Alice C. Wei

Survival after hepatic resection for colorectal metastases: a 10-year experience.

BackgroundMetastatic colorectal cancer is a major cause of cancer death in North America. Hepatic resection offers the potential for cure in selected patients. We report the long-term outcomes of patients who underwent hepatic resection for colorectal metastases over a 10-year period at a single hepatobiliary surgical oncology center.MethodsAll patients who underwent liver resection for metastatic colorectal cancer between 1992 and 2002 were identified. Data were retrospectively obtained through chart review. Major outcome variables were disease-free survival and overall survival. Risk factors for disease recurrence and mortality were identified by multivariate analysis by using the Cox proportional hazard method.ResultsA total of 423 hepatectomies were performed for metastatic colorectal cancer. Most operations (n = 276; 65%) were major (four or more segments) hepatectomies. Perioperative morbidity occurred in 74 (17%) patients. There were seven (1.6%) perioperative deaths. The disease-free survival at 1, 5, and 10 years was 64%, 27%, and 22%, respectively. The overall survival at 1, 5, and 10 years was 93%, 47%, and 28%, respectively. Multivariate analysis identified four negative predictive factors for overall survival (hazard ratio; 95% confidence interval): a positive surgical margin (2.9; 1.5–5.3), large metastases (>5 cm; 1.5; 1.1–2.0), multiple metastases (1.4; 1.1–1.9), and age >60 years (1.4; 1.1–1.9).ConclusionsHepatic resection for metastatic colorectal cancer is safe and provides good long-term overall survival rates of 47% at 5 years and 28% at 10 years. An aggressive approach is justified by the low operative mortality rate and good long-term survival, even in individuals with multiple bilobar metastases.Metastatic colorectal cancer is a major cause of cancer death in North America. Hepatic resection offers the potential for cure in selected patients. We report the long-term outcomes of patients who underwent hepatic resection for colorectal metastases over a 10-year period at a single hepatobiliary surgical oncology center. All patients who underwent liver resection for metastatic colorectal cancer between 1992 and 2002 were identified. Data were retrospectively obtained through chart review. Major outcome variables were disease-free survival and overall survival. Risk factors for disease recurrence and mortality were identified by multivariate analysis by using the Cox proportional hazard method. A total of 423 hepatectomies were performed for metastatic colorectal cancer. Most operations (n = 276; 65%) were major (four or more segments) hepatectomies. Perioperative morbidity occurred in 74 (17%) patients. There were seven (1.6%) perioperative deaths. The disease-free survival at 1, 5, and 10 years was 64%, 27%, and 22%, respectively. The overall survival at 1, 5, and 10 years was 93%, 47%, and 28%, respectively. Multivariate analysis identified four negative predictive factors for overall survival (hazard ratio; 95% confidence interval): a positive surgical margin (2.9; 1.5–5.3), large metastases (>5 cm; 1.5; 1.1–2.0), multiple metastases (1.4; 1.1–1.9), and age >60 years (1.4; 1.1–1.9). Hepatic resection for metastatic colorectal cancer is safe and provides good long-term overall survival rates of 47% at 5 years and 28% at 10 years. An aggressive approach is justified by the low operative mortality rate and good long-term survival, even in individuals with multiple bilobar metastases.

Pancreatic resection for metastatic renal cell carcinoma: presentation, treatment, and outcome.

