Zentralblatt für Chirurgie - Zeitschrift für Allgemeine, Viszeral-, Thorax- und Gefäßchirurgie, Table of Contents

Zentralbl Chir 2014; 139(2): 226-234
DOI: 10.1055/s-0032-1328565

Originalarbeit

Georg Thieme Verlag KG Stuttgart · New York

Rezidivlebermetastasen kolorektaler Karzinome: Wer profitiert von einer zweiten Leberresektion?

Recurrent Colorectal Liver Metastases: Who Benefits from a Second Hepatic Resection?

R. Konopke

Klinik und Poliklinik für Viszeral-, Thorax- u. Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der , Technischen Universität Dresden, Deutschland

,

A. Volk

Klinik und Poliklinik für Viszeral-, Thorax- u. Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der , Technischen Universität Dresden, Deutschland

,

J. Gastmeier

Klinik und Poliklinik für Viszeral-, Thorax- u. Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der , Technischen Universität Dresden, Deutschland

,

F. Ehehalt

Klinik und Poliklinik für Viszeral-, Thorax- u. Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der , Technischen Universität Dresden, Deutschland

,

M. Distler

Klinik und Poliklinik für Viszeral-, Thorax- u. Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der , Technischen Universität Dresden, Deutschland

,

H.-D. Saeger

Klinik und Poliklinik für Viszeral-, Thorax- u. Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der , Technischen Universität Dresden, Deutschland

,

S. Kersting

Klinik und Poliklinik für Viszeral-, Thorax- u. Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der , Technischen Universität Dresden, Deutschland

› Author Affiliations

Zusammenfassung

Hintergrund: Rezidivlebermetastasen kolorektaler Karzinome treten bei ca. 40 % der Patienten nach schon vorangegangener Leberresektion auf. Ziel dieser Untersuchung war es, Prognosefaktoren für das Überleben und den Nutzen einer erneuten Leberresektion zu evaluieren. Patienten und Methoden: Bei 60 Patienten, bei denen eine 2. Leberresektion wegen kolorektaler Rezidivlebermetastasen durchgeführt wurde, wurden insgesamt 39 Parameter aus einer prospektiv geführten Datenbank identifiziert und in Hinblick auf das rezidivfreie und das Gesamtüberleben analysiert. Ergebnisse: Bei einem mittleren Follow-up von 26 Monaten (Range: 2–173 Monate) nach der 2. Lebermetastasenresektion war das rezidivfreie Überleben nach 3 und 5 Jahren 50 % und 37 %. Das Gesamtüberleben betrug 61 % bzw. 52 %. Ein erneutes Rezidiv trat bei 58 % der Patienten auf. Davon war das Rezidiv bei 19 Patienten (32 %) auf die Leber beschränkt. Mittels multivariater Analyse (Cox proportional hazard model) wurden ein Abstand von weniger als 24 Monaten zwischen der Diagnose der 1. Lebermetastase(n) und der Operation des Primärkarzinoms (HR: 6,47; p = 0,002), ein CEA-Level von 4,0 ng/ml oder mehr zum Zeitpunkt der 1. Lebermetastasenresektion (HR: 3,48; p = 0,004) und eine Größe einer Metastase von mehr als 80 mm (HR: 4,73; p = 0,007) als unabhängige Prognosefaktoren für ein reduziertes rezidivfreies Überleben identifiziert. Ein erneutes Rezidiv der Lebermetastasierung ohne Option einer kurativen Resektion war der einzige Prognosefaktor für eine Reduktion des Gesamtüberlebens nach der 2. Leberresektion (p = 0,009). Hierdurch erhöhte sich das Mortalitätsrisiko um den Faktor 4,51, bei der Möglichkeit einer Resektion des Metastasenrezidivs hingegen nur um den Faktor 1,40. Schlussfolgerung: Technisch resektable Rezidivlebermetastasen sollten wie die primäre Metastasierung einer Resektion zugeführt werden. Sowohl Charakteristika der 1. Lebermetastasierung als auch Parameter des hepatischen Rezidivs beeinflussen die Prognose der Patienten nach der Resektion der Rezidivlebermetastasen. Die neuerliche Resektion kolorektaler hepatischer Rezidive nach bereits erfolgter 2-maliger Entfernung von Lebermetastasen ermöglicht für die Patienten wiederum eine Verbesserung der Prognose.

