Effect of surgical margin status on survival and site of recurrence after hepatic resection for colorectal metastases

Abstract

Objective: To evaluate the influence of surgical margin status on survival and site of recurrence in patients treated with hepatic resection for colorectal metastases.

Methods: Using a multicenter database, 557 patients who underwent hepatic resection for colorectal metastases were identified. Demographics, operative data, pathologic margin status, site of recurrence (margin, other intrahepatic site, extrahepatic), and long-term survival data were collected and analyzed.

Results: On final pathologic analysis, margin status was positive in 45 patients, and negative by 1 to 4 mm in 129, 5 to 9 mm in 85, and > or =1 cm in 298. At a median follow-up of 29 months, the 1-, 3-, and 5-year actuarial survival rates were 97%, 74%, and 58%; median survival was 74 months. Tumor size > or =5 cm, >3 tumor nodules, and carcinoembryonic antigen level >200 ng/mL predicted poor survival (all P < 0.05). Median survival was 49 months in patients with positive margins and not yet reached in patients with negative margins (P = 0.01). After hepatic resection, 225 (40.4%) patients had recurrence: 21 at the surgical margin, 56 at another intrahepatic site, 82 at an extrahepatic site, and 66 at both intrahepatic and extrahepatic sites. Patients with negative margins of 1 to 4 mm, 5 to 9 mm, and > or =1 cm had similar overall recurrence rates (P > 0.05). Patients with positive margins were more likely to have surgical margin recurrence (P = 0.003). Adverse preoperative biologic factors including tumor number greater than 3 (P = 0.01) and a preoperative CEA level greater than 200 ng/mL (P = 0.04) were associated with an increased risk of positive surgical margin.

Conclusions: A positive margin after resection of hepatic colorectal metastases is associated with adverse biologic factors and increased risk of surgical-margin recurrence. The width of a negative surgical margin does not affect survival, recurrence risk, or site of recurrence. A predicted margin of <1 cm after resection of hepatic colorectal metastases should not be used as an exclusion criterion for resection.

FIGURE 1. Imaging patterns of marginal recurrences in 2 patients. A, Contrast-enhanced computed tomography obtained 11 months after right hepatectomy shows perfusion changes along surgical margin but no tumor recurrence. B, Contrast-enhanced CT obtained 3 months after A shows hypoattenuating tumor nodule (arrow) abutting the surgical margin. C, Contrast-enhanced computed tomography obtained 17 months after right hepatectomy in another patient shows surgical clips and no recurrence. D, Contrast-enhanced computed tomography obtained 5 months after C shows recurrent tumor infiltrating the surgical margin and adjacent perihepatic tissues (arrows).

FIGURE 2. Distribution by size of the surgical resection margin (n = 557).

FIGURE 3. At a median follow-up of 29 months, the overall median survival for patients after resection of CRM was 74.3 months. The 1-, 3-, and 5-year survival rates were 97%, 74%, and 58%, respectively.

FIGURE 4. Survival stratified by margin status. Median survival was 49.6 months in patients with positive margins and not yet reached in patients with negative margins (P = 0.005). No significant difference in survival was seen in patients with a negative surgical margin, regardless of the width of the margin (all P > 0.5).