Background: The diverse natural history of renal cell carcinoma (RCC) includes metastases to the pancreas, a very unusual site for distant spread of other cancers. Considering the relatively indolent behavior of some cases of metastatic RCC, pancreatic resection is offered to select patients.Methods: We reviewed the records of patients at three affiliated university hospital centers who had prior nephrectomy for RCC and subsequent pancreatic resection of metastases.Results: Fourteen patients—9 women and 5 men with a median age of 63.8 years—underwent a total of 15 pancreatic resections for metastatic RCC. Nine (64%) had solitary metastases. The median interval from nephrectomy to diagnosis of pancreatic metastases was 83 months. The median size of metastases was 4.6 cm. There was one perioperative death. Pancreatic recurrence occurred in five patients (36%), and one patient underwent repeat resection. At a median follow-up of 32 months, seven patients (50%) are alive without evidence of disease, and four patients (28%) are alive with recurrent disease.Conclusions: Resection of pancreatic metastases from RCC is associated with long-term survival and should be considered for patients in whom complete resection is possible.Background: The diverse natural history of renal cell carcinoma (RCC) includes metastases to the pancreas, a very unusual site for distant spread of other cancers. Considering the relatively indolent behavior of some cases of metastatic RCC, pancreatic resection is offered to select patients. Methods: We reviewed the records of patients at three affiliated university hospital centers who had prior nephrectomy for RCC and subsequent pancreatic resection of metastases. Results: Fourteen patients—9 women and 5 men with a median age of 63.8 years—underwent a total of 15 pancreatic resections for metastatic RCC. Nine (64%) had solitary metastases. The median interval from nephrectomy to diagnosis of pancreatic metastases was 83 months. The median size of metastases was 4.6 cm. There was one perioperative death. Pancreatic recurrence occurred in five patients (36%), and one patient underwent repeat resection. At a median follow-up of 32 months, seven patients (50%) are alive without evidence of disease, and four patients (28%) are alive with recurrent disease. Conclusions: Resection of pancreatic metastases from RCC is associated with long-term survival and should be considered for patients in whom complete resection is possible.

Prognosis and Results After Resection of Very Large (≥10 cm) Hepatocellular Carcinoma

IntroductionFew potentially curative treatment options exist besides resection for patients with very large (≥10xa0cm) hepatocellular carcinoma (HCC). We sought to examine the outcomes and risk factors for recurrence after resection of ≥10xa0cm HCC.MethodsPerioperative and long-term outcomes were examined for 189 consecutive patients from 1993 to 2004 who underwent potentially curative resection of HCC ≥10xa0cm (nu2009=u200924; 13%) vs. those with HCC <10xa0cm (nu2009=u2009165; 87%). Disease-free survival (DFS) and overall survival (OS) were determined by Kaplan–Meier analysis and patient, tumor, and treatment characteristics were compared using univariate and multivariate analysis.ResultsMedian follow-up was 34xa0months. Tumors ≥10xa0cm were more likely to be symptomatic, of poorer grade, and have vascular invasion (pu2009<u20090.05). Twelve patients (50%) underwent an extended resection of more than four hepatic segments or resection of adjacent organs for oncologic clearance (diaphragm-2, inferior vena cava (IVC)-2, median sternotomy-1). Postoperative complications were more common after resection of >10xa0cm HCC (12/24, 50% vs. 35/165, 21%; pu2009=u20090.04). Median DFS was significantly shorter in patients with large HCC (≥10xa0cm) group compared to patients with smaller HCC (8.4 vs. 38xa0months; pu2009=u20090.001), but overall survival was not different between the two groups (5-year survival 54% vs. 53%; pu2009=u20090.43). Seventeen patients (71%) with very large HCC developed recurrences (12 intrahepatic, five systemic); eight of these patients (47%) underwent additional therapy (resection-4, TACE-3, RFA-1). Pathological positive margins and vascular invasion were significant determinants of DFS in tumors ≥10xa0cm (pu2009<u20090.05), but only vascular invasion was an independent risk factor for recurrence after multivariate analysis (HR 0.17; 95% CI: 0.04–0.8). Median OS after recurrence was 24xa0months.ConclusionSurgical resection is the optimal therapy for very large (≥10xa0cm) HCC. Although recurrences are common after resection of these tumors, overall survival was not significantly different from patients after resection of smaller HCC in this series.

An analysis of resection vs transplantation for early hepatocellular carcinoma: defining the optimal therapy at a single institution.

