World J. Surg. 15, 62-67, 1991
World Journal of Surgery 9 1991 by the Soci6t6 Internationale de Chirurgie
Resection of Synchronous Liver Metastases from Colorectal Cancer P. Vogt, M.D., R. Raab, M.D., B. Ringe, M.D., and R. Pichlmayr, M.D. Department of Surgery, Hannover Medical School, Hann0ver, Federal Rept~blic of Germany Whereas resection for metachronous liver metastases from coiorectal cancer is considered to be a potentially curative approach, little is known about the prognosis after resection of synchronous liver metastases. In the past, these patients usually underwent only palliative therapy. Therefore, we have analyzed the data of 36 patients who underwent curative hepatic resection of synchronous liver metastases from colorectal carcinomas from 1977 to 1987 at the Department of Surgery, Hannover Medical School. In 19 patients, liver resection was combined with colonic resection; in the other 17 patients, hepatic resection was performed after a median interval of 2 months following resection of the primary tumor. No operative mortality was observed in either of the approaches. The median survival time was 28 months for all patients with a median recurrence-free interval of 13.5 months. Overall 5-year survival probability for all patients was 20%. There were no significant differences observed between immediate or delayed liver resection (median survival 18 months versus 31 months). Survival rates were not different afte r resection of solitary versus multiple liver metastases (26 versus 28 months). Twenty-one of the 36 patients had a recurrence of their fiver metastases. In 7 of them, curative liver resection could be performed again. These 7 patients had a significantly improved survival (p < 0.05) compared to the residual 14 patients. It is concluded that patients with synchronous liver metastases from colorectal cancer may profit from resection of the primary tumor and liver metastases. Timing of liver resection--immediate versus delayed--~bviously has no impact on survival rates.
Resection of liver metastases from colorectal cancer has been widely shown to improve survival, providing 5-year survival rates of 20-25% to 40% with acceptable operative mortality and morbidity rates [1, 2]. Until now, operative therapy has been the only curative approach. At laparotomy for operation of primary colorectal cancer, 8.5-26% [3-6] of the patients present with synchronous liver metastases. In the past, these patients usually underwent palliative resection of the primary tumor or received no surgical therapy at all. Median survival times usually did not exceed 6 months [7]. Since the resection of metachronous lesions has given such encouraging results, synchronous lesions were also included in the concept of resection for cure; however, there has been some controversy on the general prognosis of these synchronous lesions after resection. Obviously, they are not worse than metachronous liver metastases regarding the time
Reprint requests: Peter Vogt, M.D., Klinik ffir Abdominal- und Transplantationschirurgie, Medizinische Hochschule Hannover, Konstanty Gutschowstraf~e 8, D-3000 Hannover 61, Federal Republic of Germany.
after hepatic resection [2, 8]. Furthermore, the factors that influence the outcome after resection are not yet determined, particularly which approach--combined colonic and hepatic resection or second stage hepatic resection after removal of the primary tumor--should be performed. Therefore, we have analyzed our population of patients undergoing resection of synchronous liver metastases from colorectal cancer. From 1977 to 1987, a total of 157 patients underwent hepatic resection of colorectal liver metastases at the Hannover Medical School. In 36 (23%) of these 157 patients, synchronous liver metastases diagnosed prior to or at the time of operation of the primary tumor were considered suitable for curative resection. The outcome of these patients has been investigated regarding overall survival, operative strategy, and prognostic factors possibly influencing the fate of this particular group of patients. Material and Methods
From 1977 to 1987, a total of 36 patients (16 female, 20 male) suffering from colorectal cancer and synchronous liver metastases underwent curative surgical resection of primary tumor and liver metastases. No other site of tumor localization was evident, proved by chest x-ray, computed tomography (CT) scan, bone scintigraphy, and intraoperative exploration. Median age at operation was 56.5 (32-75) years.
