Jean-Christophe Vaillant, B Nordinger, S.Deuffic, Jean-Pierre Arnaud, et al (Chirurgie digestive et Oncologique, Hopital Ambroise Pare, France)
Adjuvant Intraperitoneal 5-Fluorouracil in High-Risk Colon Cancer
A Multicenter Phase III Trial
Annals of Surgery, April 2000; 231(4), 449-456
Patients with stage II and III colon cancers are considered at risk of tumor recurrence in the liver and the peritoneum. Systemic adjuvant chemotherapy improves the survival for 6 months. It was therefore decided to conduct a study of the effect of locoregional chemotherapy on tumor recurrence.
Despite promising initial results, adjuvant intraportal chemotherapy produced controversial and very limited results. Therefore, adjuvant intraperitoneal chemotherapy was tried to add a local affect on the peritoneum as well as the liver.
The study was conducted on 267 patients randomly divided into 2 equal groups. One group was operated followed by intraperitoneal administration of 5-FU for 6 days and intraoperative intravenous chemotherapy. The other group underwent resection only.
The results showed an overall 5 year survival of 74% in Group 1, and 69% in Group 2. Disease free survival rates were 68% and 62% respectively. Survival curves were superimposed for first three years and began diverging thereafter.
They conclude that intraperitoneal and short systemic intravenous chemotherapy after surgery may not be sufficient to reduce the risk of death but it reduced the risk of recurrence.
J.Peter Lodge, Basil J.Ammori, K.Rajendra Prasad and M.C. Bellamy (The Centre for Hepatobiliary Diseases and the Department of Anaesthesia, St.James’s University Hospital, Leeds, UK)
Ex-Vivo and In Situ Resection of Inferior Vena Cava with Hepatectomy for Colorectal Metastases.
Annals of Surgery, April 2000; 231(4), 471-479.
Untreated patients with hepatic metastases from colorectal cancer have a poor prognosis with a median survival of less than 1 year. Chemotherapy may have a beneficial effect on the natural history of the unresected hepatic metastases but 5 year survivals are few and far between hepatic resection can achieve prolonged survival (25% – 50%) with a mortality rate of about 5%.
Involvement of the IVC by hepatic tumours is considered inoperable. This study undertook concomitant hepatic and IVC resection to achieve adequate tumour clearance.
158 patients were subjected to hepatic resection surgery in a single unit. Eight patients between the ages of 42 – 80 years underwent concomitant I.V.C resection along with four to six hepatic segments. Resections were carried out under total hepatic vascular occlusion in four patients and ex-vivo in four patients where the I.V.C was replaced by an autogenous vein patch a ringed Gore-Tex tube and a Dacron tube graft or patch or was repaired by primary suturing.
There were two early deaths. One who died from renal cell carcinoma survived 30 months, and the fourth died in the recurrent disease at 9 months.
The four who survived, are alive from 5 to 12 months after surgery. Two of these were free from recurrence while two had recurrences.
The authors conclude that this aggressive approach attendant with considerable surgical risk offers hope to advanced diseased patients who would otherwise have a dismal prognosis.
Daniel Azoulay, Denis Castaing, Alloua Smail, et al (the Centre Hepato-Biliaire, Hopital Paul Brousse, Villejuif, et Universite Paris-Sud, Paris, France)
Resection of Nonresectable Liver Metastases From Colorectal Cancer After Percutaneous Portal Vein Embolism.
Annals of Surgery 231(4), 480-486.
Curative liver resections of colorectal metastases is the only treatment offering a chance of long term survival (25% – 50%) of 5 years. However, it can be performed only in 10% of cases. In order to enable resections in a larger number of cases, preoperative chemotherapy has been used to downstage the disease. When a tumour is very large, the contra-indication is from the paucity of the remnant liver segment leading to liver failure. For this group of patients, preoperative portal vein embolization (PVE) of the liver has been proposed to induce ipsilateral atrophy and contralateral hypertrophy of the remnant liver thus preventing liver failure.
The aim of the study is to assess the influence of preoperative portal vein embolization on the long-term outcome of liver resection for colorectal metastases.
30 patients underwent PVE and 88 patients did not before resection of 4 or more liver segments. The groups were comparable in terms of sex, age, number and type of metastases (synchronous vs metachronous) and number of courses of neoadjuvant chemotherapy.
The main criterion for PVE was that resection was technically feasible but contraindicated because the remnant liver was too small (as estimated by CT scan volumetry). It was done when the estimated rate of remnant functional liver parenchyma (ERRFLP) was 40% or less.
PVE was feasible in all patients. There were no deaths with a complication rate of 3%. The post ERRFLP was significantly increased as compared to pre PVE value. Liver resection was performed in 19 patients (63%) with a mortality of 4% and complication rate of 7%. The survival rates after hepatectomy in both groups were comparable.
The authors conclude that PVE allows more patients with unresectable liver metastases to benefit from surgery.
Masami Minagawa, Masatoshi Makuuchi, Guido Torzilli, et al (Department of Hepato-Biliary-Pancreatic Surgery, the Department of Artificial Organ and Transplantation, Graduate School of Medicine, Univ. of Tokyo, Japan; First Department of Surgery, shinshu University, Matsumoto, Japan; and the Department of Surgery, National Cancer Center, Tokyo, Japan)
Extension of the Frontiers of Surgical Indications in the Treatment of Liver Metastases From Colorectal Cancer.
Annals of Surgery; 231(40, 487-499
Two opposite trends can be recognised in the management of liver metastases from colorectal cancer (1) an aggressive policy that extends the indications for surgery and (2) a less invasive approach with broader indications for more conservative therapies such as interstitial treatment. This study retrospectively evaluates the long term results of our aggressive policy.
235 patients underwent hepatic resection for metastatic colorectal cancer. Survival rates and disease free survival as a function of clinical and pathological determinants were examined retrospectively with univariate and multivariate analyses.
The overall 3, 5, 10 and 15 year survival rates were 51%, 38%, 26% and 24% respectively. The stage of the primary tumour, lymph node metastases and multiple nodules were significantly associated with a poor prognosis in both univariate and multivariate analyses. Disease free survival was significantly influenced by lymph node metastases, a short interval between treatment of primary and metastatic tumours and a high preoperative level of CEA. The ten year survival rate of patients with 4 or more nodules (29%) was better than that of patients with two or three nodules (16%) and similar to that of patients with a solitary lesion (32%).
The authors conclude that surgical resection is useful for treating liver metastases from colorectal cancer. Although multiple metastases significantly impaired that prognosis, the life expectancy of patients with four or more nodules mandates removal.