BackgroundThe reported survival after liver transplantation (OLT) for early hepatocellular carcinoma (HCC) is superior to the results of liver resection (LR), but few analyses have considered long waiting times and patient drop-offs due to tumor progression.MethodsFrom 1995–2005, 347 patients with HCC were evaluated at our institution and underwent either LR (nxa0=xa0174) or placed on the OLT waiting list (nxa0=xa0173). Patients who only underwent ablation were not included. After eliminating patients with 1) incidental tumors after OLT, 2) tumors outside of Milan criteria, 3) preoperative vascular invasion prior to LR and 4) Child-Pugh Class C cirrhosis prior to OLT, 261 patients (LRxa0=xa0121; OLTxa0=xa0140) were included in this analysis.ResultsMedian follow-up time was 35 months. Median waiting time for OLT was 7.7 months; during this time, 30 patients were taken off the waiting list. Overall survival (OS) from time of listing or LR was not different between the two groups; 1, 3, and 5 year OS after LR was 89%, 75%, and 56% compared with 90%, 70%, and 64% for OLT (Pxa0=xa0.84). Only patients who waited <4 months for OLT (nxa0=xa067) had better survival than those who underwent LR (Pxa0=xa0.05). Patients who waited longer that four months for OLT had a 2.5× higher risk of death in a Cox multivariate model [odds ratio (OR) 2.5; 95% confidence interval (CI): 1.3–5; Pxa0=xa0.007].ConclusionUnless waiting time is short (<4 months), the survival of patients with early HCC is similar between LR and LT.

Comparison of outcomes and costs between laparoscopic distal pancreatectomy and open resection at a single center.

BackgroundThe cost implications of laparoscopic distal pancreatectomy (LDP) and a detailed breakdown of hospital expenditures has not been presented in the literature to date. This study aimed to compare hospital costs and short-term clinical outcomes between LDP and open distal pancreatectomy (ODP).MethodsThe authors evaluated all the distal pancreatic resections performed at their center between January 2004 and March 2010. Parametric and nonparametric statistical analysis was used to compare hospital departmental and total hospital costs as well as oncologic and surgical outcomes.ResultsA total of 118 cases (42 laparoscopic resections, including 5 conversions, and 76 open resections) were analyzed. The demographic characteristics were similar between the groups except for a predominance of females in the laparoscopic group (Pxa0=xa00.036). The indications for surgery differed by a paucity of malignant tumors being approached laparoscopically (Pxa0<xa00.001). Intraoperatively, there were no differences in estimated blood loss, operating room time, or transfusion requirement. The pathologic outcomes did not differ significantly. The median hospital length of stay (LOS) was 5xa0days (range 3–31xa0days) for the LDP cohort and 7xa0days (range 4–19xa0days) for the ODP cohort (Pxa0<xa00.001). Postoperative pancreatic fistula occurred for 22 patients, with a higher proportion observed in the LDP group (28.57%; nxa0= 12) than in the open group (13.16%; nxa0=xa010; Pxa0=xa00.05). However, the rates for grade B and higher grade fistula were higher in the ODP group (0 LDP and 4 ODP). The median preadmission and operative costs did not differ significantly. The ODP cohort had significantly higher costs in all other hospital departments, including the total cost.ConclusionLDP is both a cost-effective and safe approach for distal pancreatic lesions. This series showed a shorter LOS and lower total hospital costs for LDP than for ODP, accompanied by equivalent postoperative outcomes.

The role of liver resection for colorectal cancer metastases in an era of multimodality treatment: A systematic review

BACKGROUNDnTo determine the role of liver resection in patients with liver and extrahepatic colorectal cancer metastases and the role of chemotherapy in patients in conjunction with liver resection.nnnMETHODSnMEDLINE and EMBASE databases were searched for articles published between 1995 and 2010, along with hand searching.nnnRESULTSnA total of 4875 articles were identified, and 83 were retained for inclusion. Meta-analysis was not performed because of heterogeneity and poor quality of the evidence. Outcomes in patients who had liver and lung metastases, liver and portal node metastases, and liver and other extrahepatic disease were reported in 14, 10, and 14 studies, respectively. The role of perioperative chemotherapy was assessed in 30 studies, including 1 randomized controlled trial and 1 pooled analysis. Ten studies assessed the role of chemotherapy in patients with initially unresectable disease, and 5 studies assessed the need for operation after a radiologic complete response.nnnCONCLUSIONnThe review suggests that: (1) select patients with pulmonary and hepatic CRC metastases may benefit from resection; (2) perioperative chemotherapy may improve outcome in patients undergoing a liver resection; (3) patients whose CRC liver metastases are initially unresectable may benefit from chemotherapy to identify a subgroup who may benefit later from resection; (4) after radiographic complete response (RCR), lesions should be resected if possible.

