High survival rate after two-stage resection of advanced colorectal liver metastases: response-based selection and complete resection define outcome

Abstract

Purpose: Prolonged survival after two-stage resection (TSR) of advanced colorectal liver metastases (CLM) may be the result of selection of best responders to chemotherapy. The impact of complete resection in this well-selected group is controversial.

Patients and methods: Data on 890 patients undergoing resection and 879 patients who received only chemotherapy for CLM were collected prospectively. We used intent-to-treat analysis to evaluate the survival of patients who underwent TSR. Additionally, we evaluated a cohort of nonsurgically treated patients selected to mirror the TSR population: colorectal metastases with liver-only disease, objective response to chemotherapy, and alive 1 year after chemotherapy initiation.

Results: Sixty-five patients underwent the first stage of TSR; 62 patients fulfilled the inclusion criteria for the medical group. TSR patients had a mean of 6.7 ± 3.4 CLM with mean size of 4.5 ± 3.1 cm. Nonsurgical patients had a mean of 5.9 ± 2.9 CLM with mean size of 5.4 ± 3.4 cm (not significant). Forty-seven TSR patients (72%) completed the second stage. Progression between stages was the main cause of noncompletion of the second stage (61%). After 50 months median follow-up, the 5-year survival rate was 51% in the TSR group and 15% in the medical group (P = .005). In patients who underwent TSR, noncompletion of TSR and major postoperative complications were independently associated with worse survival.

Conclusion: TSR is associated with excellent outcome in patients with advanced CLM as a result of both selection by chemotherapy and complete resection of metastatic disease.

Fig 1.

Advanced bilateral colorectal liver metastases at diagnosis (A), after preoperative chemotherapy with infusional fluorouracil, leucovorin, and oxaliplatin plus bevacizumab for five cycles (B), after the first-stage hepatectomy (C), after right portal vein embolization extended to segment IV (D), and after the second stage hepatectomy (E). White arrows indicate surgical defect after the first-stage hepatectomy; black arrowheads indicate the coils after right portal vein embolization extended to segment IV.

Fig 2.

Selection of patients with advanced bilateral colorectal liver metastases (CLM) treated with chemotherapy for inclusion in the nonsurgically treated population for this study. CRC, colorectal cancer. (*) Performance status (PS) according to the Eastern Cooperative Oncology Group scoring system.

Fig 3.

Overall survival in patients with advanced bilateral colorectal liver metastases (CLM) responding to chemotherapy enrolled in two-stage strategy (intent-to-treat analysis including patients undergoing only the first stage of two-stage hepatectomy) or receiving chemotherapy only (A) and stratified on the basis of whether two-stage resection was completed (B).