Abstract

Background: Hepatic recurrence is seen in approximately 40 % of patients undergoing hepatectomy for colorectal metastases. The authors assessed the benefit and the main prognostic factors for a second liver resection of recurrent colorectal metastases. Methods: This study reports the experience with second liver resections for recurrent liver metastases at a German University Hospital. A total of 39 parameters from 60 patients were identified from a prospective database and analysed as to their influence on recurrence-free survival and overall survival. Results: At a median follow-up of 26 months (range: 2–173 months) after second hepatic resection, recurrence-free survival at 3 and 5 years were 50 % and 37 %, respectively. The overall survival at three and five years were 61 % and 52 %, respectively. Recurrence was identified in 58.3 % of the patients. Recurrences involved exclusively the liver in 19 patients (31.6 %). By multivariate analysis (Cox proportional hazard model), a time interval between diagnosis of the liver metastases of less than 24 months after operation for colorectal primary carcinoma (HR: 6.47, p = 0.002), a CEA level of 4.0 ng/mL or more (HR: 3.48, p = 0.004) at the time of first liver metastases and a size of second liver metastases of 80 mm or more (HR: 4.73, p = 0.007) were independent prognostic factors for a reduced recurrence-free survival. A repeat recurrence of liver metastases without the option of curative resection was the only risk factor for overall survival after second hepatic resection (p = 0.009). In these cases, mortality risk was 4.51-fold, however, when the second liver recurrence was resectable, the mortality risk increased only 1.4-fold. Conclusions: Technically resectable recurrent colorectal hepatic metastases should be resected the same as the first metastases. Characteristics of the primary metastasis as well as parameters of the hepatic recurrence are shown to influence the prognosis of patients after resection of recurrent liver metastases. Repeat resection of colorectal liver metastases allows for improved survival in patients even after two previous liver operations.

Schlüsselwörter

Schlüsselwörter

Leberchirurgie - Lebermetastasenresektion - kolorektales Karzinom - Resektabilität - Rezidiv

Key words

Key words

liver surgery - resection of liver metastases - colorectal carcinoma - resectability - recurrent tumour growth - tumour recurrence

