Liver Metastases: Surgical Resection written and compiled by doctordee

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General Considerations Surgical Resection of Liver Metastases

General Considerations

Liver Metastases-General Discussion Liver metastases create a life-threatening prognosis. However, tremendous strides have been made in dealing with liver mets in the past decade, such as improved diagnostic capabilities, safe surgical resection, availability of safe nonsurgical ablative modalities, multimodality therapy, and aggressive approach to recurrent disease. Remember, the liver has the capacity to regenerate its tissue, not like lung or kidney. It is now accepted that liver resection should be done surgically as the treatment of choice when the complete excision of all demonstrable tumor with clear resection margins is feasible. Reference 1 Reference 2 Reference 3 In the presence of other abdominal tumors or of inoperable lung tumors, however, local treatment may not be the treatment of choice, and systemic treatment might be more appropriate. If liver tumors are inoperable, ablative methods are probably the techniques of choice, if the tumor size and location are favorable. If the liver tumors are inoperable, and cannot be ablated, neoadjuvant treatment with systemic chemotherapy or one of these local techniques might downsize the tumors so that they become surgically resectable. Regional chemotherapy might be useful combined with hepatic resection or as palliative therapy. Patients with localized, unresectable hepatic metastases or coexisting serious medical condition(s) may be candidates for radiation, percutaneous ethanol injection, cryosurgery, percutaneous radiofrequency, microwave ablation, laser ablation, hypoxic flow-stop perfusions with bioreductive alkylating agents, hepatic arterial ligation, embolization or chemoembolization. These new liver-directed types of treatment are being investigated and may offer new approaches to providing palliation and prolonging survival. For primary or secondary tumors of the liver, six existing minimally invasive techniques for the treatment of primary and secondary malignant hepatic tumors--radio-frequency ablation, microwave ablation, laser ablation, cryosurgical ablation, ethanol ablation, and chemoembolization have each exceeded clinical results obtained with conventional chemo- or radiation therapy. Thus, for nonsurgical patients, these techniques are becoming standard independent or adjuvant therapies. In addition, with continued improvement in technology and increasing clinical experience, one or more of these minimally invasive techniques may soon challenge surgical resection as the treatment of choice for patients with limited hepatic tumor.

Surgical Resection of Liver Metastases

Liver Metastases & Surgical Resection Surgical resection of hepatic metastases still holds a chance of cure, or of extended survival, if there is no other disease, or if other deposits are also resectable. However, the overall survival rate is still low. If the hepatic metastases are resectable, resection is the best therapeutic choice. Reference 1 Reference 2 Reference 3 Angiography and intraoperative ultrasonography are useful for resection. The number of hepatic metastases and the surgical margin are probably the most significant prognostic factors. GI tract cancer may spread predominantly to the liver making regional treatment strategies viable options. Subtotal hepatic resections and segmentectomies are potentially curable procedures for single or small numbers of hepatic metastases without other sites of disease. However, the majority of the patients relapse after hepatic resection, 50% relapsing in the liver. Re-resections of hepatic metastases also remain potentially curable procedures without other sites of disease. Furthermore, should there be a limited number of resectable pulmonary metastases as well as hepatic metastases, both the liver and the lung can be resected sequentially, in many cases yielding statistics not too different from cases that are solely liver or solely lung resections. Fundamental principles when resecting hepatic metastases are to resect all the lesions and to avoid major operative risk. In complex cases, the most frequent, these principles can only be completely followed in a specialized center. In consideration of the satisfactory results achieved with an aggressive policy of liver resection, it is probably best to be referred to a specialized liver unit where major hepatic procedures, even if extended, can