-free survival were 44% and 27%, respectively. Univariate analysis demonstrated that an elevated preoperative level of carcinoembryonic antigen (CEA), intraoperative blood loss of >300 ml, multiple metastases, large (≥35 mm) metastases and resection margins of <1 mm were associated with poor overall and disease-free survival. In addition, male sex and synchronous metastases were associated with poor disease-free survival. Postoperative complications did not have an impact on either survival measure. The multivariate model did not include complications as a predictive factor.

Conclusions

Postoperative complications were not found to influence overall or disease-free survival in the present series. The number and size of liver metastases were confirmed as significant prognostic factors.     

Hepatic resection for non-colorectal, non-neuroendocrine, non-sarcoma metastasis: a single-centre experience

Background

The aim of the present study was to analyse the outcome after hepatic resection for non-colorectal, non-neuroendocrine, non-sarcomatous (NCNNNS) metastatic tumours and to identify the factors predicting survival.

Methods

All patients who underwent hepatic resection for NCNNNS metastatic tumours between September 1996 and June 2009 were included. Patients'' demographics, clinical and histopathological parameters, overall survival and the factors predicting survival were analysed.

Results

In all, 65 patients underwent hepatic resection for metastasis. The most common site of a primary tumour was the kidney (24 patients). Fifteen patients had synchronous tumours. Fifty patients had major liver resections and 22 patients had bilobar disease. The median number of liver lesions resected was 1 and the median maximum diameter of the metastasis was 6 cm. A R0 resection was performed in 51 patients. The 1-, 3- and 5-year overall survival from the time of metastasectomy was 72.9%, 47.9% and 25.6%, respectively, with a median survival of 19 months. The presence of a tumour of greater than 6 cm (P = 0.048) and a positive resection margin (P = 0.04) were associated with poor survival.

Conclusion

Hepatic resection for metastasis from NCNNNS tumours can offer acceptable long-term survival in selected patients. To offer a chance of a cure a R0 resection must be performed.     

Prognostic significance of early recurrence: a conditional survival analysis in patients with resected colorectal liver metastasis

Background

For patients undergoing liver resection for colorectal metastases, specific clinico-pathological variables have been shown to be prognostic at baseline. This study analyses how the prognostic capability of these variables changes in a conditional survival model.

Methods

Retrospective review of a prospectively maintained database of patients who underwent an R0 resection of colorectal liver metastases from 1994 to 2004 at a single institution.

Results

In total, 807 patients were identified, with an 87-month median follow-up for survivors. Five- and 10-year disease-specific survivals (DSS) were 68% and 55%, respectively. The probability of further survival increased as the survival time increased. For 3-year survivors (n = 504), DSS were no longer significantly different between patients with a low (0–2) or high (3–5) clinical risk score (CRS, P = 0.19). On multivariate analysis, independent predictors of DSS for 3-year survivors were recurrence within the first 3 years after a liver resection, a pre-operative carcinoembryonic antigen (CEA) >200 ng/ml and disease-free interval <12 months prior to the diagnosis of liver metastasis. However, for those patients who were recurrence free at 1 year, no clinico-pathological variables retained prognostic significance.

Discussion

After 3 years of DSS and 1 year of recurrence-free survival, baseline clinico-pathological variables have a limited ability to predict future survival. Early post-operative recurrence appears to be the most useful single clinical feature in estimating conditional DSS.     

Descriptive analysis of and overall survival after surgical treatment of lung metastases

OBJECTIVE:

To describe demographic characteristics, surgical results, postoperative complications, and overall survival rates in surgically treated patients with lung metastases.

METHODS:

This was a retrospective analysis of 119 patients who underwent a total of 154 lung metastasis resections between 1997 and 2011.

RESULTS:

Among the 119 patients, 68 (57.1%) were male and 108 (90.8%) were White. The median age was 52 years (range, 15-75 years). In this sample, 63 patients (52.9%) presented with comorbidities, the most common being systemic arterial hypertension (69.8%) and diabetes (19.0%). Primary colorectal tumors (47.9%) and musculoskeletal tumors (21.8%) were the main sites of origin of the metastases. Approximately 24% of the patients underwent more than one resection of the lesions, and 71% had adjuvant treatment prior to metastasectomy. The rate of lung metastasis recurrence was 19.3%, and the median disease-free interval was 23 months. The main surgical access used was thoracotomy (78%), and the most common approach was wedge resection with segmentectomy (51%). The rate of postoperative complications was 22%, and perioperative mortality was 1.9%. The overall survival rates at 12, 36, 60, and 120 months were 96%, 77%, 56%, and 39%, respectively. A Cox analysis confirmed that complications within the first 30 postoperative days were associated with poor prognosis (hazard ratio = 1.81; 95% CI: 1.09-3.06; p = 0.02).

