Tumor biology reflected by histological growth pattern is more important than surgical margin for the prognosis of patients undergoing resection of colorectal liver metastases (original) (raw)
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World Journal of Surgery, 2013
Background The purpose of the present study was to assess the prognostic impact of positive surgical margins (R1) after liver resection (LR) of colorectal liver metastases (CRLM) in the era of modern chemotherapy regimens. R1 resection is a negative prognostic factor after LR of CRLM. The significance of R1 margins in the era of effective chemotherapy is unknown. Methods From January 2000 to December 2009, 215 patients (177 men: 62 %; median age 60 years; range 30-84 years) underwent LR of CRLM. The LR was considered R1 (margin \1 mm) in 49 patients (23 %) and R0 in 166 patients (77 %). Overall, 108 (50 %) patients received preoperative chemotherapy and 156 (72 %) patients received postoperative chemotherapy. Results With a median follow-up of 36 months (range 1-141 months), the 5-year overall survival (OS) rate (47 vs 40 %; p = 0.05) and the disease-free survival (DFS) rate (36 vs 23 %; p = 0.006) were significantly lower in the R1 group. Recurrence developed in 152 patients (71 %) and the rate of recurrence was significantly higher (84 vs 67 %; p = 0.02) in the R1 group. On multivariate analysis, N? status of the colorectal primary tumor (p = 0.008), presence of radiologically occult disease (p = 0.04), and R1 resection (p = 0.03) were independent adverse predictors of OS. The N? status of the primary tumor (p = 0.003) and R1 resection (p = 0.02) were independent adverse predictors of DFS. On multivariate analysis use of postoperative chemotherapy was the only independent predictor of improved DFS (p = 0.02) in the R1 group. Conclusions A positive resection margin remains a significant poor prognostic factor after LR of CRLM in the era of modern chemotherapy. Postoperative chemotherapy reduces recurrence rates after R1 resection of CRLM.
HPB, 2010
To determine the outcome of colorectal liver metastasis (CRLM) patients based on tumour burden, represented by tumour number and size, and tumour biology as assessed by an inflammatory response to tumour (IRT) and margin positivity. Methods: Data were collated from CRLM patients undergoing resection from January 1993 to March 2007. Patients were divided into: low (Յ3 metastases and/or Յ3 cm); moderate (4-7 metastases and/or >3-Յ5 cm); and high (Ն8 metastases and/or >5 cm) tumour burden. Results: Seven hundred and five patients underwent resection, of which 154 (21.8%), 262 (37.2%) and 289 (41.0%) patients were in the low, moderate and high tumour burden groups, respectively. The 5-year disease-free (P < 0.001) and overall (P < 0.001) survival were significantly different between the groups. IRT (P < 0.001), extent of resection (P < 0.001) and margin (P < 0.001) also differed between the groups.Sub-group analysis revealed that IRT was the only adverse predictor for disease-free and overall survival in the low group. In the moderate group, IRT predicted poorer disease-free survival on multivariate analysis. In the high group, R1 resection and transfusion were predictors of poorer disease-free survival and age Ն65 years, R1 resection and IRT were adverse predictors of overall survival. Conclusion: Resection margin influenced the outcome of patients with high tumour burden, hence the importance of achieving clear margins. IRT influenced the outcome of patients with less aggressive disease.
Introduction: Colorectal cancer liver metastasis (CRCLM) remains a lethal diagnosis with an overall 5-year survival rate of 5–10%. Two distinct histopathological growth patterns (HGPs) of CRCLM are known to have significantly differing rates of patients survival, and response to treatment. We set out to review the results of 275 patients who underwent liver resection for CRCLM at the McGill University Health Center (MUHC) and analyze their clinical outcome, mutational burden and pattern of cancer progression in light of their HGP’s, and to consider their potential effect on surgical decision making. Methods We performed a retrospective multivariate analysis on clinical data from patients with CRCLM (n = 275) who underwent liver resection at the McGill University Health Center (MUHC). All tumors were scored using international consensus guidelines by pathologists trained in HGP scoring. Results 109 patients (42.2%) were classified as desmoplastic and angiogenic whereas 149 patients (...