be safely performed. The first liver resection should be planned carefully, so that a second liver resection, if necessary, can be done efficaciously. Ultrasound at hepatic resection operations [intraoperative ultrasound] should be used; it can detect metastases not previously detected, and thereby help with resection boundaries. Patients who are found to have unresectable metastases might be able to have them resected if tumor bulk is reduced by appropriate chemotherapy or other percutaneous procedure. Another alternative for unresectable metastases is a two procedure metastectomy. First, some of the tumor is removed. The liver is allowed to recover and regenerate, so that removal of the rest of the tumor bulk with the second operation does not reduce the amount of functioning liver tissue below survival level. In a search of the literature, two studies were found dealing solely with leiomyosarcoma hepatic resections. The resection of all hepatic metastases in these patients resulted in prolonged survival. Studies of hepatic resections in other cancers were included in the following journal search in order to indicate the use of various techniques and strategies. Again, it is emphasized that these specialized & difficult operations be done at specialized liver centers, by surgeons experienced in the technique. The first resection should be planned with the second in mind. For updated information: Search Pubmed Liver Metastasectomy and Sarcoma Search Pubmed Resection of Liver Metastases Liver Metastases & Surgical Resection Selected Medical Journal Annotated References [For the full abstract, use the links provided, or search on Pubmed. Ed.] Ann Surg 2000 Apr;231(4):500-5 Hepatic metastases from leiomyosarcoma: A single-center experience with 34 liver resections during a 15-year period. Lang H, Nussbaum KT, Kaudel P, Fruhauf N, Flemming P, Raab R. Klinik fur Abdominal- und Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Germany. hauke.lang@uni-essen.de ... Liver resection is the treatment of choice for hepatic metastases from colorectal carcinoma. In contrast, the role of liver resection for hepatic metastases from leiomyosarcoma has not been defined. ... The records of 26 patients who between 1982 and 1996 underwent a total of 34 liver resections for hepatic metastases from leiomyosarcoma were reviewed. There were 23 first, 9 second, and 2 third liver resections. The records were analyzed with regard to survival and predictive factors. ... In the 23 first liver resections, there were 15 R0 [R0 resection is clear surgical margins. Ed.], 3 R1, and 5 R2 resections. Median survival was 32 months after R0 resection and 20.5 months after R1/2 resection. The 5-year survival rate was 13% for all patients and 20% after R0 resection. In 10 patients with extrahepatic tumor at the time of the first liver resection, 6 R0 and 4 R2 resections were achieved. After R0 resection, the median survival was 40 months (range 5-84 months), with a 5-year survival rate of 33%. After repeat liver resection, the median survival was 31 months (range 5-51 months); after R0 resection, median survival was 31 months and after R1/2 resection it was 28 months. There was no 5-year survivor in the overall group after repeat liver resection. ... Despite frequent tumor recurrence, the long-term outcome after liver resection for hepatic metastases from leiomyosarcoma is superior to that after chemotherapy and chemoembolization. Although survival after tumor debulking also seems to be more favorable than after nonoperative therapy, these data indicate that only an R0 resection offers the chance of long-term survival. The presence of extrahepatic tumor should not be considered a contraindication to liver resection if complete removal of all tumorous masses appears possible. In selected cases of intrahepatic tumor recurrence, even repeated liver resection might be worthwhile. In view of the poor results of chemoembolization and chemotherapy in hepatic metastases from leiomyosarcoma, liver resection should be attempted whenever possible. Fetch PMID: 10749609 J Gastrointest Surg 1998 Mar-Apr;2(2):151-5 Complete hepatic resection of metastases from leiomyosarcoma prolongs survival. Chen H, Pruitt A, Nicol TL, Gorgulu S, Choti MA.Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md, USA. ... To determine whether hepatic resection has a role in the management of metastatic leiomyosarcoma, medical records from 11 consecutive patients who underwent resection of isolated metastases from leiomyosarcoma between 1984 and 1995 were reviewed. All liver resections were for leiomyosarcomas originating in the viscera (n = 6) or retroperitoneum (n = 5). The average disease-free interval was 16 months. Five of 11 primary tumors were classified as low grade, whereas six were high grade. Hepatic resections included lobectomy or extended lobectomy (n = 4), segmentectomy and/or wedge resection (n = 5), and complex resection (n = 2). There were no operative deaths. Median survival of all patients after liver resection was 39 months. Patients who underwent complete resection of hepatic metastases (n = 6) had a significantly longer survival than those who had incomplete resections (n = 5) (P = 0.03, log-rank test). Furthermore, five of six patients who underwent complete resection are alive after hepatectomy with a median follow-up of 53 months. Therefore, in selected patients with isolated liver metastases from visceral and retroperitoneal leiomyosarcomas, complete resection of hepatic metastases results in prolonged survival. Fetch PMID: 9834411 Br J Surg 2000 Nov;87(11):1500-5 Surgical treatment of adult primary hepatic sarcoma. Poggio JL, Nagorney DM, Nascimento AG, Rowland C, Kay P, Young RM, Donohue JH. Department of Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA. ... Twenty consecutive adult patients who had surgical treatment for primary hepatic sarcomas were reviewed. Patient age ranged from 23 to 80 years. .... Nineteen patients had hepatic resection and one patient had an orthotopic liver transplant. No patient received neoadjuvant chemotherapy or radiotherapy but radiotherapy was delivered intraoperatively in one patient. ... Leiomyosarcoma was the most common histological type of sarcoma diagnosed (five of 20 patients), ... Distant metastases (ten patients) and intrahepatic recurrence (six) were the predominant sites of initial treatment failure. ...Histological grade was the only factor significantly associated with overall patient survival (P= 0.03). With complete resection, patients with high-grade tumours had a 5-year survival rate of 18 (95 per cent confidence interval 5-62) per cent compared with 80 (52-100) per cent for patients with low-grade tumours. The 5-year survival rate for all 20 patients was 37 (20-60) per cent. Surgical resection is the only effective therapy for primary hepatic sarcomas at present. Better adjuvant therapy is necessary, especially for high-grade malignancies, owing to the high failure rate with operation alone. Fetch PMID: 11091236 Am Surg 2000 Jul;66(7):611-5 Intraoperative ultrasound (IOUS) is essential in the management of metastatic colorectal liver lesions. Cervone A, Sardi A, Conaway GL. Department of Surgery, St Agnes Health Care, Baltimore, Maryland 21229, USA. Metastatic tumors to the liver account for the majority of hepatic neoplasms. Improvement in resection has been shown to be beneficial and has remained the treatment of choice, carrying a 5-year survival rate of approximately 20 to 30 per cent. In evaluating candidates for surgery, intraoperative assessment for resectability is a key factor and dictates surgical approach, as well as patient prognosis. Historically, imaging techniques such as CT scan, magnetic resonance imaging, and CT arterial portography (CTAP) have been used in preoperative evaluation. However, the sensitivities of these diagnostic tools have been found to be less than optimal. Intraoperative ultrasound (IOUS) has emerged as an important tool in accurately staging metastatic liver disease with a sensitivity of 98 per cent...The use of IOUS modified the management of 44 per cent of our patients with liver metastases. IOUS should be routinely used in patients undergoing liver resection for metastatic liver disease. Fetch PMID: 10917467 Ann Surg 2000 Dec;232(6):777-85 Two-stage hepatectomy: A planned strategy to treat irresectable liver tumors. Adam R, Laurent A, Azoulay D, Castaing D, Bismuth H. Centre Hepato-Biliaire, Hopital Paul Brousse, Villejuif, and Universite Paris-Sud, France. rene.adam@pbr.ap-hop-paris.fr ... Some patients with multiple hepatic colorectal metastases are not candidates for a complete resection by a single hepatectomy, even when downstaged by chemotherapy, after portal embolization, or combined with a locally destructive technique. In two-stage hepatectomy, the highest possible number of tumors is resected in a first, noncurative intervention, and the remaining tumors are resected after a period of liver regeneration. In selected patients with irresectable multiple metastases not amenable to a single hepatectomy