CONCLUSIONS:

Surgical treatment of lung metastases is safe and effective, with good overall survival, especially in patients with fewer metastases.     

Systematic review of pathophysiological changes following hepatic resection

Objectives

Major hepatic resection is now performed frequently and with relative safety, but is accompanied by significant pathophysiological changes. The aim of this review is to describe these changes along with interventions that may help reduce the risk for adverse outcomes after major hepatic resection.

Methods

The MEDLINE, EMBASE and CENTRAL databases were searched for relevant literature published from January 2000 to December 2011. Broad subject headings were ‘hepatectomy/’, ‘liver function/’, ‘liver failure/’ and ‘physiology/’.

Results

Predictable changes in blood biochemistry and coagulation occur following major hepatic resection and alterations from the expected path indicate a complicated course. Susceptibility to sepsis, functional renal impairment, and altered energy metabolism are important sequelae of post-resection liver failure.

Conclusions

The pathophysiology of post-resection liver failure is difficult to reverse and thus strategies aimed at prevention are key to reducing morbidity and mortality after liver surgery.     

Outcomes in patients with indeterminate pulmonary nodules undergoing resection for colorectal liver metastases

Objectives

This study aimed to assess outcomes in patients who underwent hepatic resection for colorectal liver metastases (CRLM) with subcentimetre indeterminate pulmonary nodules (IPN) and to devise a management pathway for these patients.

Methods

Patients undergoing CRLM resection from January 2006 to December 2010 were included. Survival differences following liver resection in patients with and without IPN were determined.

Results

A total of 184 patients were included, 30 of whom had IPN. There were no significant differences between the IPN and non-IPN groups in terms of demographics, surgery and pathological factors. There were no significant differences between patients with and without IPN with respect to disease-free (P = 0.190) and overall (P = 0.710) survival. Fifteen patients with IPN progressed to metastatic lung disease over a median period of 10 months (range: 3–18 months); six of these patients underwent lung resection. Of the remaining 15 patients with IPN, eight showed no IPN progression and subsequent CT scans did not identify IPN in the remaining seven.

Conclusions

Colorectal liver metastases patients with IPN who have resectable disease should be treated with liver resection and should be subject to intensive surveillance post-resection. Although 50% of these patients will progress to develop lung metastases, this does not appear to influence survival following liver resection.     

Using a ‘no drain’ policy in 342 laparoscopic hepatectomies: which factors predict failure?

Objectives

The aim of this study was to identify factors that predict the failure of a ‘no drain’ policy in laparoscopic hepatectomy.

Methods

Surgical outcomes in 342 consecutive patients undergoing laparoscopic hepatectomy were reviewed. Drains were placed only for the following predefined criteria: (i) intraoperative bile leak; (ii) bilioenteric anastomosis, and (iii) increased risk for postoperative bleeding (‘no drain’ policy). Factors leading to need for postoperative drainage or reoperation were evaluated.

Results

Drains were placed in 44 patients (drainage group). Postoperatively, additional procedures were required in five (11.4%) patients in the drainage group and in 18 (6.0%) patients in the no-drainage group. Multivariate analysis suggested that blood loss of >400 ml [odds ratio (OR) 4.50, 95% confidence interval (CI) 1.41–14.2; P = 0.010] and preoperative chemotherapy (OR = 2.24, 95% CI 0.82–6.48; P = 0.120) may increase the risk for need for postoperative procedures when intraoperative prophylactic drainage is not used.

Conclusions

Prophylactic drainage during liver resection should be considered not only in the presence of uncontrollable bile leak or concern for postoperative bleeding risk, but also in patients who have undergone neoadjuvant chemotherapy and those in whom intraoperative blood loss is >400 ml. Otherwise, a ‘no drain’ policy is safe and would enhance the advantages of minimally invasive liver surgery.     

Socioeconomic status influences the likelihood but not the outcome of liver resection for colorectal liver metastasis

Background

The aim of this study was to compare the socioeconomic profile of patients undergoing liver resection for colorectal liver metastasis (CLM) in a regional hepatopancreatobiliary unit with that of the local population. A further aim was to determine if degree of deprivation is associated with tumour recurrence after resection.