Predictors of peri-opertative morbidity and liver dysfunction after hepatic resection in patients with chronic liver disease

BACKGROUNDnHepatic resection in patients with chronic liver disease (CLD) is associated with a risk of post-operative liver failure and higher morbidity than patients without liver disease. There is no universal risk stratification scheme for CLD patients undergoing resection.nnnOBJECTIVESnThe aim of the present study was to evaluate the association between routine pre-operative laboratory investigations, model for end-stage liver disease (MELD), indocyanine green retention at 15 min (ICG15) and post-operative outcomes in CLD patients undergoing liver resection.nnnMETHODSnA retrospective review of patients undergoing resection for hepatocellular carcinoma (HCC) at the University Health Network was preformed. ICG15 results, pre- and post-operative laboratory results were obtained from clinical records. Adjusted odds ratios (AOR) were calculated for associations between pre-operative factors and post-operative outcomes using multivariate logistic regression adjusting for patient age and number of segments resected.nnnRESULTSnBetween 2001 and 2005, 129 CLD patients underwent surgical resection for HCC. Procedures included 51 (40%) resections of ≤ 2 segments, 52 (40%) hemihepatectomies and 25 (19%) extended hepatic resections. Thirty- and 90-day post-operative mortality was 1.6% and 4.1%, respectively. Prolonged (>10 days) hospital length of stay (LOS) was independently associated with an ICG15 >15% {AOR [95% confidence interval (CI)]= 8.5 (1.4-51)} and an international normalized ratio (INR) > 1.2 [AOR (95% CI) = 5.0 (1.4-18.6)]. An ICG15 > 15% and MELD score were independent predictors of prolonged LOS. An ICG15 > 15% was also independently associated with MELD > 20 on post-operative day 3 [AOR (95% CI) = 24.3 (1.8-319)].nnnCONCLUSIONSnElevated ICG retention was independently associated with post-operative liver dysfunction and morbidity. The utility of ICG in combination with other biochemical measures to predict outcomes after hepatic resection in CLD patients requires further prospective study.

Risk Factors Associated with Recurrence in Patients with Solid Pseudopapillary Tumors of the Pancreas

CONTEXTnSolid pseudopapillary tumors (SPT) are rare, generally low grade pancreatic neoplasms that occasionally display malignant behavior.nnnOBJECTIVEnTo analyze the clinical and pathological features associated with increased risk of recurrence of SPT.nnnMETHODSnCohort study of patients with SPT who underwent resection of the primary tumor and in selected cases resection of metastatic disease from 1999-2013 at a single tertiary care Hepatopancreatobiliary center. Risk factors for recurrence were statistically analyzed.nnnRESULTSnThere were 32 patients. The mean age was 35.65 years (standard deviation: 12.26), 26/32, 81.25% were female. Median size of resected tumors was 4.7 cm (1.1-14.5). Most were solid and cystic (22/32, 68.75%), encapsulated (27/32, 84.4%) and located in the pancreatic body or tail (22/32, 68.75%). All displayed strong β-catenin, cyclin D1, CD56, and progesterone receptor staining with loss of E-cadherin. Most stained positive for vimentin (15/16, 93.75%) and CD10 (17/18, 94.4%). Median follow-up was 43 months (range: 3-207); 3/32, 9.38% recurred (all after 5-years from curative resection) and 1 died by the end of the study period, 11 years after diagnosis. Patients who developed recurrences (n=3) more commonly had synchronous metastases at presentation (P=0.006), lymphovascular invasion (P=0.04) and invasion of tumor capsule (P=0.08) compared to those who did not have disease recurrence.nnnCONCLUSIONSnLymphovascular invasion, synchronous metastases and local invasion of tumor capsule are associated with aggressive behavior. Since recurrences may occur >5 years from resection, this high-risk group should undergo extended follow-up. Progression and recurrence is slow, therefore, resection of liver metastases can offer long-term survival.

