Predicting Outcome

Efficacy of resection of a solitary hepatic metastasis

Commentator: NICHOLAS PETRELLI, MD

Comment:

If a patient with a lesion in one segment of the liver asked me their probability of survival, I would say that disease-free survival — in general as reported in the literature — ranges from 30 to 40 percent at five years. Most of the literature quotes, if you will, the overall survival being anywhere from 30 to 50 percent. A large range is reported because the survival has increased over time, new techniques are used to control hemorrhage and resection techniques have improved. If you take less of the liver out, the complication rate in lower.

Comment:

Relapse after resection of liver metastases

Commentator: JOHN PRIMROSE, MD

The majority of patients who have undergone resection of liver metastases will still relapse. If relapse occurs, it may be amenable to further chemotherapy and further surgical treatment, so relapse does not automatically mean that the patient is untreatable. I tell every patient that one percent of patients die from the procedure. We warn them about the possibility of perioperative mortality as well.

Response to neoadjuvant therapy and the prognostic implications

Commentator: DANIEL HALLER, MD

Comment:

Response to neoadjuvant treatment can provide prognostic information. First of all, an excellent partial or complete response is always a good sign and tells us that the disease is sensitive to the regimen we selected. Secondly, even if pathology does not show a complete response, data from the German trial and others have shown that the better the downstaging, the better the prognosis. It’s a marker and a good prognosticator.

We know from a number of series that even with complete clinical responses in the liver, viable tumor is almost always present. Chemotherapy alone will not cure these patients, so these lesions need to be resected. A R0 resection is critical in liver surgery, versus a R1 resection with positive margins.

Average duration of survival for a patient postresection after chemotherapy only

Commentator: RENÉ ADAM, MD

Comment:

It is difficult to estimate the average survival of a patient with a single metastasis — some patients may be cured. Having a single metastasis is a good prognostic factor. Approximately 60 percent of these patients are alive at five years, depending on the biology of the tumor and how aggressive the disease is.

Prognosis of patients presenting with portal lymph node involvement

Commentator: RENÉ ADAM, MD

Comment:

It is not wise to operate on a patient who has hepatic metastasis with lymph node involvement, so patients that present with lymph node involvement should be treated with neoadjuvant chemotherapy before surgery. If a patient has portal lymph node involvement and does not respond to chemotherapy, I would not proceed. We should only operate in those who respond to chemotherapy. In a recent Journal of Clinical Oncology paper, we described the outcomes of patients treated with neoadjuvant chemotherapy who responded to chemotherapy. The message is that those with lymph node involvement of the hepatic pedicle had a 25 percent five-year survival after surgery, while those with celiac or retroperitoneal lymph node involvement had a zero percent five-year survival. Therefore, we should proceed with surgery in patients with a hepatic lymph node metastatic location, but we should not operate if patients have involvement in the celiac or retroperitoneal lymph node, even if they respond to chemotherapy.

Thoughts on surgery and disease progression

Commentator: STEVEN ALBERTS, MD

Comment:

The influence of surgery on the growth or spread of metastatic disease is controversial. Does surgery have any influence on the growth or spread of metastatic disease? According to folklore, exposing the tumor to air during surgery causes it to progress. A more scientific rationale might be that a lot of growth factors are released during surgery, particularly in liver surgery, possibly influencing the rapid regrowth of micrometastatic disease. We’ll never know.

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