Joseph G. Fortner

Clinical Score for Predicting Recurrence After Hepatic Resection for Metastatic Colorectal Cancer: Analysis of 1001 Consecutive Cases

OBJECTIVE There is a need for clearly defined and widely applicable clinical criteria for the selection of patients who may benefit from hepatic resection for metastatic colorectal cancer. Such criteria would also be useful for stratification of patients in clinical trials for this disease. METHODS Clinical, pathologic, and outcome data for 1001 consecutive patients undergoing liver resection for metastatic colorectal cancer between July 1985 and October 1998 were examined. These resections included 237 trisegmentectomies, 394 lobectomies, and 370 resections encompassing less than a lobe. The surgical mortality rate was 2.8%. RESULTS The 5-year survival rate was 37%, and the 10-year survival rate was 22%. Seven factors were found to be significant and independent predictors of poor long-term outcome by multivariate analysis: positive margin (p = 0.004), extrahepatic disease (p = 0.003), node-positive primary (p = 0.02), disease-free interval from primary to metastases <12 months (p = 0.03), number of hepatic tumors >1 (p = 0.0004), largest hepatic tumor >5 cm (p = 0.01), and carcinoembryonic antigen level >200 ng/ml (p = 0.01). When the last five of these criteria were used in a preoperative scoring system, assigning one point for each criterion, the total score was highly predictive of outcome (p < 0.0001). No patient with a score of 5 was a long-term survivor. CONCLUSION Resection of hepatic colorectal metastases may produce long-term survival and cure. Long-term outcome can be predicted from five criteria that are readily available for all patients considered for resection. Patients with up to two criteria can have a favorable outcome. Patients with three, four, or five criteria should be considered for experimental adjuvant trials. Studies of preoperative staging techniques or of adjuvant therapies should consider using such a score for stratification of patients.

Liver resection for colorectal metastases.

PURPOSE More than 50,000 patients in the United States will present each year with liver metastases from colorectal cancers. The current study was performed to determine if liver resection for colorectal metastases is safe and effective and to evaluate predictors of outcome. MATERIALS AND METHODS Data for 456 consecutive resections performed between July 1985 and December 1991 in a tertiary referral center were analyzed. RESULTS The perioperative mortality rate was 2.8%, with a mortality rate of 4.6% for resections that involved a lobectomy or more. The median hospital stay was 12 days and only 9% of patients were admitted to the intensive care unit. The 5-year survival rate is 38%, with a median survival duration of 46 months. By univariate analysis, nodal status of the primary lesion, short disease-free interval before detection of liver metastases, carcinoembryonic antigen (CEA) level greater than 200 ng/mL, multiple liver tumors, extrahepatic disease, large tumors, or positive resection margin was predictive of poorer outcome. Sex, age greater than 70 years, site of primary tumor, or perioperative transfusion was not predictive of outcome. By multivariate analysis, positive margin, size greater than 10 cm, disease-free interval less than 12 months, multiple tumors, and extrahepatic disease were independent predictors of poorer outcome. Short disease-free interval or multiple tumors were nevertheless associated with a 5-year survival rate greater than 24%. CONCLUSION Liver resection for colorectal metastases is safe and effective therapy and currently represents the only potentially curative therapy for metastatic colorectal cancer. The only absolute contraindication to resection is extrahepatic disease. A randomized trial to examine efficacy of surgical resection cannot ethically be performed. Liver resection should be considered standard therapy for all fit patients with colorectal metastases isolated to the liver.

Resection of the liver for colorectal carcinoma metastases. A multi-institutional study of long-term survivors.

In this review of a collected series of patients undergoing hepatic resection for colorectal metastases, 100 patients were found to have survived greater than five years from the time of resection. Of these 100 long-term survivors, 71 remain disease-free through the last follow-up, 19 recurred prior to five years, and ten recurred after five years. Patient characteristics that may have contributed to survival were examined. Procedures performed included five trisegmentectomies, 32 lobectomies, 16 left lateral segmentectomies, and 45 wedge resections. The margin of resection was recorded in 27 patients, one of whom had a positive margin, nine of whom had a less than or equal to 1-cm margin, and 17 of whom had a greater than 1-cm margin. Eighty-one patients had a solitary metastasis to the liver, 11 patients had two metastases, one patient had three metastases, and four patients had four metastases. Thirty patients had Stage C primary carcinoma, 40 had Stage B primary carcinoma, and one had Stage A primarycarcinoma. The disease-free interval from the time of colon resection to the time of liver resection was less than one year in 65 patients, and greater than one year in 34 patients. Three patients had bilobar metastases. Four of the patients had extrahepatic disease resected simultaneously with the liver resection. Though several contraindications to hepatic resection have been proposed in the past, five-year survival has been found in patients with extrahepatic disease resected simultaneously, patients with bilobar metastases, patients with multiple metastases, and patients with positive margins. Five-year disease-free survivors are also present in each of these subsets. It is concluded that five-year survival is possible in the presence of reported contraindications to resection, and therefore that the decision to resect the liver must be individualized.

