Treat of primary colorectal tumor and diligent pelvic follow-up impact survival in patients initially treated with liver resection

Recurrence of pelvic cancers is seen in just under 25% of patients treated with liver resection following colorectal metastases, according to the results of a study from the Johns Hopkins School of Medicine. Careful treatment of the primary tumor and diligent follow-up in the pelvic cavity can have an impact on 5-year survival.

Baltimore

“Physicians have traditionally thought that patients with stage T4 colorectal cancer with metastasis to the liver have a short survival,” says author Timothy Pawlik, MD, assistant professor of surgery and oncology at Johns Hopkins in . “Over the last 10 years, we have developed much more effective treatment modalities so that 5-year survival rates approach 55% for patients undergoing resection for colorectal liver metastasis. As patients with distant metastasis live longer, local recurrence at the site of the primary tumor becomes a bigger concern, especially for patients with rectal tumors.”

Pawlik and colleagues retrospectively looked at 582 patients who underwent curative hepatic resection for liver metastases from a primary colorectal adenocarcinoma. Of these, 24% had liver metastasis from a primary rectal tumor site. With a median follow-up of 30.7 months, 23 patients (16.3%) developed recurrence in the pelvis and more than half of these (56.5%) also had second tumors in the liver.

“We found that following liver resection of rectal metastasis local recurrence was actually fairly common,” he says. “A rate that high was surprising. That should give physicians pause with regard to making sure they adequately treat the primary tumor and not think that treatment of the metastasis alone is what drives survival.”

Of 80 patients with rectal cancer who developed a recurrence, 25.0% had pelvic disease as the first site of cancer return. At the end of the study, 28.8% of the patients developed recurrence in the pelvis.

“These pattern-of-recurrence data have important implications for post-operative surveillance programs and in planning adjuvant therapy,” says Pawlik. “Because most recurrences occur systemically, improvements in survival will likely depend on the use of systemic chemotherapy.”

In addition, their findings have implications for post-surgery follow-up in this group.

“A significant minority of patients will have recurrence of cancer in the pelvis,” says Pawlik. “Following the patient should include imaging of the pelvis to find new tumors quickly.”

Overall, the 3- and 5-year survival rate was 62.4% and 36.4% respectively. Among the 30% who had a recurrence and could have a repeat metastectomy, the survival rates remained high, at 76.7% and 38.6%.

“This underscores the importance of imaging the pelvic area often,” says Pawlik. “If they do have a recurrence and it is picked up early, there is an opportunity for a second curative operation. Many patients should be referred for a surgical work-up instead of thinking nothing can be done.”

Pawlik suggests that even in those patients with stage IV disease, the results show the importance of adequate treatment of the primary tumor, including chemo or radiotherapy where indicated.

“Issues of recurrence need to be judged in light of overall longer survival by our patients,” he notes. “The other side is that when cancers do return, well-selected patients should be considered for repeat resection.”

Gainesville

Steven Hochwald, MD, is associate professor of surgery and chief of the Division of Surgery at the University of Florida College of Medicine in and was not involved in the study.

“This adds to the body of literature indicating the need to pay close attention to treating the primary tumor even when there is metastasis,” Hochwald says. “While much of this has been shown previously, it does serve as a reminder to keep in mind local recurrence even after excision of the metastasis. Patients undergoing liver resection for rectal cancer would be expected to have advanced primary tumors and, therefore, be at increased risk for local recurrence as well as distant recurrence following liver directed therapy”

Arch Surg

Assumpcao MD, et al. Patterns of recurrence following liver resection for colorectal metastases: Effect of primary tumor site. . 2008;143:743-749.

KurtUllman

Indianapolis

is a veteran freelance health and medial writer based out of .