Repeat curative intent liver surgery is safe and effective for recurrent colorectal liver metastasis: results from an international multi-institutional analysis.
BACKGROUND
Although 5-year survival approaches 55% following resection of colorectal liver metastasis, most patients develop recurrent disease that is often isolated to the liver. Although repeat curative intent surgery (CIS) is increasingly performed for recurrent colorectal liver metastasis, only small series have been reported. We sought to determine safety and efficacy of repeat CIS for recurrent colorectal liver metastasis as well as determine factors predictive of survival in a large multicenter cohort of patients.


METHODS
Between 1982 and 2008, 1,706 patients who underwent CIS--defined as curative intent hepatic resection/radiofrequency ablation (RFA)--for colorectal liver metastasis were identified from an international multi-institutional database. Two hundred forty-six (14.4%) patients underwent 301 repeat CIS. Data on clinico-pathologic factors, morbidity, and mortality were collected and analyzed.


RESULTS
Following initial CIS, 645 (37.8%) patients had recurrence within the liver. Of these, 246 patients underwent repeat CIS for recurrent disease. The majority had hepatic resection alone as initial therapy (n = 219; 89.0%). A subset of patients underwent third (n = 46) or fourth (n = 9) repeat CIS. Mean interval between surgeries was similar (first --> second, 19.1 months; second --> third, 21.5 months; third --> fourth, 11.3 months; P = 0.20). Extent of hepatic resection decreased with subsequent CIS (>or=hemihepatectomy: first CIS, 30.9% versus second CIS, 21.1% versus third/fourth CIS, 16.4%; P = 0.004). RFA was utilized in one quarter of patients undergoing repeat CIS (second CIS, 21.1% versus third/fourth CIS, 25.5%). Mortality and morbidity were similar following second, third, and fourth CIS, respectively (all P > 0.05). Five-year survival was 47.1%, 32.6%, and 23.8% following the first, second, and third CIS, respectively. Presence of extra-hepatic disease was predictive of worse survival (HR = 2.26, P = 0.01).


CONCLUSIONS
Repeat CIS for recurrent colorectal liver metastasis can be performed with low morbidity and near-zero mortality. Patients with no extra-hepatic disease are best candidates for repeat CIS. In these patients, repeat CIS can offer the chance of long-term survival.
Department of Surgery, Johns Hopkins University School of Medicine, Harvey 611 600 N Wolfe Street, Baltimore, MD 21287, USA.
Mechteld C
MC
de Jong
Skye C
SC
Mayo
Carlo
C
Pulitano
Serena
S
Lanella
Dario
D
Ribero
Jennifer
J
Strub
Catherine
C
Hubert
Jean-François
JF
Gigot
Richard D
RD
Schulick
Michael A
MA
Choti
Luca
L
Aldrighetti
Gilles
G
Mentha
Lorenzo
L
Capussotti
Timothy M
TM
Pawlik
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017115:Catheter Ablation; D015179:Colorectal Neoplasms / Q000473:pathology*; D005260:Female; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000556:secondary* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D011379:Prognosis; D012086:Reoperation; D015996:Survival Rate; D016896:Treatment Outcome