title: Concomitant extrahepatic disease in patients with colorectal liver metastases: when is there a place for surgery?
abstract: OBJECTIVE
  To evaluate the impact of the location of extrahepatic disease (EHD) on survival and to determine patient outcome in a consecutive series of patients with both intrahepatic and extrahepatic colorectal metastases treated by an oncosurgical approach, combining repeat surgery and chemotherapy.
  
  
  BACKGROUND
  Although recognized as poor prognostic factor, concomitant EHD is no more considered an absolute contraindication to surgery in patients with colorectal liver metastases (CLM). However, the impact of the location of EHD on survival and the benefit in patient outcome is still diversely appreciated.
  
  
  METHODS
  From 840 patients resected for CLM between 1990 and 2006, 186(22%) also had resectable EHD. Sequential surgery was routinely combined with perioperative chemotherapy. Survival was compared with that of patients without EHD, prognostic factors were identified, and a predictive model was designed to better select surgical candidates.
  
  
  RESULTS
  Patients resected for CLM with concomitant EHD experienced a lower 5-year survival than those without EHD (28% vs 55%, P < 0.001). Five poor prognostic factors were identified at multivariate analysis: EHD-location other than lung metastases (5-year survival: 23% vs 33%, P = 0.02), EHD concomitant to CLM recurrence (14% vs 34%, P < 0.001), carcinoembryonic antigen level at least 10 ng/mL (16% vs 37%, P=0.02), at least 6 CLM(9% vs 32%, P = 0.02), and right colon cancer (P = 0.02). Five-year survival ranged from 64% (0 factors) to 0% (>3 factors). In the EHD group, patients with an EHD-recurrence experienced better outcomes when resected than those treated by chemotherapy alone (5-year survival: 38% vs 21%, P = 0.05).
  
  
  CONCLUSIONS
  Although sequential surgery is warranted for patients with 5 or less CLM with isolated lung metastases, low carcinoembryonic antigen levels,and no right colon primary tumor, it should be questioned in the presence of more than 3 of these prognostic factors.
authors.affiliation: AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, 12 Avenue Paul Vaillant Couturier, Villejuif, France. rene.adam@pbr.aphp.fr
authors.forename: René
authors.initials: R
authors.lastname: Adam
authors.forename: Robbert J
authors.initials: RJ
authors.lastname: de Haas
authors.forename: Dennis A
authors.initials: DA
authors.lastname: Wicherts
authors.forename: Eric
authors.initials: E
authors.lastname: Vibert
authors.forename: Chadi
authors.initials: C
authors.lastname: Salloum
authors.forename: Daniel
authors.initials: D
authors.lastname: Azoulay
authors.forename: Denis
authors.initials: D
authors.lastname: Castaing
mesh_terms: D001859:Bone Neoplasms / Q000556:secondary / Q000601:surgery; D015179:Colorectal Neoplasms / Q000473:pathology*; D000075202:Contraindications; D005260:Female; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000556:secondary* / Q000601:surgery*; D008175:Lung Neoplasms / Q000556:secondary / Q000601:surgery; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000601:surgery; D010051:Ovarian Neoplasms / Q000556:secondary / Q000601:surgery; D010534:Peritoneal Neoplasms / Q000556:secondary / Q000601:surgery