Patients who present with liver-only colorectal cancer (CRC)-related metastases (CLM) may be candidates for resection of the liver metastases through a two stage resection (TSR) procedure. TSR requires an area of the liver to be relatively spared by disease because the surgeon must be able to resect all CLM while preserving a sufficient future liver remnant (20% of total liver volume) and adequate vascular inflow and outflow.1 Patients eligible for TSR undergo liver resection at the time of diagnosis, systemic chemotherapy and then return to the surgical service for secondary resection of any remaining liver metastases. Candidates for TSR are selected on the basis of the presenting extent and location of bilateral CLM and the response to first-line chemotherapy.2
Brouquet and colleagues2 conducted a retrospective study to compare outcomes of patients undergoing at least the first stage of TSR with nonsurgically treated (i.e., treated with chemotherapy and biotherapy only) patients responding to modern chemotherapy. They hypothesized that prolonged survival after TSR of advanced CLM may be the result of selection of best responders to chemotherapy.2
The study population included 65 patients who underwent the first stage of TSR and 62 patients who fulfilled the inclusion criteria for the nonsurgical group.2
Results reported by the investigators included: 2
- TSR patients had a mean of 6.7 ± 3.4 CLM with mean size of 4.5 ± 3.1 cm.
- Nonsurgical patients had a mean of 5.9 ± 2.9 CLM with mean size of 5.4 ± 3.4 cm (not statistically significant).
- 47 (72%) TSR patients completed the second stage resection.
- Among the 65 patients who underwent the first-stage hepatectomy, 47 patients (72%) underwent the second-stage hepatectomy, a mean of 8 ± 4 weeks after the first stage.
- Progression between stages was the main cause of noncompletion of the second stage (61%).
- After 50 months median follow-up, the 5-year survival rate was 51% in the TSR group and 15% in the medical group (P = .005).
- In patients who underwent TSR, noncompletion of TSR and major postoperative complications were independently associated with worse survival.
The investigators concluded that complete TSR is associated with excellent outcome in patients with advanced bilateral CLM who respond to chemotherapy. The survival benefit associated with this aggressive surgical approach is due to (1) selection of patients with favorable tumor biology by preoperative chemotherapy, (2) selection of patients with adequate liver hypertrophy and good performance status, and (3) complete resection of metastatic disease.2
The rationale for studying this subset of patients with advanced CRC is that TSR strategy was introduced during the same period as new, more effective cytotoxic agents (oxaliplatin and irinotecan), monoclonal antibodies targeting the vascular endothelial growth factor (bevacizumab) and the epidermal growth factor receptor (cetuximab and panitumumab). TSR is a complex approach, which combines the difficulties associated with repeat hepatectomy with the difficulties associated with surgery on a regenerative liver. Brouquet and colleagues reported a 90-day mortality rate of 6 % and a 49% morbidity rate after the second stage of hepatectomy2 which is consistent with previously reported mortality and morbidity rates after TSR. Although a retrospective study is less rigorous than a randomized controlled trial (RCT), RTCs are unlikely because of the small subset of patients who are potential candidates for this approach (< 10% of patients with advanced colorectal cancer).2 Oncology healthcare providers should consider the efficacy of modern CRC chemotherapeutic approaches when evaluating patients for two-stage surgical interventions.
Charnsangavej C, Clary B, Fong Y, et al. Selection of patients for resection of hepatic colorectal metastases: Expert consensus statement. Ann Surg Oncol. 2006; 13:1261–1268. doi:10.1245/s10434-006-9023-y Link to free full text http://www.springerlink.com/content/g10w837448g53v54/fulltext.pdf
- Brouquet A, Abdalla EK, Kopetz S, et al. High survival rate after two-stage resection of advanced colorectal liver metastases: Response-based selection and complete resection define outcome. J Clin Oncol. 2011; 29:1083-1090. doi:10.1200/JCO.2010.32.6132 Link to abstract http://jco.ascopubs.org/content/early/2011/01/24/JCO.2010.32.6132.abstract