Surgical Management Nineteen (53%) of the 36 patients were operated in a combined procedure with synchronous resection of hepatic metastases and primary tumor (Fig. 1A). In 11 cases anatomical liver resections were performed; in 8, atypical (wedge) resections were performed. Surgical treatment is depicted in Figure lB. The other 17 patients underwent resection of their liver metastases after an interval of 2 -+ 1 (median + S.D.) months after resection of the primary tumor. The number of liver metastases removed by either of the approaches is given in Table 1.
Follow-Up Patients were regularly seen every 3 months during the first 2 years after the operation and every 6 months in the third year.
P. Vogt et al.: Liver Metastases from Colorectal Cancer
A
63
Table 2. Localization of primary col0rectal carcinoma in 29 patients with Dukes' D carcinoma and synchronous liver metastases.
% patients 100"/o
75% "
50%-
25% -
Localization
No. of patients
Cecum Right colon Ascending colon Sigmoid Upper rectum Middle rectum Lower rectum Total
3 5 3 14 4 1 6 36
0o/o 84
Table 3. Tumor staging according to the TNM system.
Wedge excision
Segmentectorny kobectomy
l
NUMBEROF PTS.
B
Tumor stage
No. of patients
T2_ 3, No T2_3, N t T2_3, N 2
9 22 2 1 2
T4, N O T4, N I
T4, N2 factors was investigated and differences in survival times were analyzed for statistical significance by the Mantel-Cox chisquared test. Results Hemi.re.
Hemi.li.
Transversum
Sigmoid Ant. Rectum COLONICRESECTION
Exstirp.
LIVER RESECTION ~B
Lobectomy
l
Trisegm.
~
Segmentect.
~We~e
Fig. 1A. Types of hepatic resection for synchronous colorectal liver metastases in a combined and consecutive approach. Resection: "res" and "r." B. Techniques of combined colonic and hepatic resections in 19 of 36 patients with synchronous colorectal liver metastases. PTS: patients, Hemi. re.: right hemicolectomy, Transversum: transverse colectomy, Hemi. li.: left hemicolectomy, Ant.: anterior, Extirp.: extirpation, Trisegm.: trisegmentectomy, Segmentect.: segmentectomy.
There were no lethal complications and none of the patients died from the operation. Operative complications occurred in 4 patients (11%). Following synchronous liver and colonic resection, a bile leakage occurred in 1 patient. In the delayed approach, 2 patients suffered from intraabdominal hematomas. Another patient had to be reooperated because of an ileus of the small bowel following metachronous resection of the liver. The median duration of hospital treatment was 15 -+ 1.3 days for the combined procedure (range: 10-29), and 26 -+ i.2 days for the 2 operations in second-stage liver resection.
Localization and Stage of the Primary Tumor Table 1. No. of liver metastases per patient.
No. of liver metastases
Immediate liver resection
Delayed liver resection
1
12 3 2 1 1
11 1 1 4 -
2 3 4 5 6
Twenty-five (69%) patients presented with tumors located in the sigmoid or rectum (Table 2). Most of the tumors comprised T 2 or T~ and Nt stages. Only 3 patients suffered from locally advanced cancer (T4). Twenty-six of the 36 patients had lymph node metastases (Table 3).
Localization and Characteristics of Liver Metastases
Investigations comprised physical examination, colonoscopy or barium enema x-ray of the bowel, CT scan of the abdomen, and abdominal sonography.
Solitary liver metastases were found in 23 patients (64%) and multiple metastases in 13 patients (36%). Two patients showed metastatic spread into both lobes of the liver (Table 4). The size of the lesions removed from the liver is depicted in Figure 2. There were no significant differences in survival between patients with lesions less than 4 cm and 5 cm, respectively, or more.
