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. 2024 Nov 14;56(1):19.
doi: 10.1007/s12029-024-01139-y.

The Extent of Tumor in the Peritoneum and Liver Influences Outcomes After Surgery for Synchronous Liver and Peritoneal Colorectal Metastases: A Cohort Study

Pearl Sanchez Salas  1   2 , Jozef Urdzik  3   4 , Wilhelm Graf  3   4 , Bengt Isaksson  3   4 , Helgi Birgisson  3   4
Affiliations

The Extent of Tumor in the Peritoneum and Liver Influences Outcomes After Surgery for Synchronous Liver and Peritoneal Colorectal Metastases: A Cohort Study

Pearl Sanchez Salas et al. J Gastrointest Cancer. .

Abstract

Purpose: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRSH) or liver resection have led to increased survival in patients with peritoneal or liver metastases of colorectal cancer. Selected patients undergo concomitant CRSH and liver resection. Differences in survival and morbidity between patients who underwent concomitant surgery, CRSH or liver resection for peritoneal and/or liver metastases were compared.

Methods: Patients who underwent liver resection and/or CRSH for colorectal liver and/or peritoneal metastases, 2006-2016, were included. Regression analysis was used to evaluate the associations between baseline characteristics and survival.

Results: Overall, 634 patients were studied. Twenty-eight patients had peritoneal and liver metastases, 121 patients had peritoneal metastases only, and 485 patients had isolated liver metastases. Median survival after concomitant treatment was 23.8 months (95% CI 12.8-43.8), after CRSH 34.5 months (95% CI 27.1-41.9), and after liver resection 54.2 months (95% CI 47.4-61.0) (p < 0.001). Increased hepatic tumor burden (HR 3.2, 95% CI 1.8-5.8) and high-volume peritoneal disease (HR 6.0, 95% CI 3.7-9.8) were associated with decreased survival in multivariate analysis. Postoperative complications according to a Clavien-Dindo score > 3a were observed in 11% in the liver resection group, 15% in the CRSH group, and 11% in the concomitant treatment group (p = 0.945).

Conclusions: Patients treated with concomitant surgery for liver and peritoneal metastases experienced a shorter median overall survival than patients treated for metastases at an isolated site but had a similar rate of severe postoperative complications. The extent of peritoneal spread seemed to impact survival more than the tumor burden in the liver.

Keywords: CRS; Colorectal cancer; HIPEC; Liver metastases; Liver resection; Peritoneal metastases.

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Conflict of interest statement

Declarations Ethics Approval The study was approved by the Swedish Ethical Review Authority in Uppsala (Dnr. 2013/203 and 2018/086). Consent to Participate Not applicable. All patient data is presented at group level and is unidentifiable. Consent for publication Not applicable. Competing Interests The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Consort diagram. Consort diagram for the 639 patients who underwent primary surgery for colorectal cancer metastases in the peritoneum and/or liver. LRx, liver resection; CRSH, cytoreductive surgery and hyperthermic intraperitoneal chemotherapy; CRSH + LRx, concomitant CRSH and LRx; CCS, Completeness of Cytoreduction Score; PCI, Peritoneal Cancer Index
Fig. 2
Fig. 2
Operation Type. Overall survival for 634 patients after surgery for liver and/or peritoneal metastases with either LRx (liver resection only), CRSH + LRx (cytoreductive surgery, hyperthermic intraperitoneal chemotherapy, and liver resection), or CRSH (cytoreductive surgery and hyperthermic intraperitoneal chemotherapy only). The median survival times were 54.2 months (95% CI 47.6–61.0) for LRx, 23.8 months (95% CI 12.8–34.8) for CRSH + LRx and 34.5 months (95% CI 27.1–41.9) for CRSH. A log rank (Mantel Cox) p-value < 0.001 was used
Fig. 3
Fig. 3
PCI. Overall survival for 634 patients after surgery for liver and/or peritoneal metastases based on the PCI (Peritoneal Cancer Index) of peritoneal metastases. LM only (liver metastases only), PCI ≤ 20 or PCI > 20). The median survival times were 54.2 months (95% CI 47.6–61.0) for LM only patients (same group as the LRx patients in Fig. 2), 37.6 months (95% CI 27.0–48.3) for patients with a PCI ≤ 20 and 20.4 months (95% CI 16.3–24.6) for patients with a PCI > 20. A log rank (Mantel Cox) p-value < 0.001 was used
Fig. 4
Fig. 4
TBS. Overall survival for 634 patients after surgery for liver and/or peritoneal metastases based on the TBS (Tumor Burden Score) of liver metastases. PM only (peritoneal metastases only), TBS < 3, TBS 3–6, or TBS > 6. The median survival times were 34.5 months (95% CI 27.1–41.9) for the PM only patients (same group as the CRSH patients in Fig. 2), 66.5 months (95% CI 52.6–80.4) for patients with a TBS < 3, 49.3 months (95% CI 42.2–56.5) for patients with a TBS of 3–6 and 35.9 months (95% CI 26.2–45.7) for patients with a TBS > 6. A log rank (Mantel Cox) p-value < 0.001 was used
Fig. 5
Fig. 5
Recurrence free survival after CRSH and CRSH + LRx. Recurrence free survival for 118 of 149 patients (15 patients were excluded due to CCS = 1 and 16 patients had missing data) after surgery for peritoneal and liver metastases only or peritoneal metastases only with either CRSH + LRx (cytoreductive surgery, hyperthermic intraperitoneal chemotherapy and liver resection), or CRSH (cytoreductive surgery and hyperthermic intraperitoneal chemotherapy only). The median survival times were 9.7 months (95% CI 8.6–12.3) for CRSH + LRx and 12.6 months (95% CI 10.0–17.0) for CRSH. A log rank (Mantel Cox) p-value < 0.008 was used
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