Surgical Oncology 1992; 1: 399-404

Resection of hepatic and pulmonary metastases from colorectal cancer J. W. SMITH, J. G. FORTNER* AND M. BURT Thoracic Service, and the *Gastric and Mixed Tumour Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA

Resection

of hepatic

when

patients

often

considered

retrospective underwent

incurable

1970 survival

respectively.

and

1990.

after

are offered

Ten

and

patients and

of 18 months

metastases

of effective of colorectal

possibility

for long-term

Keywords:

colon carcinoma,

(AWD)

three

patients

be considered

Surgical

Oncology

liver/pulmonary

78%

disease was

first described

[I, 21. How-

in the late 19th century

the

above

34

and

patients with

origin

criteria.

18

and 52%,

a

who

months,

respectively.

have no evidence

hepatic

for resection

of

(DOD).

In

and pulmonary

as it offers the only

1992; 1: 399-404.

metastases.

therefore Elective hepatic resection for malignant

Center

of colorectal

met

are

performed

Cancer

were

manifestation

INTRODUCTION

We

but

they

and three are dead of disease

selected

origin should

who

are 89%,

acceptance,

only.

metastases

resections

after second operation,

survival.

therapy

identified

survivals

chemotherapy,

metastases,

pulmonary

were

(NED), four are alive with disease

the absence

wide

pulmonary Sloan-Kettering

pulmonary

I-, 3- and 5-year

has gained

systemic

at Memorial

hepatic

hepatic

origin

or metachronous

patients

of both

Actuarial

With a median

and

of the

resection

between

of colorectal

synchronous

review

Median

disease

metastases

have

of

widely

metastatic

not considered

disease

a surgical problem.

true in a large percentage

and

This is

of cases. There are how-

ever a small number of patients who develop stases only to the lungs.

resection

in

has become

these patients has resulted in survival comparable

to

peutic

widely

approach

accepted

in selected

metastases

of colorectal

from

institutions

large

origin.

with

therahepatic

Numerous

have documented

series not only

resection of hepatic metastases We undertook

the present

[14-l 91. study to examine

results of patients who have undergone

with operative

mortali-

and

5%, but also efficacy

in long-

colorectal cancer.

the safety of the procedure ties of approximately

as an effective patients

Pulmonary

meta-

ever, it is only during the past IO-I 5 years that it

pulmonary

resections

for

the

both hepatic

metastases

from

term control of the disease [3-121. The

lung is the most common

site of metastases

MATERIALS

AND

METHODS

We performed

a retrospective

carcinoma

[131.

regarded

as a

Burt, MD, PhD, Memorial

Sloan-

tions for

metastatic

Kettering Cancer Center, 1275 York Avenue, New York, New

Memorial

Sloan-Kettering

Pulmonary

from colorectal

extra-abdominal

metastases

are

usually

who underwent Correspondence:

Michael

York 10021, USA. Present address: James Smith, MD, Department

both hepatic and pulmonary colon

Section of Surgical Oncology, Loma Linda University Medical Center, Loma Linda, California 92354, USA.

the

clinicopathological

or rectal Cancer

1970 and 1990. We were of Surgery,

review of the patients

Center

particularly

features

scope of hepatic and pulmonary

Presented in part at the 45th Annual Meeting of the Socien/ of

of resection, major complications,

Surgical Oncology, New York, New York, March 17, 1992.

vals and long-term

of

resec-

carcinoma interested the

resections,

in

turnours, margins

disease-free

survival. We considered

at

between

interhepatic

400

1. W Smith et al.

margins

to be negative

liver parenchyma In the

evaluation

determined

the

intestinal

of to

or

pulmonary).

interval

from

resection

time

from the

of diagnosis

as the interval

the tumour. intervals,

the

time

diagnosis

as well as location

(hepatic

1 cm of normal

beyond

disease-free

interval

resection

recurrence

if at least

was resected

initial

the

first

of the first recurrence

We also

determined

of the second

to the

recurrence,

diagnosis

as well

and resection

of

To analyse surgical

the morbidity the

wound

infections

require

Disease-free rates were

was 28.2 months

developed

metachron-

The

median

disease-free

(range

IO-48

Table 2 shows the number metastases right

in

this

disease.

had a solitary median

of the

one

of hepatic patient

were survival

obtained

rates

and

Comparisons

log-rank

[21].

Significance

analysis

and

patient

such as

drainage did

of the

had the left lobe as Seven

and three

metastatic

patients

had two.

lesions

or not

diagnosis

operation

underwent

metastasis tion

between

and

was

wedge

was

at the time

as mentioned

above.

One

in the analysis.

by resection.

The median

overall

eight patients

was 51 days (range

method

were was

Of

the

made

by

resections.

defined

as

lobectomy.