Methods

A retrospective analysis of patients undergoing liver resection for CLM was performed. Geodemographic segmentation was used to divide the population into five categories of socioeconomic status (SES).

Results

During a 7-year period, 303 patients underwent resection for CLM. The proportion of these patients in the two least deprived categories of SES was greater than that of the local population (50.2% versus 40.2%) and the proportion in the two most deprived categories was lower (18.3% versus 30.1%) (P < 0.001). There was no difference in recurrence rate (P = 0.867) or disease-free survival among categories of SES (P = 0.913). Multivariate analysis demonstrated no association between SES and tumour recurrence (P = 0.700).

Conclusions

Liver resection for CLM is performed more commonly among the least socioeconomically deprived population than among the most deprived. However, degree of deprivation was not associated with tumour recurrence after resection.     

Outcomes of extended versus limited indications for patients undergoing a liver resection for colorectal cancer liver metastases

Background

Currently, resection criteria for colorectal cancer liver metastases (CRCLM) are only limited by remnant liver function. Morbidity and survival after a partial hepatectomy with limited or extended indication criteria were compared.

Methods/Design

Between 1991 and 2010, patients undergoing a liver resection for CRCLM with limited (n = 169) or extended indication criteria (n = 129) were retrospectively identified in a prospectively collected single-centre database. Limited indication criteria were defined as less than three unilateral, not centrally located liver metastases in the absence of extra hepatic metastases. The extended criteria were only limited by predicted remnant liver volume and patients fitness. Data on co-morbidity, resection margin, short- and long-term morbidity, disease-free (DFS) and overall survival were compared.

Results

Patients with limited indications had less major complications (19.5% vs. 33.1%, P < 0.01), longer overall survival of 68.8 months [confidence interval (CI) 46.5–91.1] vs. 41.4 months (CI 33.4–49.0, P ≤ 0.001) and longer median DFS of 22.0 months [confidence interval (CI) 15.8–28.2] vs 10.2 months (CI 8.4–11.9, P < 0.001) compared with the extended indication group. Cure rates, defined as 10-year DFS, were 35.5% and 15.8%, respectively. Fewer patients in the extended indication group underwent an R0 resection (92.9% vs. 77.5%, P < 0.001). Only 17% of all R1 resected patients had recurrences at the transection plane.

Conclusion

A partial hepatectomy for CRCLM with extended indications seems justified but is associated with higher complication rates, earlier recurrence and lower overall survival compared with limited indications. However, the median 5-year survival was substantial and a cure was achieved in 15.8% of patients.     

Prognostic factors for resection of isolated pulmonary metastases in breast cancer patients: a systematic review and meta-analysis

Background

Lung is a common organ of metastases in patients with primary breast cancer. Pulmonary metastasis of primary breast cancer is usually considered as a systemic disease, however, the systemic approaches have achieved little progress in terms of prolonging survival time. In contrast, some studies revealed a probable survival benefit of pulmonary metastasectomy for such patients. However, the prognostic factor for pulmonary metastasectomy in breast cancer patients is still a controversial issue. The aim of this study was to conduct a systematic review and meta-analysis of cohort studies to assess the pooled 5-year overall survival (OS) rate and the prognostic factors for pulmonary metastasectomy from breast cancer.

Methods

An electronic search in MEDLINE (via PubMed), EMBASE (via OVID), CENTRAL (via Cochrane Library), and Chinese BioMedical Literature Database (CBM) complemented by manual searches in article references were conducted to identify eligible studies. All cohort studies in which survival and/or prognostic factors for pulmonary metastasectomy from breast cancer were reported were included in the analysis. We calculated the pooled 5-year survival rates, identified the prognostic factors for OS and combined the hazard ratios (HRs) of the identified prognostic factors.

Results

Sixteen studies with a total of 1937 patients were included in this meta-analysis. The pooled 5-year survival rates after pulmonary metastasectomy was 46% [95% confidence interval (95% CI): 43-49%]. The poor prognostic factors were disease-free interval (DFI) (<3 years) with HR =1.70 (95% CI: 1.37-2.10), resection of metastases (incomplete) with HR =2.06 (95% CI: 1.63-2.62), No. of pulmonary metastases (>1) with HR =1.31 (95% CI: 1.13-1.50) and the hormone receptor status of metastases (negative) with HR =2.30 (95% CI: 1.43-3.70).

