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Editorial |
University of Medicine and Dentistry of New Jersey-New Jersey Medical School, 185 South Orange Avenue, Room G-524, Newark, New Jersey 07103
Correspondence: Address correspondence and reprint requests to: Lawrence E. Harrison, MD; E-mail: l.harrison{at}umdnj.edu.
The liver is a common site for metastatic spread from a variety of cancers, and for most patients, hepatic metastasis is a marker of additional disseminated systemic disease. However, there is a select subset of patients who present with isolated hepatic metastasis whose tumor biology is such that hepatic resection provides a long-term survival advantage. Most data related to survival after hepatic resection for isolated liver metastases have been derived from patients undergoing resection for colorectal metastasis, and in this select group of patients, 5-year survivorship can reach 25% to 35%.1 Because resection for both primary and metastatic liver tumors offers the best option for overall survival and because hepatic resection can be accomplished with low morbidity and mortality rates, indications for resection have been liberalized. Over the last decade, there has been increased interest in the role of hepatic resection for noncolorectal, nonneuroendocrine malignancies (NCNNM), and as more series are being published, the role of liver resection for NCNNM is being better defined.
In this issue of Annals of Surgical Oncology, Ercolani et al.2 provide further evidence that hepatic resection in a highly selected group of patients with NCNNM provides long-term survival. With an operative mortality of 0%, they report a 5-year overall survival of 34.3% in 83 patients undergoing hepatic resection for NCNNM. The authors state that patient selection is the key to achieving a durable survival advantage, and they suggest that primary tumor site and total tumor volume (TTV) may help in deciding which patients may benefit from resection. As these authors demonstrate, major hepatic surgery can be performed safely with low mortality and morbidity. As more and more institutions publish their results of hepatic resection for either primary or metastatic disease, the question of "can we?" seems to have been sufficiently answered, and the question of "should we?" now needs to be addressed. The "should we" question really is an issue of patient selection. Stated differently, there is no question that hepatic resection for NCNNM can offer a long-term survival advantage; the issue is which patients will benefit. Therefore, the significance of this article is not just that the authors can perform hepatic resection safely; it is also important to note that they offer additional insight into which patients will benefit from surgical resection.
Which patients should be o?ered hepatic resection for isolated NCNNM? Two criteria that are almost universally accepted for selecting patients for curative hepatic resection are (1) the absence of extrahepatic disease and (2) the ability of the surgeon to perform an R0 resection, and most would agree that these two criteria are a very good starting point. Not surprisingly, the number of patients identified as surgical candidates on the basis of these two simple criteria will be higher in patients with colorectal hepatic metastases as compared with patients with NCNNM, thus further emphasizing the highly selective nature of patients undergoing hepatic resection for NCNNM. However, on the basis of the sheer volume of patients with NCNNM, the number of patients who may benefit from surgical resection can still be significant.
Even after these two criteria are met, variations in 5-year survival after hepatic resection can range from 10% to 50%.3–5 Additional factors need to be identified to better select patients who may benefit from hepatic resection. Previous reports of hepatic surgery for primary and metastatic tumors suggest that disease-free interval, serum markers, and tumor size predict outcome.1,3–7 Collectively, these act as surrogates for tumor biology. In this study, the authors identify two factors that predict outcome. First, they suggest that the primary tumor site is a good indictor of survival and that patients with genitourinary primary tumors maximally benefit from hepatic resection (median survival, 52.5 months), whereas patients with gastrointestinal-origin tumors have a significantly worse survival (median survival, 26.2 months). The primary tumor site has been noted in multiple series as a predictive factor and seems to be a reliable third criterion to consider.3–5 In general, patients with a genitourinary tumor (kidney, adrenal, or ovary) have a better survival than those with a soft tissue tumor (sarcoma, breast, or melanoma), whereas patients with tumors of the gastrointestinal tract fare the worst. As experience increases within each primary tumor site, additional site-specific criteria will, it is hoped, be identified.
The authors also conclude that the extent of hepatic disease is an independent predictor of survival. By univariate analysis, tumor diameter, percentage of parenchymal involvement, and TTV predicted overall survival after hepatic resection. By multivariate analysis, TTV was the only significant predictor of survival besides the primary tumor site. The predictive value of TTV has also been noted by this same group in patients undergoing hepatic resection for colorectal metastases.7 Hepatic tumor burden, regardless of how it is measured, seems to be another measure of tumor/host biology and may be useful in patient selection. One factor that represents tumor aggressiveness and is often cited as a highly predictive factor for outcome after surgery for metastatic disease is disease-free interval.1,3,5,6 Although disease-free interval was not a significant factor predicting outcome in this study, there was a trend toward improved survival.
There are broader implications of this type of series. The overall role for surgery in metastatic disease has perhaps been underappreciated. There are data supporting resection not only of hepatic metastases, but also of other sites, including adrenal, lung, brain, pancreas, and, recently, peritoneum. In the parlance of our medical oncology colleagues, surgical resection in this highly select group of patients can o?er a rapid, complete, and durable response. This data set from Ercolani et al. not only provides further evidence supporting the role of hepatic resection for isolated metastases in patients with NCNNM, but also provides additional evidence supporting resection of isolated metastatic disease resection in general, as long as we can select our patients correctly.
Received for publication February 10, 2005. Accepted for publication March 1, 2005.
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