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Editorial |
Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10021
Correspondence: Address correspondence and reprint requests to: Ronald P. DeMatteo, MD; E-mail: dematter{at}mskcc.org.
The article in this issue by Yedibela et al.1 addresses the controversial topic of hepatectomy for noncolorectal metastases. In a retrospective analysis, they report their results with a large number of hepatic resections for metastases from tumors with a variety of histologic characteristics. By dividing their experience into two time periods (1978–1989 and 1990–2001), they demonstrate that outcome has improved.
The improved recent results seem to be due to better patient selection and surgical technique, as the authors point out. As with most retrospective reports, the true denominator from which the patients were chosen was not defined. In terms of patient selection, extrahepatic disease was present in 36% in the early group but only 13% in the recent group. Accordingly, the R0 resection rate went from 49% to 72%. There were 53% with synchronous metastases in the first time period but only 36% in the later group. Surprisingly, though, patients in the first group who had synchronous metastases fared better than those with metachronous disease (table 5). The percentage of patients with multiple tumors decreased from 53% to 35% between the two time periods, although the authors did not find that outcome depended on the number of tumors.
Tumor histology is a vital factor in outcome, but it is always di:cult to provide extensive details in a collective report such as this. For instance, it is unclear whether the tumors listed as "gallbladder" were true metastases or just represented local extension, in which case they should have been excluded. Although the 20 recent patients with metastatic gastrointestinal carcinoma who underwent R0 resection had a median survival of 30 months, the authors nevertheless concluded that these patients should not generally undergo resection. There were 15 patients with leiomyosarcoma, as stated in table 6 (although there are only 8 sarcomas listed in table 1), but it is likely that many or most of these were actually gastrointestinal stromal tumors.
Can we quantify the selection process so that lower-volume centers can benefit from these data? Unfortunately, the authors could not identify any prognostic predictors except complete resection. In contrast, in our recent report2 (published after the submission of this manuscript), we found that the disease-free interval from the primary tumor predicted survival on multivariate analysis. Patients with a disease-free interval of >2 years had a median survival of 52 vs. 34 months. In addition, we identified tumor histology as critical. Patients with reproductive tract tumors fared better, with a median survival of 115 vs. 36 months. In the current study, the authors did not report the survival in their "kidney/genitourinary" category listed in table 1. We too found that R0 resection was important.
The surgeons and their teams also improved. Although throughout the study period most operations were minor hepatectomies, 25% of patients in the early period required reoperation, and 8% (vs. 1% in the recent group) died perioperatively. In the recent period, fewer (40% vs. 11%) had high blood loss, and fewer patients received transfusions. The authors concluded that blood loss alone predicts survival (table 3), but it does not seem that a multivariate analysis was performed to substantiate this. On the basis of their inability to achieve complete resection more often in the patients with synchronous metastases, the authors recommend two-stage procedures. However, it is not certain from the data whether that would actually have led to more R0 resections. It is more likely that the unfavorable tumor biology present in the patients with synchronous metastases would prevail over the number of operations.
In the discussion, the authors state that there are well-defined guidelines for hepatectomy of colorectal carcinoma. However, to some surgeons and many oncologists, the guidelines are quite cloudy, especially given recent advances in chemotherapy. Nevertheless, what we can glean from this article is that surgeons have become expert in selecting patients and resecting liver tumors. So is there room for the surgeon to improve? Well, we can produce more surgeons to do the same. However, the most meaningful advances in patient outcome depend on the development of better systemic therapies to use in combination with gross tumor resection. An obvious example is the recent experience with gastrointestinal stromal tumors. Imatinib mesylate has dramatically improved the outcome of patients with gastrointestinal stromal tumor metastases to the liver. The combination of imatinib and hepatectomy is likely to prove even more eIective and certainly will be better than our previous results with hepatectomy alone.3 What underscores the need for better adjuvant therapies after hepatectomy for noncolorectal liver metastases is the generally low recurrence-free survival, which was not analyzed in this study. In our report, we found it to be only 30% at 3 years. The true effect, and limitations, of liver resection can be interpreted only in this context.
Received for publication May 17, 2005. Accepted for publication June 9, 2005.
REFERENCES
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