Literatur
1 Jaffe BM, Donegan WL, Watson F et al. Factors influencing survival in patients with untreated hepatic metastases. Surg Gynecol Obstet 1968; 127: 1-11
2 Bengmark S, Hafstrom L. The natural history of primary and secondary malignant tumors of the liver. I. The prognosis for patients with hepatic metastases from colonic and rectal carcinoma by laparotomy. Cancer 1969; 23: 198-202
3 Hurwitz H, Fehrenbacher L, Novotny W et al. Bevacizumab plus irinotecan, fluorouracil, and leucovorin for metastatic colorectal cancer. N Engl J Med 2004; 350: 2335-2342
4 Flieger D, Keller R, Fischbach W. [Palliative treatment for colorectal cancer]. Internist (Berl) 2004; 45: 786-794
5 Nordlinger B, Quilichini MA, Parc R et al. Hepatic resection for colorectal liver metastases. Influence on survival of preoperative factors and surgery for recurrences in 80 patients. Ann Surg 1987; 205: 256-263
6 Fong Y, Fortner J, Sun RL et al. Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer: analysis of 1001 consecutive cases. Ann Surg 1999; 230: 309-318 discussion 318–321
7 Huguet C, Bona S, Nordlinger B et al. Repeat hepatic resection for primary and metastatic carcinoma of the liver. Surg Gynecol Obstet 1990; 171: 398-402
8 Vaillant JC, Balladur P, Nordlinger B et al. Repeat liver resection for recurrent colorectal metastases. Br J Surg 1993; 80: 340-344
9 Petrowsky H, Gonen M, Jarnagin W et al. Second liver resections are safe and effective treatment for recurrent hepatic metastases from colorectal cancer: a bi-institutional analysis. Ann Surg 2002; 235: 863-871
10 Adam R, Bismuth H, Castaing D et al. Repeat hepatectomy for colorectal liver metastases. Ann Surg 1997; 225: 51-60 discussion 60–62
11 Sugawara G, Isogai M, Kaneoka Y et al. Repeat hepatectomy for recurrent colorectal metastases. Surg Today 2005; 35: 282-289
12 Nordlinger B, Vaillant JC, Guiguet M et al. Survival benefit of repeat liver resections for recurrent colorectal metastases: 143 cases. Association Francaise de Chirurgie. J Clin Oncol 1994; 12: 1491-1496
13 Nishio H, Hamady ZZ, Malik HZ et al. Outcome following repeat liver resection for colorectal liver metastases. Eur J Surg Oncol 2007; 33: 729-734
14 Yan TD, Lian KQ, Chang D et al. Management of intrahepatic recurrence after curative treatment of colorectal liver metastases. Br J Surg 2006; 93: 854-859
15 Ishiguro S, Akasu T, Fujimoto Y et al. Second hepatectomy for recurrent colorectal liver metastasis: analysis of preoperative prognostic factors. Ann Surg Oncol 2006; 13: 1579-1587
16 Schmiegel W, Reinacher-Schick A, Arnold D et al. [Update S3-guideline “colorectal cancer” 2008]. Z Gastroenterol 2008; 46: 799-840
17 Goldsmith NA, Woodburne RT. The surgical anatomy pertaining to liver resection. Surg Gynecol Obstet 1957; 105: 310-318
18 Riesener KP, Kasperk R, Winkeltau G et al. Repeat resection of recurrent hepatic metastases–improvement in prognosis?. Eur J Surg 1996; 162: 709-715
19 Tanaka K, Shimada H, Ohta M et al. Procedures of choice for resection of primary and recurrent liver metastases from colorectal cancer. World J Surg 2004; 28: 482-487
20 Nordlinger B, Guiguet M, Vaillant JC et al. Surgical resection of colorectal carcinoma metastases to the liver. A prognostic scoring system to improve case selection, based on 1568 patients. Association Francaise de Chirurgie. Cancer 1996; 77: 1254-1262
21 Hughes KS, Rosenstein RB, Songhorabodi S et al. Resection of the liver for colorectal carcinoma metastases. A multi-institutional study of long-term survivors. Dis Colon Rectum 1988; 31: 1-4
22 de Jong MC, Mayo SC, Pulitano C et al. Repeat curative intent liver surgery is safe and effective for recurrent colorectal liver metastasis: results from an international multi-institutional analysis. J Gastrointest Surg 2009; 13: 2141-2151
23 Adam R, Pascal G, Azoulay D et al. Liver resection for colorectal metastases: the third hepatectomy. Ann Surg 2003; 238: 871-883 discussion 883–884
24 Seehofer D, Neuhaus P. [Current status of multimodal therapy for colorectal liver metastases]. Zentralbl Chir 2011; 136: 343-351
25 Stone MD, Cady B, Jenkins RL et al. Surgical therapy for recurrent liver metastases from colorectal cancer. Arch Surg 1990; 125: 718-721 discussion 722
26 Lange JF, Leese T, Castaing D et al. Repeat hepatectomy for recurrent malignant tumors of the liver. Surg Gynecol Obstet 1989; 169: 119-126
27 Fong Y, Blumgart LH, Cohen A et al. Repeat hepatic resections for metastatic colorectal cancer. Ann Surg 1994; 220: 657-662