Utility of preoperative imaging in evaluating colorectal liver metastases declines over time

OBJECTIVESnReports on the sensitivity and accuracy of contrast-enhanced helical computed tomography (HCT) in the preoperative evaluation of colorectal liver metastases (CLM) have been conflicting. Few studies have controlled for and reported on the time interval between HCT and eventual surgery.nnnMETHODSnA multi-institution, retrospective review of consecutive patients who underwent hepatic resection for CLM from January 1999 to September 2004 was conducted. Data regarding lesion characteristics and resectability were extracted from radiology reports, operative findings and histopathological records. Findings in HCT were evaluated according to their sensitivity for detecting CLM and ability to predict resectability.nnnRESULTSnA total of 217 consecutive patients who underwent hepatic resection for CLM were identified. The overall sensitivity of HCT for detection of CLM was 83.2%. Prolonged time between imaging and surgery was a negative predictor for HCT sensitivity in univariate and multivariate analysis (P < 0.001). In predicting resectability, preoperative HCT was accurate 77.0% of the time. The time interval to surgery was negatively correlated with HCT prediction accuracy in univariate and multivariate analyses (P < 0.001).nnnCONCLUSIONSnThe utility of HCT as a preoperative tool to evaluate CLM is inversely proportional to the time interval between imaging and surgery. This may explain conflicting reports of the accuracy of HCT in the current literature.

Impact of Viral Hepatitis on Outcomes after Liver Resection for Hepatocellular Carcinoma: Results from a North American Center

Hepatitis B (HBV) and hepatitis C (HCV) are well-recognized risk factors for hepatocellular carcinoma (HCC). The characteristics and clinical outcomes of HCC arising from these conditions may differ. This study was conducted to compare the outcomes of HCC associated with HBV and HCV after liver resection. Of 386 liver resections for HCC performed between July 1992 and April 2011, 181 patients had HBV and 74 patients had HCV. Patients with HBV/HCV coinfections (nxa0=xa020), non-HBV/HCV etiology (nxa0=xa094), and postoperative death within 3xa0months (nxa0=xa017) were excluded. Patient, tumor characteristics, and perioperative and oncologic outcomes were compared between patients with HBV and HCV. The patients with HBV had better overall survival (OS) than patients with HCV (68 vs. 59xa0months, pxa0=xa00.03); however, there was no difference in recurrence-free survival (RFS) between the groups (44 vs. 45xa0months, pxa0=xa00.1). The factors predictive of OS based on multivariate analyses included: vascular invasion [pxa0<xa00.01, hazard ratio (HR)xa0=xa03.4], Child-Pugh Score (pxa0<xa00.01, HRxa0=xa04.8), and underlying liver disease (HCV vs HBV) (pxa0=xa00.01, HRxa0=xa01.9). Vascular invasion and tumor number (pxa0<xa00.01, HRxa0=xa02.3 and pxa0<xa00.01, HRxa0=xa02.1) were independent predictors of RFS. OS but not RFS after liver resection for HCC is better in patients with HBV than HCV. This survival advantage for HBV patients may be due to differences in tumor biology and outcomes after disease recurrence.BackgroundHepatitis B (HBV) and hepatitis C (HCV) are well-recognized risk factors for hepatocellular carcinoma (HCC). The characteristics and clinical outcomes of HCC arising from these conditions may differ. This study was conducted to compare the outcomes of HCC associated with HBV and HCV after liver resection.MethodsOf 386 liver resections for HCC performed between July 1992 and April 2011, 181 patients had HBV and 74 patients had HCV. Patients with HBV/HCV coinfections (nxa0=xa020), non-HBV/HCV etiology (nxa0=xa094), and postoperative death within 3xa0months (nxa0=xa017) were excluded. Patient, tumor characteristics, and perioperative and oncologic outcomes were compared between patients with HBV and HCV.ResultsThe patients with HBV had better overall survival (OS) than patients with HCV (68 vs. 59xa0months, pxa0=xa00.03); however, there was no difference in recurrence-free survival (RFS) between the groups (44 vs. 45xa0months, pxa0=xa00.1). The factors predictive of OS based on multivariate analyses included: vascular invasion [pxa0<xa00.01, hazard ratio (HR)xa0=xa03.4], Child-Pugh Score (pxa0<xa00.01, HRxa0=xa04.8), and underlying liver disease (HCV vs HBV) (pxa0=xa00.01, HRxa0=xa01.9). Vascular invasion and tumor number (pxa0<xa00.01, HRxa0=xa02.3 and pxa0<xa00.01, HRxa0=xa02.1) were independent predictors of RFS.ConclusionsOS but not RFS after liver resection for HCC is better in patients with HBV than HCV. This survival advantage for HBV patients may be due to differences in tumor biology and outcomes after disease recurrence.