Long-term results after resection for gallbladder cancer. Implications for staging and management.

BACKGROUND The surgical management of gallbladder cancer is controversial. There is no consensus among surgeons as to the indications for reoperation or radical resection. OBJECTIVE The purpose of this study was to examine results of reoperation after an incidental finding of gallbladder cancer after cholecystectomy, and results of radical resection in patients with advanced disease. METHODS A retrospective review of 149 patients with the diagnosis of gallbladder cancer treated from 1985 to 1993 was performed. Fifty-eight patients were explored and 23 underwent resection for cure. Resection included trisegmentectomy in nine patients and bile duct resection in ten patients. Seventeen patients underwent re-exploration after an incidental finding of gallbladder cancer at initial cholecystectomy. RESULTS Surgical resection is associated with an actuarial 51% 5-year disease-free survival rate, with a median follow-up time of 48 months. Eight patients are alive beyond 50 months. There were no operative deaths; the perioperative morbidity rate was 26%. Nodal status is the most powerful predictor of outcome. Two patients with T4, NO disease are alive without evidence of disease beyond 4 years. Thirteen of the 17 patients (76%) undergoing reoperation after simple cholecystectomy for T2 or T3 tumors had residual disease. CONCLUSIONS Patients with nodal metastasis beyond the pericholedochal nodes should not be considered for curative resection. Tumors staged T4, NO should be included with stage III disease, and resection should be considered. Re-resection of T2 or T3 tumors after simple cholecystectomy is likely to include residual disease and should thus provide the only chance for long-term survival.

Surgical treatment of 297 soft tissue sarcomas of the lower extremity.

The results of surgical treatment of 297 soft tissue sarcomas arising in the lower extremity were critically examined. En bloc wide soft part resection (158 cases) yielded five and ten year survival rates of 63% and 50%. Amputation or major disarticulation (139 cases) gave corresponding survival rates of 45% and 29%. The most frequent cause of treatment failure was distant metastases, commonly in the lungs. The tissue type of sarcoma, histologic grade of malignancy, and tumor size appear to be important determinants of survival irrespective of the type of surgical treatment. Local recurrence of sarcoma occurred in 18% of the cases, more commonly after soft part resections than amputations. The proximity of a sarcoma to major vessels, bone or joint tends to compromise the margins of a wide soft part resection, thus increasing the risk of local recurrence. In appropriate cases, the scope of soft part resection can be extended by en bloc excision of the femoral vessels, with the hope of improving local control of sarcoma. Amputation should be resorted to if an adequate margin of resection cannot otherwise be obtained. This decision must be weighed against the high frequency of distant metastases in this disease. Postoperative adjuvant chemotherapy and immunotherapy offer prospects of prevention of this tragic outcome.

Factors affecting long-term outcome after hepatic resection for hepatocellular carcinoma

BACKGROUND Experience with hepatocellular carcinoma (HCC) is limited in the West and factors affecting outcome after resection are not clearly defined. METHODS Between 1970 and 1992, 106 patients (including 74 Caucasians, 31 Orientals, and 1 black) underwent hepatic resection for HCC at Memorial Sloan-Kettering Cancer Center. Clinical and histopathologic factors of outcome were analyzed. RESULTS Cirrhosis was present in 33% and 95% were Child-Pugh A. Operative mortality was 6%, 14% in cirrhotics versus 1% in non-cirrhotics (P = 0.013). Orientals had a higher prevalence of cirrhosis (68% versus 19%) (P < 0.0001) and smaller tumors (mean 8.7 cm versus 11.0 cm) (P = 0.028) compared to Caucasians. Overall survival was 41% and 32% at 5 and 10 years, respectively. By univariate analysis, survival was greater in association with the following: absence of vascular invasion (69% versus 28%, P = 0.002); absence of symptoms (66% versus 38%, P = 0.014); solitary tumor (53% versus 28%, P = 0.014); negative margins (46% versus 21%, P = 0.022); small tumor (< or = 5 cm) (75% versus 36%, P = 0.027); and presence of tumor capsule (69% versus 35%, P = 0.047). Ethnic origin, cirrhosis, necrosis and grade did not affect survival. By multivariate analysis, only vascular invasion predicted outcome (P = 0.0025, risk ratio 2.9). CONCLUSIONS One third of patients resected for HCC can be expected to survive long-term. Except for a higher incidence of cirrhosis in Orientals, no major histopathologic or prognostic differences were noted between Orientals and Caucasians undergoing resection. Early cirrhosis (Child-Pugh A) did not adversely affect survival. Vascular invasion predicted long-term outcome.