10 patients, Six

patient

interval nine

had

resecunderwent followed

for the remaining 15-l 50 days).

underwent a formal

anatomic

right

hepatic

trisegmentectomies.

The

patient

RESULTS

Table 1. Gender, age, location and Dukes’ stage of

with

bilobar

patients who underwent

hepatic

were

and

identified

pulmonary

colorectal

carcinoma

Follow-up

was available

Table

1 shows

who

resections between

Male

primary

left colon

primaries. lesion

30-73

ing of the primary

metastatic and

1 :I.

five

had rectal

Dukes’

in only

were

resected

not available.

at other

institutions

All six available

Variable

N

primaries

and these were

Male Female Location of primary Left colon Rectum Dukes‘ stage C Unknown

Table 2. Number and location of hepatic metastases

data

Dukes’ C.

Variable

N of metastases

1 2

a synchronous

in this series was found

solitary

liver

metastasis

lobe at laparotomy

for an abdomino-perineal a wedge

resection

to have

of the

tion

He underwent

of the colon and rectum

stag-

metastases

One of the patients

right

both hepatic and pulmonary

resections for adenocarcinoma

Number

Hepatic

a

six of 10

This is due to the fact that their

were

had

had a primary

colon.

available

Median

recurrence

Five patients

while

or transverse was

was

series

in this

underwent

Sex

of the patients

of the first years).

disease

1990.

and Dukes’ stage of

ratio

carcinomas

No patient

in the right

patients.

to female

of resection

(range

both

on all patients.

the sex distribution

age at the time was 50 years

for 1970

in this series, as well as location the primary.

underwent

One

a solitary

for 5 months,

underwent

Two

of

of abdomino-perineal

chemotherapy

survival

hepatic

varied.

P-c 0.05.

patients

The 6 cm

of the

quite

resection

preoperative

using the product-limit

[20].

interval

hepatic

which

not included

The

metastases

complications

atelectasis

we and

the

of Kaplan-Meier

Ten

had

had metastases

metastasis.

metastasis,

size

Only

and one patient

site of hepatic

months).

and location

series.

Eight patients

lobe only

the only

medical

did not require

and

antibiotics

major

both

Minor

which

therapy,

of

for

operations.

antibiotic

of these procedures,

incidence

complications

pulmonary

interval

patients

metastases.

(range 2-l 1 cm).

each recurrence. determined

nine

hepatic

bilobar

the

of the first recurrence

between

ous

we

of

of

The remaining

left

resec-

at that time.

Location Right lobe only Left lobe only Bilobar

401

Resection of hepatic and pulmonary metastases hepatic

lobectomy

lesion

in the

metastasis

and a wedge

left lobe. The

to the

left

resection

patient

lobe

with

of the a single

underwent

a wedge

postoperative

complica-

resection. developed

tions as shown effusions

in Table 3. Two developed

requiring

intra-abdominal

thoracentesis.

abscesses

drainage,

and

resolved

with

one

Pulmonary

Two

requiring

developed

pleural

developed

percutaneous

a bile

non-operative

required re-operation

both hepatic

metastatic

colorectal

therapy.

leak

which

No

patient

were

an extended

found

right

to

have

metastases.

hepatic

synchronous

N

Treatment

Pleural effusion

2

Thoracentesis

Abdominal

2

Percutaneous

1

Plonged

1

NG suctioning

Hepatic

combined

lobectomy

thoraco-abdominal

underwent

a left by

upper

month

later

patient

subsequently

and wedge

resection: abscess

Bile leak Pulmonary

drainage

JP drain

resection

lleus JP = Jackson-Pratt

drain.

NG = naso-gastric.

Table 4. Location

of pulmonary

incision.

lobectomy

a right

hepatic

developed

The

second

followed

lobectomy. diffuse

Location

of metastases

Solitary Right upper

lobe

one

Right lower

lobe

This

Left upper

lobe

Left lower

lobe

abdominal

Multiple Right upper

tion. The remaining

eight patients

developed

pulmon-

ary metastases

a median of 18 months (range IO-36

months)

liver

after

resection.

location and number

Table

of pulmonary

5 lists the operations

resections

were

the remaining

4 shows

metastases

performed.

performed seven

wedge

consisted

had a significant

of an

ileus

which

while

resections

complication. prolonged

his

hospitalization.

Recurrence Two patients were documented liver.

One

recurred

after liver resection resection.

The

in the

recurred

liver

underwent

repeat

and multiple wedge

14 months

after

15 months

undergone

two additional

metastases, thoracotomy.

