IDENTIFYING PROGNOSTIC FACTORS FOR OVERALL SURVIVAL IN PATIENTS WITH RECURRENT DISEASE FOLLOWING LIVER RESECTION FOR COLORECTAL CANCER METASTASIS
Lily J. Park*5, Vivian Li1, Betty Zhang1, Sanaa Faisal4, Raghdah G. Faisal4, Matthew Fabbro5, Chu-Shu Gu1, Victoria Zuk2, Julie Hallet2, Guillaume Martel3, Pablo E. Serrano1
1McMaster University, Hamilton, ON, Canada; 2Sunnybrook Health Sciences Centre, Toronto, ON, Canada; 3Ottawa Hospital, Ottawa, ON, Canada; 4The University of Dublin Trinity College, Dublin, Ireland; 5Royal College of Surgeons in Ireland, Dublin, Ireland
Despite high recurrence rates following hepatic resection for colorectal cancer liver metastasis (CRLM), there lacks robust evidence to guide management of recurrent disease in this setting. We aimed to evaluate risk factors for survival in this population. Secondary objectives included: identifying the most common sites of recurrence and their management, and to determine overall survival (OS) and disease-free survival (DFS) in patients who undergo curative surgery after first recurrence following initial liver resection.
This was a multi-institutional retrospective cohort study (3 academic institutions) of patients with disease recurrence following first liver resection for CRLM. Recurrence was defined as metastatic disease following therapy with curative intent for the preceding recurrence. Curative management included surgery, radiation therapy and/or radiofrequency ablation. Risk factors included: bilateral liver metastasis, first clinical presentation of colon cancer (i.e., perforation), number of recurrence sites, extrahepatic disease at the time of liver resection, tumour grade and size, perioperative chemotherapy, node and margin positivity of primary tumour, synchronous CRLM, and time to recurrence. Cox regression models were used to identify poor prognostic factors, which classified patients into low and high survival risk groups. These groups were compared using the Kaplan-Meier method.
Of 473 patients who underwent liver resection and experienced recurrent disease (52% liver, 33% lung), 270/473 (57%) underwent curative management (179 surgery, 66%). Of those, 167/270 (62%) experienced second recurrence (30% liver, 23% lung), of which 108/167 (65%) underwent curative treatment (54 surgery, 50%). Third and fourth recurrence occurred in 56/108 (52%) and 3/13 (23%) patients (Figure 1). Mean OS and DFS following curative surgery at the time of first recurrence was 53.6 months (95% confidence interval (CI) 50.1-57.1) and 17.4 months (95% CI 17.0-17.8), respectively. The high-risk group, based on prognostic risk factors, included: patients with time to first recurrence less than 8.5 months following liver resection, (hazard ratio (HR) 3.23, 95% CI 1.97-5.31) OR perforation as initial clinical presentation (HR 3.54, 95% CI 1.27-9.89) AND presence of extrahepatic disease at the time of first liver resection (HR 2.86, 95% CI 1.32-6.20). The high-risk group had median OS 38.7 months (95% CI 59.4-74.9) versus 64.8 months (95% CI 34.0-44.2) in the low risk group (HR=2.60, 95% CI 1.99-3.40).
The decision to offer surgical re-resection in patients with recurrent disease following hepatectomy for CRLM should be guided by careful analysis of prognostic risk factors. These high-risk factors include perforation as initial clinical presentation, extrahepatic disease at the time of liver resection and time to recurrence.
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