Pancreatic or liver resection for malignancy is safe and effective for the elderly.

Background Liver resection, or pancreaticoduodenectomy, has traditionally been thought to have a high morbidity and mortality rate among the elderly. Recent improvements in surgical and anesthetic techniques, an increasing number of elderly patients, and an increasing need to justify use of limited health care resources prompted an assessment of recent surgical outcomes. Methods Five hundred seventy‐seven liver resections (July 1985‐July 1994) performed for metastatic colorectal cancer and 488 pancreatic resections (October 1983‐July 1994) performed for pancreatic malignancies were identified in departmental data bases. Outcomes of patients younger than age 70 years were compared with those of patients age 70 years or older. Results Liver resection for 128 patients age 70 years or older resulted in a 4% perioperative mortality rate and a 42% complication rate. Median hospital stay was 13 days, and 8% of the patients required admission to the intensive care unit (ICU). Median survival was 40 months, and the 5‐year survival rate was 35%. No differences were found between results for the elderly and those for younger patients who had undergone liver resection, except for a minimally shorter hospital stay for the younger patients (median, 12 days vs. 13 days; p = 0.003). Pancreatic resection for 138 elderly patients resulted in a mortality rate of 6% and a complication rate of 45%. Median stay was 20 days, and 19% of the patients required ICU admission, results identical to those for the younger cohort. Long‐term survival was poorer for the elderly patients, with a 5‐year survival rate of 21% compared with 29% for the younger cohort (p = 0.03). Conclusions Major liver or pancreatic resections can be performed for the elderly with acceptable morbidity and mortality rates and possible long‐term survival. Chronologic age alone is not a contraindication to liver or pancreatic resection for malignancy.

Malignant schwannoma. A clinicopathologic study.

During the period from 1920‐1970, 902 patients with a tumor of the peripheral nervous system were treated at the Memorial Sloan‐Kettering Cancer Center. Histologic review of this material revealed 115 cases which fulfilled strict criteria for clinicopathologic diagnosis of malignant schwannoma, i.e., tumorinvolved nerve trunks with fusiform or oval swelling and arising from the nerve sheath. There was no significant age or sex predilection. Association with plexiform neuroma or with stigmata of von Recklinghausens disease was found to be indicative of a poor prognosis. Radical local excision controlled small tumors. Muscle group dissection or major amputation was reserved where large tumors or recurrence precluded local excision. Lymphatic invasion and lymph node involvement by malignant schwannoma was not observed. Regional lymph node dissection is unnecessary.

Major Hepatic Resection Using Vascular Isolation and Hypothermic Perfusion

The technique and results of 29 major hepatic resections using the method of complete vascular isolation and hypothermic perfusion of the liver are reported. The method enables the surgeon to perform otherwise difficult or impossible resections through chilled bloodless hepatic parenchyma. Major intrahepatic vascular structures can thus be recognized and controlled readily under clear vision. Direct neoplastic involvement of, or tumor thrombi in the portal vein, hepatic vein or vena cava, can be successfully dealt with by appropriate surgical measures. The operative mortality was 10.3% for this series which included many tumors previously deemed unresectable. The technical detail and intraoperative physiologic monitoring crucial to success in the use of the method are described. It is hoped that with the widened scope of resectability afforded by this technique, and the use of adjuvant chemotherapy, the currently experienced low cure rates for hepatic cancer can be improved.

Tendosynovial sarcoma. A clinicopathological study of 136 Cases

A series of 136 cases of tendosynovial sarcomas were studied from the histologic point of view. All of the primary, recurrent and metastatic tumors were reclassified according to histologic type, anatomic site and size; age and sex of the patients and modality of surgical treatment. The overall 5‐year survival rate was 40%. Among the factors which most favorably influenced the prognosis were: small size (74%, 5‐year survival), “exposed” primary site (53%, 5‐year survival), and histologic type (biphasic form: 55%, 5‐year survival and epithelioid sarcoma: 58%, 5‐year survival). Children and elderly patients had also better than the average prognosis. Sixty percent of the sarcomas recurred after wide local excision. Twelve percent of the tumors metastasized to regional lymph nodes and 10% to bones. Almost all of the 24 patients who were autopsied died because of cardio‐pulmonary insufficiency due to massive pleuropulmonary metastasis. It is hoped that better understanding of the natural history of these tumors will lead to optimal local and systemic therapy and better survival.