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PREVENTING FUTILE LIVER RESECTION: A RISK-BASED APPROACH TO LIVER-ONLY METASTATIC COLORECTAL CANCER
Marc W. Fromer*, Robert C. Martin
Surgery, University of Louisville, Louisville, KY

BACKGROUND: Several factors have been shown previously to predict disease recurrence after liver resection for metastatic colorectal cancer (mCRC). Enhanced liver-directed and systemic therapies have lengthened survival even after these recurrences. Despite these clinical improvements, there exists a clear subset of patients who rapidly succumb to early recurrence after their index liver resection. Since liver resection is not without significant morbidity, we aim to identify factors that estimate the risk of a futile liver resection in metastatic colorectal cancer.

METHODS: Sequential anatomic liver resections performed for mCRC between 1995-2019 were selected from our prospectively-maintained database. A cohort of patients with a disease-specific survival of <12 months was designated as having had a "futile operation." Group comparisons were made using chi-square tests, Mann-Whitney U-tests and Student T-tests, where appropriate. Cox proportional hazards regression and Kaplan-Meier testing were used for survival analyses and to develop a risk model for futility in hepatectomy.

RESULTS: A total of 231 hepatectomies were included in the analysis. The mean age was 60.5 years (STD=11.8), and the median number of liver tumors was 2 (IQR= 2). Most tumors were synchronous, with 58.8% being diagnosed within 3 months of their colorectal primary. A majority (53.3%) were male, and 24.3% underwent a trisegmentectomy. Disease-specific mortality occurred in 30 (11.6%) patients after liver resections within one year (futile liver resection). The hepatic remnant was involved in 62.5% of futile recurrences. Greater than 3 liver lesions was highly predictive of a futile liver resection, which was present in nearly half (46.7%) of this cohort (p<0.001). None of the patients in the futile resection group achieved a 50% or greater reduction in their carcinoembryonic antigen (CEA) level with neoadjuvant chemotherapy. Other associated factors included positive nodal disease with the primary colorectal tumor, inflammatory changes to liver parenchyma, use of cisplatin chemotherapy, and disappearing extrahepatic disease after chemotherapy. These data were used to create and validate a risk model for futile liver resection.

CONCLUSION: Discretion should be exercised when considering major liver resection for patients with liver-only metastatic colorectal cancer and the high-risk features ascertained from these data. The likelihood of a nontherapeutic hepatectomy in these cases is substantial and less morbid alternative therapies should be considered when discussing with the patient. A deliberate approach with risk stratification for futility is recommended to avoid potentially harmful operations and provide accurate expectations to patients.


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