24

recurred in the lung. One exploratory

and

30

after her last thoracotomy.

performed

for pulmonary metastases

Procedure

N

Right upper lobectomy and wedge resection of left lower lobe Left upper lobectomy Lingulectomy and segmental resection right lower lobe Solitary wedge resection Bilateral wedge resections

1 1 1

5 2

resections months

One

patient

who

rence also developed developed

developed

pulmonary

a brain metastasis. intra-abdominal

recur-

Four subrecurrences

which were unresectable.

thoracotomy

later. One other patient

She is alive with

Table 5. Operations

sequently

resections. She has no evidence

of disease

1

lobe and lingula

2 months

after pulmonary

initial resection and is alive with disease. Six patients subsequently

Right upper

to have recurrence

and 4 months

second

lobe and left

lobe

and

only. Only one patient

lower

the

Anatomic

in three patients,

underwent

metastases

through a

disease and died 7.5 months after the hepatic resec-

patient

for

One underwent

resection of a right lower lobe metastasis

in the

resections

metastases

patients

Table

and pulmonary

adenocarcinoma

for complications.

hepatic and pulmonary

This

undergoing

Complication

Five patients

Two

Table 3. Postoperative complications in patients

has

of pulmonary

after disease

her

initial

3 months

Adjuvant Five

therapy

patients

underwent

the agents

varied

used

5-fluorouracil

were

5-FWMeCCNU,

from

adjuvant patient

chemotherapy;

to patient.

(5 FU),

Agents

5-FWleucovorin,

5-FWactinomycin-D/methotrexate.

402

J. W Smith et al.

Due to the small numbers, drawn

no conclusions

as to the effectiveness

men. When

operation

compared

alone,

in disease-free There

evidence

after

As

difference

occult

effect

to

the who

erythroleukemia

She

of recurrence

4 years

underwent

in that the patient

developed

treatment.

cancer.

many

currently

of the colorectal

her second

8

shows

no

operation

for meta-

of the primary develop liver

was not used in these patients.

Median

survival

months.

after

Median

was 18 months. 89%,

survival primaries. have

and

52%,

disease

respectively

difference

patients

With

a median

operation

for

no evidence

resection

was

pulmonary

I-, 3- and 5-year

significant between

second

after

Actuarial

78%

statistically

the hepatic

survival

with

is the only

metastases,

of disease,

three

four

are

the

patients alive

with

available

for hepatic the operation

and three are dead of disease.

gained

rates

Although

candidates of

the

patients

lung

carcinoma patients

are expected will

die

approximately in men

of

disease.

leading

superseded

only

colorectal

half of these

It accounts

12% of cancer-related

USA and is the third ity

cases

in 1991 and

of their

deaths

cause of cancer by lung

and

for

in the mortalprostate

static

the total) These effort

to

0.9

.P .? $

I_,

c+

co

tumour

is controlled

been

adopted

0.5

g &

o.4 0.3

0

0

OO

indications

12

24

36

48

Time (months)

Figure 1. Survival after resection of second metastasis.

60

for

in the

possible

enumerated

series,

colorectal comparable

for

been:

resection

(i)

the

same

of

primary

(ii) the liver

and (iii) the patient indications

indications

for

is is a

have

resection

of

as well [14]. indications

who have already

recurred

1141. in an

small from

or controllable;

metastases

or lung and have

0.1

alone

operatively

in survivals

risk. These as

meta-

10% (1% of

In several

have

We have taken those Patients

0.2

of widely

metastases

site of metastases;

pulmonary

with

[I 4-l 91.

the

0.6

g ‘Z

facet

metastases

resulted

metastases

operative

of

pulmonary

approximately

survival.

hepatic

good

developing

as one

resection

the only

referral

only a frac-

carcinoma

of pulmonary

0.7

the

extra-abdominal

pulmonary

Traditionally,

I

USA

common

can be managed

have

in the

colorectal

However,

prolong

carcinoma

17,

and mortal-

Consequently

patients

develop

resection

annually morbidity made

42%

5000-6000

most

usually

patients

to

from

of all

disease.

25%

is

[4]. Five

ever come to operation.

of metastases

with hepatic

0.0

procedure

is the

10%

mortality

rate 20-30%

prohibitive has

recent

as improve-

are an estimated

procedure

metastases, new

operative

less than optimal.

nearly 160,000

care,

from

years

With

as well

range

for this

origin.

in the late

the past IO-15

technique

there

[5], the perceived

currently

of colorectal

acceptance.

in peri-operative

The

Approximately

who

Untreated

treatment

during

wide

tion of that number

DISCUSSION

Meta-

of 4.5 to 15

was first performed

in surgical

25-281.

site

die.

time

metastases

it is only

it has

advances

ity

they

curative

survival

after

[23].

of resection

[25].

