Department of Surgery, Johns Hopkins University School of Medicine, Harvey 611 600 N Wolfe Street, Baltimore, MD 21287, USA.
J Gastrointest Surg. 2009 Dec;13(12):2141-51. doi: 10.1007/s11605-009-1050-0. Epub 2009 Oct 1.
Although 5-year survival approaches 55% following resection of colorectal liver metastasis, most patients develop recurrent disease that is often isolated to the liver. Although repeat curative intent surgery (CIS) is increasingly performed for recurrent colorectal liver metastasis, only small series have been reported. We sought to determine safety and efficacy of repeat CIS for recurrent colorectal liver metastasis as well as determine factors predictive of survival in a large multicenter cohort of patients.
Between 1982 and 2008, 1,706 patients who underwent CIS--defined as curative intent hepatic resection/radiofrequency ablation (RFA)--for colorectal liver metastasis were identified from an international multi-institutional database. Two hundred forty-six (14.4%) patients underwent 301 repeat CIS. Data on clinico-pathologic factors, morbidity, and mortality were collected and analyzed.
Following initial CIS, 645 (37.8%) patients had recurrence within the liver. Of these, 246 patients underwent repeat CIS for recurrent disease. The majority had hepatic resection alone as initial therapy (n = 219; 89.0%). A subset of patients underwent third (n = 46) or fourth (n = 9) repeat CIS. Mean interval between surgeries was similar (first --> second, 19.1 months; second --> third, 21.5 months; third --> fourth, 11.3 months; P = 0.20). Extent of hepatic resection decreased with subsequent CIS (>or=hemihepatectomy: first CIS, 30.9% versus second CIS, 21.1% versus third/fourth CIS, 16.4%; P = 0.004). RFA was utilized in one quarter of patients undergoing repeat CIS (second CIS, 21.1% versus third/fourth CIS, 25.5%). Mortality and morbidity were similar following second, third, and fourth CIS, respectively (all P > 0.05). Five-year survival was 47.1%, 32.6%, and 23.8% following the first, second, and third CIS, respectively. Presence of extra-hepatic disease was predictive of worse survival (HR = 2.26, P = 0.01).
Repeat CIS for recurrent colorectal liver metastasis can be performed with low morbidity and near-zero mortality. Patients with no extra-hepatic disease are best candidates for repeat CIS. In these patients, repeat CIS can offer the chance of long-term survival.
尽管结直肠肝转移切除术后 5 年生存率达到 55%，但大多数患者会出现孤立于肝脏的复发性疾病。尽管对于复发性结直肠肝转移瘤越来越多地采用再次治愈性意向手术（CIS），但仅有少数小系列报道。我们旨在确定再次 CIS 治疗复发性结直肠肝转移瘤的安全性和有效性，并在一个大型多中心患者队列中确定预测生存的因素。
1982 年至 2008 年间，从一个国际多机构数据库中确定了 1706 例接受 CIS（定义为治愈性意向性肝切除术/射频消融术（RFA））治疗结直肠肝转移瘤的患者。246 例（14.4%）患者接受了 301 次重复 CIS。收集并分析了临床病理因素、发病率和死亡率的数据。
在初次 CIS 后，645 例（37.8%）患者肝内复发。其中，246 例患者因复发性疾病接受了重复 CIS。大多数患者最初接受的是单独的肝切除术（n=219；89.0%）。部分患者接受了第三次（n=46）或第四次（n=9）重复 CIS。手术间隔时间相似（第一次到第二次，19.1 个月；第二次到第三次，21.5 个月；第三次到第四次，11.3 个月；P=0.20）。随着随后的 CIS，肝切除术的范围缩小（半肝切除术：第一次 CIS，30.9%；第二次 CIS，21.1%；第三次/第四次 CIS，16.4%；P=0.004）。RFA 应用于接受重复 CIS 的患者的四分之一（第二次 CIS，21.1%；第三次/第四次 CIS，25.5%）。第二次、第三次和第四次 CIS 后的死亡率和发病率相似（均 P＞0.05）。第一次、第二次和第三次 CIS 后的 5 年生存率分别为 47.1%、32.6%和 23.8%。存在肝外疾病是生存较差的预测因素（HR=2.26，P=0.01）。
复发性结直肠肝转移瘤的重复 CIS 可实现低发病率和接近零的死亡率。无肝外疾病的患者是重复 CIS 的最佳候选者。在这些患者中，重复 CIS 可以提供长期生存的机会。
