Resection of the liver for colorectal carcinoma metastases: A multi- institutional study of indications for resection

In an investigation of the indications for hepatic resection in the treatment of colorectal carcinoma metastases, the records of 859 patients who had undergone this procedure were reviewed. This patient group, from 24 institutions, was found to have a 5-year actuarial survival of 33% and a 5year actuarial disease-free survival of 21%. The only factors that might by themselves be considered contraindications to hepatic resection are the presence of positive hepatic nodes, the presence of resectable extrahepatic metastases, or the presence of four or more metastases. Other factors that had a negative effect on long-term survival were margins of resection on the liver metastases less than or equal to 1 cm (S [5-year actuarial survival = 23%), the presence of positive mesenteric nodes in the primary tumor specimen (S = 23%), and a disease-free interval of less than 1 year (S = 24%). The effect of any one of these factors was not great enough to contraindicate resection. However, combinations of prognostic factors must be considered before resection is recommended. The overall 5-year survival rate for this large series has been very satisfying. Decision making in the future must take into account such factors as number of metastases, extrahepatic involvement, and stage of the primary tumor. Hepatic resection is the only curative treatment currently available for colorectal carcinoma metastases to the liver, and it is estimated that every year approximately 6,000 to 12,000 patients in the United States are candidates for this procedure.1,2 Previous studies suggest that the 5-year survival from this procedure is in the range of 25% to 35%.2–22 However, at this time, only an estimated 1,000 hepatic resections are done each year in the United States Reprint requests: Kevin S. Hughes, M.D., Department of Surgery, University of California, Davis, 4301 X St., Sacramento, CA 95817. *Kevin S. Hughes, M.D., National Cancer Institute, Bethesda, Md.; Richard Simon, Ph.D., National Cancer Institute; Sate Songhorabodi, M.S., National Cancer Institute; Martin A. Adson, M.D., Mayo Clinic, Rochester, Minn.; Duane M. Ilstrup, M.S., Mayo Clinic; Joseph G. Former, M.D., Memorial Sloan-Kettering Cancer Center, New York, N.Y.; Barbara J. Maclean, B.S., Memorial Sloan-Kettering Cancer Center; James H. Foster, M.D., University of Connecticut, Farmington, Conn.; John M. Daly, M.D., Memorial Sloan-Kettering Cancer Center; Diane Fitzherbert, R.N., Memorial Sloan-Kettering Cancer Center; Paul H. Sugarbaker, M.D., National Cancer Institute; Shunzaboro Iwatsuki, M.D., University of Pittsburgh, Pittsburgh, Pa.; Thomas Starzl, M.D., University of Pittsburgh; Kenneth P. Ramming, M.D., University of California, Los Angeles, Calif.; William P. Longmire, Jr., M.D., University of California; Kathy O’Toole, R.N., University of California; Nicholas J. Petrelli, M.D., Roswell Park, Buffalo, N.Y.; Lemuel Herrera, M.D., Roswell Park; Blake Cady, M.D., New England Deaconess Hospital, Boston, Mass.; William McDermott, M.D., New England Deaconess Hospital; Thomas Nims, M.D., Grant Hospital, Columbus, Ohio; Warren E. Enker, M.D., Memorial Sloan-Kettering Cancer Center; Gene F. Coppa, M.D., New York University; Leslie H. Blumgart, M.D., Hammersmith Hospital, London, England; Howard Bradpiece, M.D., Hammersmith Hospital; Marshall Urist, M.D., University of Alabama, Birmingham, Ala.; Joaquin S. Aldrete, M.D., University of Alabama; Peter Schlag, M.D., Klinikum der Universitat Heidelberg, Heidelberg, W. Germany; Peter Hohenberger, M.D., Klinikum der Universitat Heidelberg; Glenn Steele, Jr., M.D., New England Deaconess Hospital; W. John Hodgson, M.D., New York Medical College, Valhalla, N.Y.; Thomas G. Hardy, M.D., Central Ohio Colon and Rectal Center, Columbus, Ohio; Denise Harbora, R.N., Cross Cancer Institute, Alberta, Canada; T. Alexander McPherson, M.D., Cross Cancer Institute; Christopher Lim, M.D., Cross Cancer Institute; Daniel Dillon, M.D., The Mercy Hospital of Pittsburgh, Pittsburgh, Pa.; Richard Happ, M.D., The Mercy Hospital of Pittsburgh; Phillip Ripepi, M.D., The Mercy Hospital of Pittsburgh; Edward Villella, M.D., The Mercy Hospital of Pittsburgh; Ricardo L. Rossi, M.D., Lahey Clinic, Burlington, Mass.; Stephen G. Remine, M.D., Lahey Clinic; Mary Oster, B.S., Lahey Clinic; David P. Connolly, M.D., St. Margaret’s Hospital, Pittsburgh, Pa.; Jerome Abrams, M.D., University of Vermont, Burlington, Vt.; Adel Al-Jurf, M.D., University of Iowa, Iowa City, Iowa; K. E. F. Hobbs, M.D., Royal Free Hospital, London, England; Michael K. W. Li, M.D., Royal Free Hospital; Ted Howard, M.D., Kings College Hospital, London, England; Emonuel Lee, M.D., John Radcliffe Infirmary, Oxford, England. NIH Public Access Author Manuscript Surgery. Author manuscript; available in PMC 2010 December 21. Published in final edited form as: Surgery. 1988 March ; 103(3): 278–288. N IH PA Athor M anscript N IH PA Athor M anscript N IH PA Athor M anscript (personal communication). The limited use of this procedure stems from three common beliefs: (1) Hepatic metastases are fatal regardless of treatment, (2) hepatic resection is effective only for solitary metastases, and (3) hepatic resection results in extreme morbidity and a high mortality rate. The third belief can be readily dismissed, as the mortality rate for hepatic resection has been addressed in several previous articles and is only about 5%.3–6 This is a rate considered acceptable for a major surgical procedure. The purpose of this article is to evaluate the first two beliefs. A collaborative effort involving 24 institutions intimately involved in hepatic resection provided data on a large series of patients in order to answer questions regarding the indications and contraindications to hepatic resection. Our results indicate that 5-year survival of patients is not unusual after hepatic resection and that multiple metastases, bilobar metastases, or large metastases are not, in themselves, contraindications to this procedure.