Method of Analysis
Overall Survival
A retrospective study on survival was conducted using the method of Kaplan and Meier (1958). The influence of different
The median survival for all patients (n = 36) was 28 months (range: 3-125). Sixteen (44%) of the 36 patients are alive at a
64
World J. Surg. Vol. 15, No. 1, Jan./Feb. 1991
Table 4. Localization of synchronous liver metastases of colorectal
Metastases
Right
Left
Solitary Multiple
12 9
11 2
Bilateral
Total
Disease free
809 f
2
_
60-
40
Diameter of lesions (mm)
World Journal of Surgery 9 1991 by the Soci6t6 Internationale de Chirurgie
Resection of Synchronous Liver Metastases from Colorectal Cancer P. Vogt, M.D., R. Raab, M.D., B. Ringe, M.D., and R. Pichlmayr, M.D. Department of Surgery, Hannover Medical School, Hann0ver, Federal Rept~blic of Germany Whereas resection for metachronous liver metastases from coiorectal cancer is considered to be a potentially curative approach, little is known about the prognosis after resection of synchronous liver metastases. In the past, these patients usually underwent only palliative therapy. Therefore, we have analyzed the data of 36 patients who underwent curative hepatic resection of synchronous liver metastases from colorectal carcinomas from 1977 to 1987 at the Department of Surgery, Hannover Medical School. In 19 patients, liver resection was combined with colonic resection; in the other 17 patients, hepatic resection was performed after a median interval of 2 months following resection of the primary tumor. No operative mortality was observed in either of the approaches. The median survival time was 28 months for all patients with a median recurrence-free interval of 13.5 months. Overall 5-year survival probability for all patients was 20%. There were no significant differences observed between immediate or delayed liver resection (median survival 18 months versus 31 months). Survival rates were not different afte r resection of solitary versus multiple liver metastases (26 versus 28 months). Twenty-one of the 36 patients had a recurrence of their fiver metastases. In 7 of them, curative liver resection could be performed again. These 7 patients had a significantly improved survival (p < 0.05) compared to the residual 14 patients. It is concluded that patients with synchronous liver metastases from colorectal cancer may profit from resection of the primary tumor and liver metastases. Timing of liver resection--immediate versus delayed--~bviously has no impact on survival rates.
Resection of liver metastases from colorectal cancer has been widely shown to improve survival, providing 5-year survival rates of 20-25% to 40% with acceptable operative mortality and morbidity rates [1, 2]. Until now, operative therapy has been the only curative approach. At laparotomy for operation of primary colorectal cancer, 8.5-26% [3-6] of the patients present with synchronous liver metastases. In the past, these patients usually underwent palliative resection of the primary tumor or received no surgical therapy at all. Median survival times usually did not exceed 6 months [7]. Since the resection of metachronous lesions has given such encouraging results, synchronous lesions were also included in the concept of resection for cure; however, there has been some controversy on the general prognosis of these synchronous lesions after resection. Obviously, they are not worse than metachronous liver metastases regarding the time
Reprint requests: Peter Vogt, M.D., Klinik ffir Abdominal- und Transplantationschirurgie, Medizinische Hochschule Hannover, Konstanty Gutschowstraf~e 8, D-3000 Hannover 61, Federal Republic of Germany.
after hepatic resection [2, 8]. Furthermore, the factors that influence the outcome after resection are not yet determined, particularly which approach--combined colonic and hepatic resection or second stage hepatic resection after removal of the primary tumor--should be performed. Therefore, we have analyzed our population of patients undergoing resection of synchronous liver metastases from colorectal cancer. From 1977 to 1987, a total of 157 patients underwent hepatic resection of colorectal liver metastases at the Hannover Medical School. In 36 (23%) of these 157 patients, synchronous liver metastases diagnosed prior to or at the time of operation of the primary tumor were considered suitable for curative resection. The outcome of these patients has been investigated regarding overall survival, operative strategy, and prognostic factors possibly influencing the fate of this particular group of patients. Material and Methods
From 1977 to 1987, a total of 36 patients (16 female, 20 male) suffering from colorectal cancer and synchronous liver metastases underwent curative surgical resection of primary tumor and liver metastases. No other site of tumor localization was evident, proved by chest x-ray, computed tomography (CT) scan, bone scintigraphy, and intraoperative exploration. Median age at operation was 56.5 (32-75) years.