procedure, two-stage hepatectomy might offer a chance of long-term remission. ... Two-stage hepatectomy was feasible in 13 of 16 patients (81%). There were no surgical deaths. The postoperative death rate (2 months or less) was 0% for the first-stage procedure and 15% for the second-stage one. Postoperative complication rates were 31% and 45%, respectively, with only one complication leading to reoperation. The 3-year survival rate was 35%, with four patients (31%) disease-free at 7, 22, 36, and 54 months. Median survival was 31 months from the second hepatectomy and 44 months from the diagnosis of metastases. ...Two-stage hepatectomy combined with chemotherapy may allow a long-term remission in selected patients with irresectable multiple metastases and increases the proportion of patients with resectable disease. Fetch PMID: 11088072 Arch Surg 2001 Mar;136(3):318-23 Colorectal hepatic metastases: resection, local ablation, and hepatic artery infusion pump are associated with prolonged survival. Heslin MJ, Medina-Franco H, Parker M, Vickers SM, Aldrete J, Urist MM. Department of Surgery, University of Alabama, Birminghan 35294, USA. marty.heslin@ccc.uab.edu ... Treatment of metastatic colorectal cancer to the liver is not uniform. We describe the management of metastatic colorectal cancer of the liver at a single institution during a 10-year period. ...Fifty-two patients underwent lobectomy or wedge resection, 5 underwent cryotherapy, and 16 had a hepatic artery infusion pump (HAIP) inserted... The 3-year actuarial survivals for patients who underwent resection, HAIP, or those with unresectable disease were 70 months, 32 months, and 3 months, respectively (P.001). .... Surgical resection should be attempted for hepatic colorectal metastases, as this is associated with prolonged overall survival. Hepatic artery infusion pump insertion seems to prolong overall survival for those with unresectable hepatic metastases, but it is not equal to resection. Aggressive surgical management of patients with hepatic colorectal metastases is safe, may prolong overall survival, and therefore should be considered in all patients with metastases confined to the liver. Fetch PMID: 11231853 Surg Oncol 2000 Aug;9(2):71-5 Recurrent gastrointestinal stromal sarcomas. Eilber FC, Rosen G, Forscher C, Nelson SD, Dorey F, Eilber FR. Division of Surgical Oncology, 54-140 CHS, UCLA Medical Center, Los Angeles, CA 90095-1782, USA. Gastrointestinal stromal sarcomas, formerly categorized as leiomyosarcomas of gastrointestinal origin, have a common pattern of intraperitoneal dissemination. Despite surgical resection with or without adjuvant systemic chemotherapy the vast majority of these patients succumb to intraperitoneal sarcomatosis and/or hepatic metastases. ... we and several other centers have begun treating these patients with intraperitoneal chemotherapy. We have found that aggressive surgical resection with postoperative intraperitoneal chemotherapy has significantly lowered the peritoneal recurrence rate in patients with recurrent gastrointestinal stromal sarcomas as compared to those who have undergone surgical resection alone. However, this treatment approach has proven to be ineffective in preventing hepatic metastases, and thus has had little effect upon overall survival. With the treatment of primary rather than recurrent disease we hope to interrupt the disease process at an earlier stage ... Fetch PMID: 11094326 Med Oncol 2000 Aug;17(3):163-73 Global approach to hepatic metastases from colorectal cancer: indication and outcome of intra-arterial chemotherapy and other hepatic-directed treatments. Fiorentini G, Poddie DB, Giorgi UD, Guglielminetti D, Giovanis P, Leoni M, Latino W, Dazzi C, Cariello A, Turci D, Marangolo M. Department of Oncology and Hematology, City Hospital, Ravenna, Italy. g.fiorentini@iol.it Liver metastases of colorectal cancer ...