Conclusions

Surgery with a relatively high 5-year OS rate after pulmonary metastasectomy (46%), may be a promising treatment for pulmonary metastases in the breast cancer patients with a good performance status and limited disease. The main poor prognostic factors were DFI (<3 years), resection of metastases (incomplete), No. of pulmonary metastasis (>1) and hormone receptor status of metastases (negative). And prospective randomized trials will be needed to address these issues in the future.     

Clinicopathological analysis and prognosis of extrahepatic bile duct cancer with a microscopic positive ductal margin

Background

The fate of a microscopic positive ductal margin (MPDM) of extrahepatic bile duct (EHBD) cancer is unclear. The purpose of this study was to analyse the clinicopathological features of EHBD cancer with MPDM and to identify the prognostic factors associated with survival.

Methods

Between 1995 and 2007, a retrospective analysis of 464 patients who had undergone surgical resection for EHBD cancer was conducted. Clinicopathological factors likely to influence survival were assessed using univariate and multivariate analysis.

Results

One hundred twenty-four patients had MPDM which included invasive carcinoma (IC) (n =85) and carcinoma in situ (CIS)/ high-grade dysplasia (HGD) (n = 39). The median survival (MS) of R0, R1 as CIS/ HGD, and R1 as IC were 41 months, 29 months, and 18 months, respectively. Adverse prognostic factors were ‘IC’ on the resection margin [HR = 1.66, 95% confidence intervals (CIs) 1.06–2.59, P = 0.026], and no use of adjuvant chemoradiotherapy (HR = 1.57, 95% CIs 1.04–2.39, P = 0.033). Adjuvant chemoradiotherapy was beneficial in patients with MPDM as IC (5-year survival rate 19.7 compared with 2.8%, P = 0.011).

Conclusions

The presence of MPDM is an important prognostic factor in EHBD cancer. When a ductal resection margin is positive, discrimination between ‘IC’ and ‘CIS/ HGD’ is important.     

The effect of hepatic steatosis on survival following resection of colorectal liver metastases in patients without preoperative chemotherapy

Background Hepatic steatosis, a common condition associated with insulin resistance and excess body weight, is reported to be associated with an increased risk for perioperative mortality in patients undergoing resection of colorectal liver metastases (CLM), but its impact upon longterm survival is less well documented.Methods The effects of background liver pathology, categorized as ‘normal’, ‘with steatosis’ and ‘other’, on perioperative mortality, overall survival (OS) and cancer-specific survival (CSS) were assessed in patients undergoing resection for CLM according to data maintained in the LiverMetSurvey database. As preoperative chemotherapy may confound the effects of steatosis, patients who had been given preoperative chemotherapy were excluded. Survival analyses included log-rank tests for comparisons, and multivariate Cox models, including well-established prognosticators.Results Of 5853 patients who underwent first-time liver resection without preoperative chemotherapy, 1793 (30.6%) had background steatosis. Rates of 90-day perioperative mortality in patients with normal, steatosis and other pathologies were 2.8%, 2.1% and 4.9%, respectively. Steatosis was associated with improved 5-year OS (47.4% versus 43.0%; log rank, P = 0.0017) and CSS (56.1% versus 50.3%; P = 0.002) compared with normal background liver. After adjustments, the survival advantage associated with steatosis remained (hazard ratio = 0.806, 95% confidence interval 0.717–0.905 for CSS).Discussion The paradoxical survival advantage observed in patients with steatosis undergoing liver resection for CLM generates a hypothesis that peri-diagnosis of excess body adiposity has a survival protective effect that warrants further research.     

Staged hepatectomy for bilobar colorectal hepatic metastases

Objectives

This study describes the management of patients with bilobar colorectal liver metastases (CRLM).

Methods

A retrospective collection of data on all patients with CRLM who were considered for staged resection (n = 85) from January 2003 to January 2011 was performed. Patients who underwent one hepatic resection were considered to have had a failed staged resection (FSR), whereas those who underwent a second or third hepatic resection to produce a cure were considered to have had a successful staged resection (SSR). Survival was calculated from the date of diagnosis of liver metastases. Complete follow-up and dates of death were obtained from the Government of Quebec population database.

Results

Median survival was 46 months (range: 30–62 months) in the SSR group and 22 months (range: 19–29 months) in the FSR group. Rates of 5-year survival were 42% and 4% in the SSR and FSR groups, respectively. Fifteen of the 19 patients who remained alive at the last follow-up date belonged to the SSR group.

Conclusions

In patients in whom staged resection for bilobar CRLM is feasible, surgery would appear to offer benefit.