br Several factors have been found to correlate
Several factors have been found to correlate with sur-vival after the resection of hepatic or pulmonary metasta-ses, such as the number of metastases, tumor size,
presence of extrahepatic or pulmonary metastases, serum CEA levels, and N stage of the primary tumor.17,18,22 In our
present study, the multivariate analysis revealed that an unresectable lesion and an RFS <6 months were significant risk factors for overall survival after a first metastasectomy. Elias et al15 reported that the total number of metastases, regardless of location, showed a stronger prognostic effect than the sites of the metastases, with 5-year survival rates of 38% in patients with 1e3 metastases, 29% in patients with 4e6 metastases, and 18% in patients with less than six metastases (p Z 0.002). In our study, metastasectomies were performed even when the metastases were found in the extrahepatic or extrapulmonary regions. Most patients had single E64d (>70%), and no patients who under-went metastasectomies had more than four metastatic le-sions. This may be an important factor in explaining the relatively high OS rate that was observed in our present study.
In our study, only one patient had severe morbidity (grade III, according to the Clavien-Dindo classification) after the first and third metastasectomy. Therefore, repeated resections should be a part of a multidisciplinary management in specialized centers, where the incidences
of operative complications would be expected to be reasonable. Our findings suggest that the frequency (about 70%) of parenchyma-saving resections (partial hepatectomy or pulmonary wedge resection) appears to increase the likelihood of a subsequent effective repeated resection.
Radiofrequency ablation is considered to be an alter-native treatment in certain indications for patients not suitable to undergo surgical resection. Accordingly, the proportion of nonsurgical treatments, such as RFA or ste-reotactic body radiation therapy, has been increasing in our hospital. A previous study demonstrated that hepatic resection should be preferred for the treatment of liver metastasis, whereas RFA might be considered as a reason-able alternative for solitary hepatic metastases <3 cm in diameter.23 However, because the purpose of this study was to evaluate the oncologic outcomes of surgical treatment, the method of treatment was limited to surgery. In this study, among the 117 patients who underwent first meta-stasectomy for liver metastasis, 70 had multiple metastases or large metastases >3 cm in diameter.
Recently, biologic agents that selectively target proteins altered in cancer cells have been developed. In particular, both inhibitors of the vascular endothelial growth factor (VEGF) and the epidermal growth factor receptor (EGFR) have shown to improve the efficacy of the available chemotherapeutic regimens.24 However, in the present study, only 7 patients received bevacizumab after the first metastasectomy. Because the use of target agent in Korea was not active during the research period, there are re-strictions according to strict Korean government health insurance reimbursement policy.
Please cite this article as: Yang KM et al., Benefits of repeated resections for liver and lung metastases from colorectal cancer, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.03.002
The limitations of this study included the retrospective nature of the data analysis and the highly selective patient population. The patients in this study likely had favorable tumor biology and were good surgical candidates; hence, these results may not be reflective of the general popula-tion of patients with metastatic CRC. Despite this limita-tion, our survival estimates are still valuable, since this study is one of the largest series to date concerning pa-tients who have undergone both lung and liver resections for metastatic CRC.
In conclusion, repeated resections may improve long-term survival. We report that a second metastasectomy should be considered as the optimal treatment strategy for a second recurrence in patients with recurrent disease after an initial hepatic or pulmonary resection. However, careful consideration should be made before performing a third metastasectomy.
Conflict of interest statement
The authors have no conflicts of interest, financial or otherwise.
Appendix A. Supplementary data
4. Rees M, Tekkis PP, Welsh FK, O’Rourke T, John TG. Evaluation of long-term survival after hepatic resection for metastatic colorectal cancer: a multifactorial model of 929 patients. Ann Surg. 2008;247:125e135.
5. Nanji S, Tsang ME, Wei X, Booth CM. Outcomes after repeat hepatic resection for recurrent metastatic colorectal cancer: a population-based study. Am J Surg. 2017;213:1053e1059.