[has] a life-threatening prognostic aspect. Hepatic resection, when possible, is the best therapeutic modality, although the overall survival rate is still low (30%). Angiography and intraoperative ultrasonography are useful for resection. The number of hepatic metastases and the surgical margin are probably the most significant prognostic factors. ... Subtotal hepatic resections and segmentectomies are potentially curable procedures for single or small numbers of hepatic metastases without other sites of disease. However, there have been no prospective randomized trials comparing patients with unresected liver metastases and resected metastases. Regional chemotherapy ... seems useful combined with hepatic resection or as palliative therapy. ... Patients with localized, unresectable hepatic metastases or concomitant bad medical condition may be candidates for radiation, percutaneous ethanol injection, cryosurgery, percutaneous radiofrequency, hypoxic flow-stop perfusions with bioreductive alkylating agents, hepatic arterial ligation, embolization and chemoembolization. These new hepatic-directed modalities of treatment are being investigated and may offer new approaches to providing palliation and prolonging survival. ... Fetch PMID: 10962525 Cancer 2000 Jul 15;89(2):276-84 Microwave coagulation therapy for multiple hepatic metastases from colorectal carcinoma. Shibata T, Niinobu T, Ogata N, Takami M. Department of Surgery, Toyonaka Municipal Hospital, Osaka, Japan. ...Compared with other treatments, microwave coagulation is a relatively less invasive treatment for various kinds of solid tumors. Although its effectiveness in primary hepatocellular carcinoma has been shown, its effectiveness in the treatment of hepatic metastases from colorectal carcinoma has been unclear. ... One-, 2-, and 3-year survival rates and mean survival times were 71%, 57%, 14%, and 27 months, respectively, in the microwave group, whereas they were 69%, 56%, 23%, and 25 months, respectively, in the hepatectomy group.[no significant difference in these results... ...Microwave coagulation therapy is suggested to be equally effective as hepatic resection in the treatment of multiple (two to nine) hepatic metastases from colorectal carcinoma, whereas its surgical invasiveness is less than that of hepatic resection. Copyright 2000 American Cancer Society. Clinical trial Randomized controlled trial Fetch PMID: 10918156 Surg Clin North Am 2000 Apr;80(2):603-32 Hepatic malignancies. Tsao JI, DeSanctis J, Rossi RL, Oberfield RA. Department of Surgery, Tufts University School of Medicine, Burlington, Massachusetts, USA. The battle against malignancies of the liver is far from over, although tremendous strides have been made in the past decade, such as improved diagnostic capabilities, safe surgical resection, availability of safe nonsurgical ablative modalities, multimodality therapy, and aggressive approach to recurrent disease. ...The battle continues in the laboratories, where investigations are focused on delineating the pathophysiology of cancer on the molecular and genetic levels and mapping the patterns of cancer emergence and spread. ... Fetch PMID: 10836009 Baillieres Best Pract Res Clin Gastroenterol 1999 Dec;13(4):557-74 Surgical treatment of malignant liver tumours. DeMatteo RP, Fong Y, Blumgart LH. Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York,USA. Surgical resection is the mainstay of treatment for malignant liver tumours and offers the only chance of cure. Advances in radiological imaging, surgical technique and peri-operative management have enabled liver resection to be performed safely. Partial hepatectomy ... may be utilized for selected patients with liver metastases from other primary tumours. .... The role of cryosurgery has not been precisely defined, and it needs to be compared with other palliative therapies such as ethanol injection and hepatic artery embolization. Fetch PMID: 10654920 Ann Surg 1999 Dec;230(6):759-65; discussion 765-6 Does the subspecialty of the surgeon performing primary colonic resection influence the outcome of patients with hepatic metastases referred for resection? Wigmore SJ, Madhavan K, Currie EJ, Bartolo DC, Garden OJ. University Department of Surgery, Royal Infirmary of Edinburgh, United Kingdom. ... To compare resection rates and outcome of patients subsequently referred with hepatic metastases whose initial colon cancers were resected by surgeons with different specialty interests. ...Variation in practice among noncolorectal specialist surgeons has led to recommendations that colorectal cancers should be treated by surgeons trained in colorectal surgery or surgical oncology. ...The resectability of metastases, the frequency and pattern of recurrence after resection, and the length of survival were compared in patients referred to a single center for resection of colorectal hepatic metastases. The patients were divided into those whose colorectal resection had been performed by general surgeons (GS) with other subspecialty interests (n = 108) or by colorectal specialists (CS; n = 122). ...No differences were observed with respect to age, sex, tumor stage, site of primary tumor, or frequency of