28 Fernandez-Trigo V, Shamsa F, Sugarbaker PH. Repeat liver resections from colorectal metastasis. Repeat Hepatic Metastases Registry. Surgery 1995; 117: 296-304
29 Neeleman N, Andersson R. Repeated liver resection for recurrent liver cancer. Br J Surg 1996; 83: 893-901
30 Yamamoto J, Kosuge T, Shimada K et al. Repeat liver resection for recurrent colorectal liver metastases. Am J Surg 1999; 178: 275-281
31 Sugarbaker PH. Repeat hepatectomy for colorectal metastases. J Hepatobiliary Pancreat Surg 1999; 6: 30-38
32 Muratore A, Polastri R, Bouzari H et al. Repeat hepatectomy for colorectal liver metastases: A worthwhile operation?. J Surg Oncol 2001; 76: 127-132
33 Suzuki S, Sakaguchi T, Yokoi Y et al. Impact of repeat hepatectomy on recurrent colorectal liver metastases. Surgery 2001; 129: 421-428
34 Nagakura S, Shirai Y, Suda T et al. Multiple repeat resections of intra- and extrahepatic recurrences in patients undergoing initial hepatectomy for colorectal carcinoma metastases. World J Surg 2002; 26: 141-147
35 Pessaux P, Lermite E, Brehant O et al. Repeat hepatectomy for recurrent colorectal liver metastases. J Surg Oncol 2006; 93: 1-7
36 Shaw IM, Rees M, Welsh FK et al. Repeat hepatic resection for recurrent colorectal liver metastases is associated with favourable long-term survival. Br J Surg 2006; 93: 457-464
37 Sa Cunha A, Laurent C, Rault A et al. A second liver resection due to recurrent colorectal liver metastases. Arch Surg 2007; 142: 1144-1149 discussion 1150
38 Thelen A, Jonas S, Benckert C et al. Repeat liver resection for recurrent liver metastases from colorectal cancer. Eur J Surg Oncol 2007; 33: 324-328
39 van der Pool AE, Lalmahomed ZS, de Wilt JH et al. Local treatment for recurrent colorectal hepatic metastases after partial hepatectomy. J Gastrointest Surg 2009; 13: 890-895
40 Brachet D, Lermite E, Rouquette A et al. Prognostic factors of survival in repeat liver resection for recurrent colorectal metastases: review of sixty-two cases treated at a single institution. Dis Colon Rectum 2009; 52: 475-483
41 Mise Y, Imamura H, Hashimoto T et al. Cohort study of the survival benefit of resection for recurrent hepatic and/or pulmonary metastases after primary hepatectomy for colorectal metastases. Ann Surg 2010; 251: 902-909
42 Andreou A, Brouquet A, Abdalla EK et al. Repeat hepatectomy for recurrent colorectal liver metastases is associated with a high survival rate. HPB (Oxford) 2011; 13: 774-782
43 Nakamura S, Yokoi Y, Suzuki S et al. Results of extensive surgery for liver metastases in colorectal carcinoma. Br J Surg 1992; 79: 35-38
44 Fong Y, Cohen AM, Fortner JG et al. Liver resection for colorectal metastases. J Clin Oncol 1997; 15: 938-946
45 Scheele J, Stang R, Altendorf-Hofmann A et al. Resection of colorectal liver metastases. World J Surg 1995; 19: 59-71
46 Minagawa M, Makuuchi M, Torzilli G et al. Extension of the frontiers of surgical indications in the treatment of liver metastases from colorectal cancer: long-term results. Ann Surg 2000; 231: 487-499
47 Yamada H, Katoh H, Kondo S et al. Repeat hepatectomy for recurrent hepatic metastases from colorectal cancer. Hepatogastroenterology 2001; 48: 828-830
48 Ohlsson B, Stenram U, Tranberg KG. Resection of colorectal liver metastases: 25-year experience. World J Surg 1998; 22: 268-276 discussion 276–277
49 Pinson CW, Wright JK, Chapman WC et al. Repeat hepatic surgery for colorectal cancer metastasis to the liver. Ann Surg 1996; 223: 765-773 discussion 773–776
50 Kato T, Yasui K, Hirai T et al. Therapeutic results for hepatic metastasis of colorectal cancer with special reference to effectiveness of hepatectomy: analysis of prognostic factors for 763 cases recorded at 18 institutions. Dis Colon Rectum 2003; 46: S22-S31
51 Adam R, Delvart V, Pascal G et al. Rescue surgery for unresectable colorectal liver metastases downstaged by chemotherapy: a model to predict long-term survival. Ann Surg 2004; 240: 644-657
52 Takahashi S, Inoue K, Konishi M et al. Prognostic factors for poor survival after repeat hepatectomy in patients with colorectal liver metastases. Surgery 2003; 133: 627-634
53 Sa Cunha A, Laurent C, Rault A et al. A second liver resection due to recurrent colorectal liver metastases. Arch Surg 2007; 142: 1144-1149 discussion 1150
54 Junginger T, Kneist W, Dunschede F et al. [Liver metastases of colorectal carcinoma–how often can be operated upon?]. Zentralbl Chir 2007; 132: 281-286
55 Yan TD, Sim J, Black D et al. Systematic review on safety and efficacy of repeat hepatectomy for recurrent liver metastases from colorectal carcinoma. Ann Surg Oncol 2007; 14: 2069-2077