title: Resection of nonresectable liver metastases from colorectal cancer after neoadjuvant chemotherapy.
abstract: OBJECTIVE
  The authors discuss the technique and evaluate the results of an aggressive surgical approach in patients with primarily unresectable colorectal liver metastases that were downstaged by chronomodulated chemotherapy.
  
  
  BACKGROUND
  Resection is the best treatment of colorectal liver metastases, but it may be achieved in only 10% of patients. In the remaining 90%, survival is poor, even after partial response to chemotherapy. Little is known about the results of curative hepatectomy in patients whose metastases are downstaged by chemotherapy.
  
  
  METHODS
  Fifty-three patients with colorectal liver metastases initially unresectable because of ill located (8), large (8), multinodular (24) lesions, or because of extrahepatic disease (13) were downstaged by a systemic chronomodulated chemotherapy associating 5-fluorouracil, folinic acid and Oxaliplatin to the point that operation could be performed. This consisted of a major hepatectomy in 37 patients and a minor resection in 16. Associated procedures (including 5 two-stage hepatectomies and 3 pulmonary resections) were performed in 25 patients.
  
  
  RESULTS
  There was no operative mortality. Complications occurred in 14 patients. The cumulative 3- and 5-year survival rates were 54% and 40% (according to the type of lesions: ill-located, 75% and 48%; large, 62% and 62%; multinodular, 54% and 40%; extrahepatic, 43% and 14%). Hepatic recurrence (34 patients, 64%) was amenable to repeat surgery in 15 cases.
  
  
  CONCLUSIONS
  Liver resection may be achieved in some previously unresectable patients with the help of an effective chemotherapy. The benefit in survival seems comparable to that obtained with primary liver resection (40% at 5 years). This therapeutic strategy involves a multimodal approach, including repeat hepatectomies and extrahepatic surgery.
authors.affiliation: Hepatobiliary Surgery and Liver Transplant Research Center, Laboratory of Biological and Chronotherapeutical Rhythms, Hôpital Paul Brousse, Villejuif, France.
authors.forename: H
authors.initials: H
authors.lastname: Bismuth
authors.forename: R
authors.initials: R
authors.lastname: Adam
authors.forename: F
authors.initials: F
authors.lastname: Lévi
authors.forename: C
authors.initials: C
authors.lastname: Farabos
authors.forename: F
authors.initials: F
authors.lastname: Waechter
authors.forename: D
authors.initials: D
authors.lastname: Castaing
authors.forename: P
authors.initials: P
authors.lastname: Majno
authors.forename: L
authors.initials: L
authors.lastname: Engerran
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017024:Chemotherapy, Adjuvant; D015179:Colorectal Neoplasms / Q000401:mortality / Q000473:pathology*; D005260:Female; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000556:secondary* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis; D009364:Neoplasm Recurrence, Local; D011183:Postoperative Complications; D015996:Survival Rate