Resection Margin and Recurrence-Free Survival After Liver Resection of Colorectal Metastases
Annals of Surgical Oncology, 2010
Background. Optimal margin width is uncertain because of conflicting results from recent studies using overall survival as the end-point. After recurrence, re-resection and aggressive chemotherapy heavily affect survival time; the potential confounding effect of such factors has not been investigated. Use of recurrence-free survival (RFS) may overcome this limitation. The aim of this study is to evaluate the impact of width of resection margin on RFS and site of recurrence after hepatic resection for colorectal metastases (CRM). Methods. From a prospectively maintained institutional database (1/1999-12/2007) we identified 314 patients undergone hepatectomy for CRM (1/1999-12/2007) with detailed pathologic analysis of the surgical margin and complete follow-up imaging studies documenting disease status and site of recurrence, which was categorized as: resection margin (M arg ), other intra-hepatic ( other IH), lung (L) or other extra-hepatic ( other EH). Recurrence-free estimation was the survival end-point. Results. Median follow-up was 56.5 months. Two hundred and fifteen patients (68.8%) recurred at 288 sites after a mean of 15.5 months. A positive resection margin was associated with an increased risk of M arg recurrence (P \ 0.001). The presence of C2 metastases was the only factor increasing the risk of positive margins (P \ 0.05). The width of the negative resection margin (C1 cm versus [1 cm) was not a prognostic factor of worse RFS (30.2% versus 37.3%, P = 0.6). Node status of the primary tumour, and size and number of CRM were independent predictors of RFS. Conclusions. Tumour biology and not the width of the negative resection margin affect RFS.
Annals of Surgical Oncology, 2013
Introduction. Outcome after hepatic resection for colorectal cancer liver metastases (CRLM) is heterogeneous and accurate predictors of survival are lacking. This study analyzes the prognostic relevance of pathologic details of the primary colorectal tumor in patients undergoing hepatic resection for CRLM. Methods. Retrospective review of a prospective database identified patients who underwent resection for CRLM. Clinicopathological variables were investigated and their association with outcome was analyzed. Results. From 1997-2007, 1,004 patients underwent hepatic resection for CRLM. The median follow-up was 59 months with a 5-year survival of 47 %. Univariate analysis identified nine factors associated with poor survival; three of these related to the primary tumor: lymphovascular invasion (LVI, p \ 0.0001), perineural invasion (p = 0.005), and degree of regional lymph node involvement (N0 vs. N1 vs. N2, p \ 0.0001). Multivariate analysis identified seven factors associated with poor survival, two of which related to the primary tumor: LVI (hazard ratio (HR) 1.3, 95 % confidence interval (CI) 1.06-1.64, p = 0.01) and degree of regional lymph node involvement [N1 (HR 1.3, 95 % CI 1.04-1.69, p = 0.02) vs. N2 (HR 1.7, 95 % CI 1.27-2.21, p \ 0.0005)]. A significant decrease in survival along the spectrum of patients ranging from LVI negative/N0 to LVI positive/N2 was present. Patients who were LVI-positive/N2 had a median survival of 40 months compared with 74 months for patients who were LVI-negative/NO (p \ 0.0001).
Surgery, 2008
Background. Hepatectomy for colorectal liver metastases (CRLM) may offer good long-term survival. The impact of the tumor-free surgical margin on long-term results remains controversial, and we have assessed this component in 185 patients. Methods. Between 1992 and 2005, 185 patients underwent primary hepatectomy with curative intent for CRLM (which originated from colon/rectum 133/52, synchronous/metachronous 66/119, and single/multiple 100/85). In this study, 105 major and 80 minor hepatectomies were evaluated; 133 hepatectomies had pedicle clamping. Results. Operative mortality was 1.1%, morbidity was 25.7%, and blood transfusion requirement was 27.6%. Stratification of tumor-free margin in the patients with R0 liver resection was greater than or equal to 10 mm (63.0% of patients), 6--9 mm (11.4% of patients), 3--5 mm (16.5% of patients), and less than or equal to 2 mm (9.1% of patients), with infiltrated margin in the remainder (R1 liver resection 4.9% of the total number of patients). The 3-year, 5-year, and 10-year survival rates were 54.9%, 37.9%, and 22.9%, respectively. Global and surgical margin recurrence rates increased as the tumor-free margin decreased (P = .01 and P < .001, respectively). At univariate analysis, the width of surgical margin (P < .001), transfusion requirement, major hepatectomy, R1 resection, number of metastases, high preoperative CEA, and increasing tumor size (P value from .001 to .03) were associated with lesser rates of long-term survival. A similar association was found with disease-free survival. At multivariate analysis, width of surgical margin was the only independent predictor of both overall (P = .003) and disease-free (P < .001) survival. Although smaller margins were associated with synchronicity, increasing number of, and with bilobar distribution of, metastases which contributed to explaine recurrences away from the margin), the width of surgical margin maintained the prominent impact on outcome. Conclusions. In our patients, the width of the surgical margin was a powerful prognostic factor after hepatectomy for CRLM. A resection margin less than or equal to 5 mm was associated with a greater risk of recurrence on the surgical margin, with a lesser rate of overall and disease-free survival. (Surgery
