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Determinants of Repeat Curative Intent Surgery in Colorectal Liver Metastasis
Afif N. Kulaylat*1,2, Jane R. Schubart2, Audrey L. Stokes1, Eric Kimchi1, Kevin F. Staveley-O1, Neil Bhayani1, Jussuf T. Kaifi1, Niraj J. Gusani1
1Surgical Oncology, Penn State Hershey Medical Center, Hershey, PA; 2Public Health Sciences, Penn State College of Medicine, Hershey, PA
Introduction: Following curative intent surgery (CIS) for colorectal liver metastasis (CRLM), repeat CIS for recurrence improves survival. The factors associated with repeat CIS are not widely reported.
Methods: An institutional database (January 2002-December 2012) was reviewed to evaluate factors influencing repeat CIS following initial CIS for CRLM. A policy of aggressive repeat CIS was utilized whenever possible, including potential repeat liver/lung resection/ablation or cytoreductive surgery/HIPEC.
Results: 183 patients with CRLM underwent CIS (liver resection, ablation, or both). Median follow-up and disease-free interval (DFI) was 28 and 16 months, respectively. After initial CIS, 102 (56%) patients recurred. 53 (52%) of these patients were able to undergo second CIS. After second CIS, 33 (62%) patients developed a second recurrence and in 13 (39%) patients a third CIS was possible. A few patients underwent additional repeat CIS procedures with one patient undergoing a total of 7 CIS procedures over 8 years. There was a significant decrease between DFI following first and subsequent CIS (1st CIS vs. 2nd CIS vs. ≥ 3rd CIS [20 vs. 15 vs. 8.5 months], p=<0.0001). Overall 5-year survival in all patients was 51%, while patients who recurred had a 5-year survival of 67% if they underwent repeat CIS vs. 7.8% if they could not undergo repeat CIS. After adjusting for potential confounders, second CIS was less likely with increasing number of tumors (OR 0.43, p<0.0001) and with node negative primary tumors (OR 0.28, p=0.042). Receipt of adjuvant chemotherapy (OR 7.03, p=0.046) was associated with increased likelihood of repeat CIS, while increasing DFI (OR 1.05, p=0.071) and response to initial neoadjuvant chemotherapy (OR 3.26, p=0.087) approached significance.
Conclusion: Despite high recurrence and decreasing DFI, repeat CIS provides a survival benefit with 5-year overall survival of 67%. The number of tumors at the time of recurrence, nodal status of the primary colorectal tumor and receipt of adjuvant therapy after the first CIS were significant predictors of repeat CIS.
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