Peter Kornprat

PURPOSE: Resection of colorectal liver metastases (CLM) in selected patients has evolved as the standard of care during the last 20 years. In the absence of prospective randomized clinical trials, a survival benefit has been deduced relative to historical controls based on actuarial data. There is now sufficient follow-up on a significant number of patients to address the curative intent of resecting CLM. METHODS: Retrospective review of a prospectively maintained database was performed on patients who underwent resection of CLM from 1985 to 1994. Postoperative deaths were excluded. Disease-specific survival (DSS) was calculated from the time of hepatectomy using the Kaplan-Meier method. RESULTS: There were 612 consecutive patients identified with 10-year follow-up. Median DSS was 44 months. There were 102 actual 10-year survivors. Ninety-nine (97%) of the 102 were disease free at last follow-up. Only one patient experienced a disease-specific death after 10 years of survival. In contrast, 34% of the 5-year survivors suffered a cancer-related death. Previously identified poor prognostic factors found among the 102 actual 10-year survivors included 7% synchronous disease, 36% disease-free interval less than 12 months, 25% bilobar metastases, 50% node-positive primary, 39% more than one metastasis, and 35% tumor size more than 5 cm. CONCLUSION: Patients who survive 10 years appear to be cured of their disease, whereas approximately one third of actual 5-year survivors succumb to a cancer-related death. In well-selected patients, there is at least a one in six chance of cure after hepatectomy for CLM. The presence of poor prognostic factors does not preclude the possibility of long-term survival and cure.

BACKGROUND: Blood vessel invasion has been associated with poor outcome in colorectal cancer (CRC), whereas the prognostic impact of lymphatic invasion is less clear. The authors of this report evaluated venous and lymphatic invasion as potential prognostic indicators in patients with CRC focusing on lymph node-negative patients and compared routine and review pathology diagnoses. METHODS: In total, 381 tumors from randomly selected patients were retrospectively reviewed. The presence of vascular invasion was related to disease-free and cancer-specific survival using the Kaplan-Meier method. For multivariable analysis, Cox proportional hazards regression models were performed. RESULTS: Lymphatic invasion and venous invasion were observed in 126 patients (33%) and 87 patients (23%), respectively, and were associated significantly with tumor classification, lymph node status, American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) disease stage, tumor differentiation, pattern of invasion, and extent of tumor budding. The detection of vascular invasion was related to the number of examined tissue blocks. Venous and lymphatic invasion proved to be significant prognostic variables in univariable and multivariable analyses. Extramural vascular involvement was of particular significance. When the analysis was restricted to patients with (AJCC/UICC) stage II disease, venous invasion, but not lymphatic invasion, was identified as an independent prognostic variable. Review pathology diagnoses differed significantly from routine diagnoses with respect to prognostic impact. CONCLUSIONS: Venous and lymphatic invasion proved to be significant prognostic variables in patients with CRC. The detection of vascular invasion and, consequently, risk stratification of affected patients were related to the quality of pathology workup, ie, the number of examined tissue blocks. Observed differences between review and routine pathology diagnoses illustrated the need for high-quality pathology reporting and also for standardized quality control.

OBJECTIVE: The aim of this study was to determine the results of liver resection for patients with bilateral hepatic metastases from colorectal cancer. We aimed to assess the evolution of the technical approach over time and correlations with morbidity, mortality, and oncologic outcome. SUMMARY BACKGROUND DATA: Although hepatic resection for isolated colorectal metastases to the liver is thought to be beneficial when feasible, resection of bilateral liver metastases carries unique technical issues and is often associated with more aggressive tumor biology. Little has been written specifically about the results achieved in this subset of patients. METHODS: Data from a prospectively maintained database of patients undergoing hepatic resection at a single institution over an 11-year time period were reviewed. RESULTS: Resection of bilateral liver metastases from colorectal cancer was accomplished in 443 cases (440 patients) with a 29% incidence of major complications and a 5.4% 90-day mortality. Kaplan-Meier estimated 5-year disease-specific survival was 30% and 5-year recurrence-free survival was 18%. Operative technique changed over time toward a parenchymal-sparing approach as evidenced by the greater use of multiple simultaneous liver resections, wedge resections, and ablations. Similarly, there was a decrease in the use of major hepatectomies. This correlated with decreased mortality without change in disease-specific survival or liver recurrence. CONCLUSIONS: Resection of bilateral colorectal liver metastases can be accomplished with acceptable morbidity, mortality, and oncologic results. Increased use of a parenchymal-sparing approach is associated with decreased mortality without compromise in cancer-related outcome.