Surgery, Gastroenterology and Oncology, 2018
Background: Liver resection for colorectal liver metastasis (CRLM) represents a valid therapeutic option. It can offer a chance of good long-term survival, with a 5 year survival of 25-40%. Recent studies have shown that achieving a minimum of 1 cm surgical margin is not essential for long-term survival, and a microscopic free liver resection margin can be sufficient. The aim of this study is to evaluate the impact of the resection margin on recurrence, disease free survival and the overall survival. Materials and Method: All the primary liver resections with curative intention for CRLM at our surgical division between 2000 and 2010 were retrospectively reviewed. The liver resection margins were stratified according to their width. The positive and negative prognostic factors were analyzed in a univariate analysis. Results: A total of 130 patients met the study inclusion criteria. Twenty-four patients underwent major hepatectomies, while 106 patients underwent minor hepatectomies. On statistical analysis, surgical margin width (p=0.045), advanced age (p<0.001), metachronous metastasis (p=0.018) and multiple tumours (p=0.019) were associated with lower long-term survival rates. In addition, advanced age (p=0.0004), rectal tumour (p=0.004), metachronous metastases (p=0.026), multiple tumours (p=0.017), lower width in surgical margin (p=0.002) were linked to a reduced disease-free survival. Conclusion: Our study confirms that the extent of the resection margin is a powerful factor influencing prognosis after hepatectomy for CRLM. According to our experience, resection margin width is significantly associated with a higher risk of intra and extra-hepatic recurrence and less disease-free survival. However, the impossibility of achieving a resection margin greater than or equal to 10 mm should not be considered as a contraindication to surgery.
Hpb, 2021
Background: The aim of this study was to investigate the influence of resection margin status in patients with KRAS mutations (mt-KRAS) when compared to those with wild-type KRAS (wt-KRAS) on long-term outcomes in patients with resected CRLM. Methods: All patients who underwent resection of CRLM with curative intent between January 2011 and December 2016 and had a KRAS type recorded were included in the study. Overall survival (OS), as well as death-censored overall (RFS) and liver-specific (LS-RFS) recurrence-free survival between KRAS types and the margin status within KRAS subgroups were compared using Cox regression models. Results: Data were available for N = 500 patients (30.4% mt-KRAS). mt-KRAS status was independently associated with significantly shorter OS. Within the wt-KRAS subgroup, smaller margins were found to be associated with significantly shorter death-censored LS-RFS (p < 0.001), with HRs of 1.93 (p = 0.005) for 1-4 mm margins and 2.83 (p < 0.001) for <1 mm margins, relative to those with clear margins. No such association was observed in the mt-KRAS subgroup (p = 0.721). Conclusion: The resection margin status is of greater importance in patients with wt-KRAS. Such information could be useful in the operative planning, especially for those with multiple metastatic deposits, and also in the post-operative counselling and surveillance based on the margin and KRAS status.
The Issue of Survival After Colorectal Liver Metastasis Surgery: Parenchyma Sparing vs. Radicality
Anticancer Research, 2018
Background/Aim: Nowadays, obtaining optimal surgical margin of the resected metastasis and the parenchyma-sparing surgical technique are a great challenge for hepatic surgeons. The aim of this follow-up study was to investigate the prognostic value of the surgical margin and the parenchyma-sparing liver resection technique. Patients and Methods: We performed a retrospective analysis of the data of 319 patients [123 (36.6%) female and 196 (61.4%) male] who had colorectal cancer and underwent surgery to treat colorectal liver metastases in our Department between 2005 and 2014. Results: The most commonly used resection type was the non-anatomic resection (43%). Multivariate analysis indicated that there was no significant difference in survival (p=0.473) between the microscopically-negative (R0) and microscopically-positive (R1) resections, as well as between the resection types (p=0.257). Conclusion: Parenchymalsparing non-anatomic resection and spray diathermy on the resection surface of the liver should be applied not only for hemostasis, but also to destroy the area containing possible tumor cells after an R1 resection and not to have worse survival outcomes. According to the latest WHO data, the worldwide incidence of colorectal cancer (CRC) is over 1.4 million. With approximately 447,000 newly-diagnosed cases per year, CRC is the most common gastrointestinal malignancy in Europe (1, 2). According to the Global Burden of Cancer Study (GLOBOCAN), CRC was found to be the third most frequently occurring cancer type and the third most common cause of cancer related deaths in Europe (3).