synchronous metastases. Comparing the GS group with the CS group, resectable disease was identified in 26% versus 66%, with tumor recurrence after a median follow-up of 19 months in 75% versus 44%, respectively. Recurrences involving bowel or lymph nodes accounted for 55% versus 24% of all recurrences, with respective median survivals of 14 months versus 26 months. CONCLUSION: Fewer patients referred by general surgeons had resectable liver disease. After surgery, recurrent tumor was more likely to develop in the GS group; their overall outcome was worse than that of the CS group. This observation is partly explained by a lower local recurrence rate in the CS group. [Ed. Expertise makes a difference. Choose your surgeon and your other doctors carefully. It usually is a good idea to find a specialist or subspecialist in the field.] Fetch PMID: 10615930 Liver Transpl Surg 1999 Jan;5(1):65-80 Management of hepatic metastases. Choti MA, Bulkley GB. Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. Although the liver is the most common site of metastatic disease from a variety of tumor types, isolated hepatic metastases most commonly occur from colorectal cancer and, less frequently, from ... gastrointestinal sarcoma, .... Complete evaluation of the extent of metastatic disease, both intrahepatically and extrahepatically, is important before considering treatment options. Based on a preponderance of uncontrolled studies for hepatic metastatic colorectal carcinoma, surgical resection offers the only potential for cure of selected patients with completely resected disease, with 5-year survival rates of 25% to 46%. Systemic and hepatic arterial infusion chemotherapy may be useful treatment options in patients with unresectable disease and possibly as an adjuvant treatment after liver resection. Other techniques of local tumor ablation, including cryotherapy and radiofrequency ablation, although promising, remain unproved. Management of hepatic metastases from .. noncolorectal primary tumors should be individualized based on the patient's clinical course, extent of disease, and symptoms. Fetch PMID:9873095 Br J Surg 1998 Oct;85(10):1423-7 Results of surgical resection of liver metastases from non-colorectal primaries. Berney T, Mentha G, Roth AD, Morel P. Clinic of Digestive Surgery, Geneva University Hospital, Switzerland. ... Advances in the field of liver surgery have lowered its associated mortality and morbidity rates, and hepatic resection for metastatic disease is increasingly performed. There are few well defined guidelines for the heterogeneous group of non-colorectal metastases. ... A retrospective study was performed of 34 patients who underwent 37 operations over a 10-year period. Compilation of data from 141 patients from eight additional recent series was performed in order to analyse the effect of histological type on survival. ...There were no perioperative deaths. Complications occurred after seven of 37 procedures. Actuarial survival rates were 61, 43 and 27 per cent at 1, 2 and 5 years. Survival was significantly improved for curative versus palliative resection (P < 0.05), and for single versus multiple metastases (P < 0.05). A strong correlation was observed between time to presentation with metastasis and length of survival (P< 0.0001). ... CONCLUSION: The low mortality and morbidity rates and the satisfactory survival figures reported justify this type of surgery for selected patients, in the absence of therapeutic alternatives. Fetch PMID: 9782030 Aust N Z J Surg 1998 Oct;68(10):716-21 One hundred liver resections including comparison to non-resected liver-mobilized patients. Hardy KJ, Fletcher DR, Jones RM. Department of Surgery, University of Melbourne, Austin Campus, Victoria, Australia. surgery@austin.unimelb.edu.au ...Major hepatic resection can be performed with low mortality, morbidity and short hospital stay, with a 5-year survival for colorectal carcinoma better than 50%. ... Re-resection is a safe and rewarding treatment and needs to be planned at the first resection. Fetch PMID: 9768608 Am Surg 1998 Mar;64(3):211-20; discussion 220-1 Surgical and nonsurgical management of primary and metastatic liver tumors. Zibari GB, Riche A, Zizzi HC, McMillan RW, Aultman DF, Boykin KN, Gonzalez E, Nandy I, Dies DF, Gholson CF, Holcombe RF, McDonald JC. Louisiana State University Medical Center, Department of Surgery, Shreveport 71130, USA. The medical records of 267 patients who had liver tumors, primary and metastatic, from 1988 to 1995 were retrospectively reviewed. ... The