Surgical Management Nineteen (53%) of the 36 patients were operated in a combined procedure with synchronous resection of hepatic metastases and primary tumor (Fig. 1A). In 11 cases anatomical liver resections were performed; in 8, atypical (wedge) resections were performed. Surgical treatment is depicted in Figure lB. The other 17 patients underwent resection of their liver metastases after an interval of 2 -+ 1 (median + S.D.) months after resection of the primary tumor. The number of liver metastases removed by either of the approaches is given in Table 1.
Follow-Up Patients were regularly seen every 3 months during the first 2 years after the operation and every 6 months in the third year.
P. Vogt et al.: Liver Metastases from Colorectal Cancer
A
63
Table 2. Localization of primary col0rectal carcinoma in 29 patients with Dukes' D carcinoma and synchronous liver metastases.
% patients 100"/o
75% "
50%-
25% -
Localization
No. of patients
Cecum Right colon Ascending colon Sigmoid Upper rectum Middle rectum Lower rectum Total
3 5 3 14 4 1 6 36
0o/o 84
Table 3. Tumor staging according to the TNM system.
Wedge excision
Segmentectorny kobectomy
l
NUMBEROF PTS.
B
Tumor stage
No. of patients
T2_ 3, No T2_3, N t T2_3, N 2
9 22 2 1 2
T4, N O T4, N I
T4, N2 factors was investigated and differences in survival times were analyzed for statistical significance by the Mantel-Cox chisquared test. Results Hemi.re.
Hemi.li.
Transversum
Sigmoid Ant. Rectum COLONICRESECTION
Exstirp.
LIVER RESECTION ~B
Lobectomy
l
Trisegm.
~
Segmentect.
~We~e
Fig. 1A. Types of hepatic resection for synchronous colorectal liver metastases in a combined and consecutive approach. Resection: "res" and "r." B. Techniques of combined colonic and hepatic resections in 19 of 36 patients with synchronous colorectal liver metastases. PTS: patients, Hemi. re.: right hemicolectomy, Transversum: transverse colectomy, Hemi. li.: left hemicolectomy, Ant.: anterior, Extirp.: extirpation, Trisegm.: trisegmentectomy, Segmentect.: segmentectomy.
There were no lethal complications and none of the patients died from the operation. Operative complications occurred in 4 patients (11%). Following synchronous liver and colonic resection, a bile leakage occurred in 1 patient. In the delayed approach, 2 patients suffered from intraabdominal hematomas. Another patient had to be reooperated because of an ileus of the small bowel following metachronous resection of the liver. The median duration of hospital treatment was 15 -+ 1.3 days for the combined procedure (range: 10-29), and 26 -+ i.2 days for the 2 operations in second-stage liver resection.
Localization and Stage of the Primary Tumor Table 1. No. of liver metastases per patient.
No. of liver metastases
Immediate liver resection
Delayed liver resection
1
12 3 2 1 1
11 1 1 4 -
2 3 4 5 6
Twenty-five (69%) patients presented with tumors located in the sigmoid or rectum (Table 2). Most of the tumors comprised T 2 or T~ and Nt stages. Only 3 patients suffered from locally advanced cancer (T4). Twenty-six of the 36 patients had lymph node metastases (Table 3).
Localization and Characteristics of Liver Metastases
Investigations comprised physical examination, colonoscopy or barium enema x-ray of the bowel, CT scan of the abdomen, and abdominal sonography.
Solitary liver metastases were found in 23 patients (64%) and multiple metastases in 13 patients (36%). Two patients showed metastatic spread into both lobes of the liver (Table 4). The size of the lesions removed from the liver is depicted in Figure 2. There were no significant differences in survival between patients with lesions less than 4 cm and 5 cm, respectively, or more.
Method of Analysis
Overall Survival
A retrospective study on survival was conducted using the method of Kaplan and Meier (1958). The influence of different
The median survival for all patients (n = 36) was 28 months (range: 3-125). Sixteen (44%) of the 36 patients are alive at a
64
World J. Surg. Vol. 15, No. 1, Jan./Feb. 1991
Table 4. Localization of synchronous liver metastases of colorectal
Metastases
Right
Left
Solitary Multiple
12 9
11 2
Bilateral
Total
Disease free
809 f
2
_
60-
40
Diameter of lesions (mm)
