Hepatic cryotherapy and regional chemotherapy with or without resection for liver metastases from colorectal carcinoma: how many are too many?

Background: The number of hepatic metastases for which resection or ablation is appropriate remains controversial.

Methods: A retrospective analysis was performed of prospectively collected data from patients with liver metastases from colorectal carcinoma who underwent hepatic cryotherapy and hepatic arterial chemotherapy (HAC) with or without undergoing resection. Patients routinely had preoperative bone scans, chest computed tomography (CT) scans, and abdominal angio-CT scans. Positron emission tomography scans were unavailable. All patients were followed until June 2002 or until death occurred. Kaplan-Meier and Cox regression methods were used to evaluate the impact of 17 potentially prognostic factors on survival.

Results: One hundred seventy-two patients who underwent hepatic cryotherapy and HAC with or without undergoing liver resection for in situ eradication of metastases formed the basis of this report. One patient (0.6%) died postoperatively from myocardial infarction. The morbidity rate was 27.9%. The median survival was 28 months (range, 0-98 months). The factors age < or = 50 years, well-differentiated or moderately differentiated primary tumor, small cryolesions (<3.5 cm), complete eradication of extrahepatic metastases at cryotherapy, and low preoperative carcinoembryonic antigen (CEA) levels were associated independently with a favorable outcome. In addition, a univariate analysis showed that the absence of untreated extrahepatic disease at laparotomy, postoperative CEA normalization, and a large decline in CEA levels were significant statistically. The number of lesions was not prognostic. One hundred forty-six patients (84.9%) who underwent a complete operation had 1-year, 2-year, 3-year, 4-year, and 5-year survival rates of 89%, 65%, 41%, 24%, and 19%, respectively. The median survival of patients with 1 metastasis, 2 metastases, 3 metastases, 4 metastases, 5 metastases, 6 or 7 metastases, and 8-12 metastases were 32 months, 29 months, 30 months, 31 months, 27 months, 37 months, and 21 months, respectively (P=0.7859). Twenty-five patients had 6 or 7 lesions, and their 5-year survival rate was 25%.

Conclusions: When all colorectal hepatic lesions were eradicated, the numbers of hepatic metastases were not prognostic of survival in patients with liver metastases from colorectal carcinoma.