patients who underwent surgery had a 32 per cent 5-year survival rate compared to a 0 per cent 5-year survival in the patients who did not have surgery (p = 0.0001). The patients who had resections had a better survival rate than those deemed unresectable at surgery (62% versus 0% at 5-years with p = 0.0008). The perioperative morbidity rate was 16 per cent, with lobectomies having the best rate and trisegmentectomies having the worst. Perioperative mortality rate was zero for all liver resections. Hepatic resection and, in selected patients, liver transplantation are the only two available therapeutic modalities that produce long-term survival with a possible cure in patients with primary and metastatic liver tumor. Fetch PMID: 9520809 Eur J Surg 1996 Sep;162(9):709-15 Repeat resection of recurrent hepatic metastases--improvement in prognosis? Riesener KP, Kasperk R, Winkeltau G, Schumpelick V. Department of Surgery, Medical Faculty, Rhenish Westphalian Technical University, Aachen, Germany. ... To find out if resection of recurrent hepatic metastases improves survival. ... 25 patients who had recurrent metastases after radical resection of hepatic metastases from colorectal and other primary carcinomas. ... Repeat liver resection with the intention to cure. .... Actuarial survival rates after radical repeat liver resections were 94% after one year, 53% after two years, and 24% after three years. ... CONCLUSIONS: Repeat hepatic resections seem to improve prognosis and are recommended in patients with recurrent metastases confined to the liver. Fetch PMID: 8908452 Ann Surg 1999 Sep;230(3):309-18; discussion 318-21 Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer: analysis of 1001 consecutive cases. Fong Y, Fortner J, Sun RL, Brennan MF, Blumgart LH. Hepatobiliary Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York City, New York 10021, USA. ... data for 1001 consecutive patients undergoing liver resection for metastatic colorectal cancer ...were examined. These resections included 237 trisegmentectomies, 394 lobectomies, and 370 resections encompassing less than a lobe. The surgical mortality rate was 2.8%. ...: The 5-year survival rate was 37%, and the 10-year survival rate was 22%. Seven factors were found to be significant and independent predictors of poor long-term outcome by multivariate analysis: positive margin (p = 0.004), extrahepatic disease (p = 0.003), node-positive primary (p = 0.02), disease-free interval from primary to metastases <12 months (p = 0.03), number of hepatic tumors >1 (p = 0.0004), largest hepatic tumor >5 cm (p = 0.01), and carcinoembryonic antigen level >200 ng/ml (p = 0.01). When the last five of these criteria were used in a preoperative scoring system, assigning one point for each criterion, the total score was highly predictive of outcome (p < 0.0001). No patient with a score of 5 was a long-term survivor. CONCLUSION: Resection of hepatic colorectal metastases may produce long-term survival and cure. Long-term outcome can be predicted from five criteria that are readily available for all patients considered for resection. Patients with up to two criteria can have a favorable outcome. Patients with three, four, or five criteria should be considered for experimental adjuvant trials. Studies of preoperative staging techniques or of adjuvant therapies should consider using such a score for stratification of patients. Fetch PMID: 10493478 Can J Surg 1997 Jun;40(3):175-81 Long-term survival after hepatic cryosurgery versus surgical resection for metastatic colorectal carcinoma: a critical review of the literature. Tandan VR, Harmantas A, Gallinger S. Department of Surgery, University of Toronto, Mount Sinal Hospital, Ont. ...To critically assess the evidence for long-term survival after hepatic resection and hepatic cryosurgery for metastatic colorectal cancer. The purpose of this review is to determine if a randomized controlled trial comparing these two treatment modalities is justified. ... : Although hepatic cryosurgery offers some unequivocal and other potential advantages over surgical resection for colorectal metastases to the liver, the published data do not support its use in patients with resectable disease outside a clinical trial, and do not yet justify a randomized trial. A study that collects prospective data on 2 groups of patients (resectable v. unresectable) who differ only in the anatomic location of their metastases within the liver is needed. Fetch PMID: 9194777

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