year

rectal

or

50% of patients

time

5% and the resectability

in

cancer 2 years

survival

ments

and

of 18 months

by the a median

about

1). No

obvious

[24], and 65% will have

survivals found

colon

colon within

resection (Fig.

was

34

have

at the time of exploration

metastases

Though that

are

have

19th century,

Survival

patients

occur

metastases

months

of

in approximately

hepatic

carcinoma

per year [22].

of a primary

Resection

therapy

lung and breast

metastases

tumours

patients

carcinoma

only

as 35%

hepatic

chronous

static disease. Radiation

In women,

cause more cancer deaths

for resection side

administered

after

nearly

important

MeCCNU,

years

who

regi-

or survival.

one

chemotherapy

patients

was no significant

interval

was

received

with

there

can be

of any particular

recurred

one step further. once in the liver

been

resected,

who

subsequently

second

location

were

re-evaluated

resection above.

using If all

the

same

criteria

were

indications met,

they

Resection

of hepatic

and pulmonary

metastases

were offered resection as their only chance for cure.

Gastrointestinal

Survival

C/in Oncol1991;

after the second operation

the same as would be expected single recurrence.

after operation for a

The search for other

sites must be thorough operations,

was essentially

only to find additional,

able disease. Computerized and abdomen

of the chest

Bone and brain scans

are done only if the patient is symptomatic. The extent number, The

of liver resection

is dictated

is to preserve

assuring

complete

liver

resection

parenchyma,

at our institution,

significant primary

prognostic (with

factors

sigmoid colon being associated carcinoembryonic

is dictated

or

antigen

(ii) pre-

(CEA)

levels;

of pulmonary

metastases

of

large

bowel

lesion which

in a patient

cancer

may

be

be

with

a

made

histologically,

lobectomy

is the

of choice [14]. chemotherapy,

synchronous

in selected

or

pulmonary

metastases

considered

for resection

bility for long-term

of colorectal

of

cases, patients

metachronous

analysis

patients

6. Butler

hepatic

cancer

after

RB, Cox EB, MacLean

of a personal

with

J, Attiyeh

series

liver metastases

BJ.

of 247 con-

from

colorectal

FF, Daly

of the

JM.

colon

Hepatic

and

resection

rectum.

Surg

for

Gynecol

Obstet 1986; 162: 109-l 3. 7. Hughes

KS,

Resection

Rosenstein

RB, Songhorabodi

of the liver

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a multi-institutional

vivors.

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meta-

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sur-

Dis Colon Rectum 1988; 103: l-4.

8. Hughes

K. Registry

theliver

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resection

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Surgery

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HA, Benjamin

hepatic

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A, Blumgart

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LH.

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Br J Surg 1987; 74: 324-6. 10. Steele

G, Ravikumar from

11. Cady

TS. Resection

colorectal

B, McDermott

cancer.

of hepatic

Ann

meta-

Surg 1989;

210:

Major hepatic resection for

WV.

Surg 1985; 201: 204-209. 12. Vetto

JT,

Morbidity static

and

origin should be

as it offers the only possi-

KS,

Rosenstein

colorectal

R, Sugarbaker

of hepatic

carcinoma.

resection

P.

for meta-

Dis Co/on Rectum

7990;

33: 408-I 3. 13. Gilbert

JM,

Evans

JM,

after ‘curative’

for adjuvant

therapy.

14. McCormack

PM,

metastases

from

Kark

AE.

colorectal

Sites

of

surgery:

recurrent

implications

Br J Surg 1984; 71: 203-5. Attiyeh

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colorectal

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cancer.

pulmonary

Dis Co/on Rectum

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survival.

Hughes

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From this study we feel that in the absence effective

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or a second primary. If the differentiation

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with a either

of

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is the rule. A solitary

6584. J

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cancer.

stases

by the number and location of lesions. In

metastasis cannot

of

left

with a lower recurr-

to be adenocarcinoma

history

site

episodes [29].

conservation

all tumour proven

(i)

in the

to be

and 4) Number of intraop-

The extent of resection general,

are:

in other locations);

(iii) number of metastases erative hypotensive

shown

originating

ence rate than primaries operative

In a recent study

variables

tumours

while

with at least 1 cm of

normal tissue beyond the tumour. performed

by the disease.

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Am J Surg 1988; 155: 378-82.

JG, Silva JS, Golbey

secutive

Group

2.

Recurrence

metastases

size and location of the metastatic

rule

5. Fortner

Study

9: 1105-l

resection.

Multivariate

often unresect-

tomography

are essential.

major

Tumour

JG.

hepatic

metastatic

to avoid performing

4. Fortner

403

static

survival

JS, Willis after

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GW,

Farr GH, Sardi

pulmonary

carcinoma.

resection

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