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EDITORIALS |
From Allegheny General Hospital, MCP-Hahnemann School of Medicine, Pittsburgh, Pennsylvania.
Correspondence: Address correspondence to: Mark S. Roh, MD, Chairman and Professor of Surgery, Allegheny General Hospital, MCP-Hahnemann School of Medicine, 320 E. North Ave., Pittsburgh, PA 15212; Fax: 412-359-6288; E-mail: markroh@ earthlink.net.
As surgical oncologists, we continually strive to cure our patients of their diseases. We have defined cure as no evidence of disease at the 5-year anniversary of the therapy. Only a statistically significant improvement in survival is accepted as a reasonable end point for new treatment modalities. If a particular therapy does not increase the number of patients achieving this end point, we are reluctant to recommend it. Likewise, a specific clinical or pathologic finding that predicts a poor prognosis (i.e., very few, if any, 5-year survivors) is frequently considered a contraindication to a specific treatment. However, should a therapy that cannot cure a patient but can prolong his or her life with an acceptable quality of life still be offered?
Numerous therapies have been evaluated to treat metastatic colorectal cancer and have eventually fallen into disfavor when a significant survival advantage could not be documented. In some cases, significant benefit was observed at 2 and 3 years only to disappear at 5 years. Should we add to our list of acceptable oncologic goals the prolongation of survival? A patient with a particular prognostic outlook may have a small chance (0%–10%) for cure yet may obtain 2 to 3 years of additional life with treatment. Are we being nihilistic by defining success only as 5-year disease-free survival? Should success also be defined as prolonging survival with a low-risk treatment?
The article by Jaeck et al.1 in this issue of the Annals of Surgical Oncology examines the prognostic significance of histopathologic involvement of hepatic pedicle lymph nodes in patients undergoing hepatic resection of colorectal liver metastases. The authors prospectively performed a complete lymphadenectomy in 160 patients undergoing hepatic resection for colorectal metastases. A complete lymphadenectomy included the dissection of the hepatoduodenal ligament and retropancreatic and celiac lymphatics. Histopathologic involvement occurred in 10.6% of the patients and was significantly associated with four or more metastases, lesions located in segments 4 and/or 5, poorly differentiated histology, and the presence of a solitary peritoneal deposit. Despite the presence of portal lymphatic metastases, 19% of the patients survived 3 years. Patients with metastases limited to the proximal (within the porta hepatis) lymphatics had a better prognosis at 3 years than did those with distal (at the origin and along the transverse part of the hepatic artery) involvement (38% vs. 0%). This study challenges the premise that portal lymphatic metastases are an absolute contraindication to hepatic resection.
For many years, the classic contraindication to hepatectomy has been the presence of portal lymphatic metastases, as this reflected systemic disease that could not be successfully treated with resection. Liver metastases originate from the hematogenous spread from the colorectum, growth of these intrahepatic tumor cells, and remetastasis to the regional lymph nodes via drainage from the liver.2 The lymphatic drainage from the liver is to the portal hepatis, celiac axis, and diaphragmatic nodal basins.3 This study has shown that the location of the metastases is important, as involvement of certain nodal basins is associated with an improved prognosis. Nodal spread to the proximal lymphatics may reflect only local disease that may be favorably impacted by combined excision of hepatic and portal metastases.
Primary colorectal cancer patients frequently present with nodal involvement and can achieve long-term survival with surgery. Potentially, patients with hepatic and proximal portal metastases could also obtain long-term survival by undergoing a portal lymphadenectomy with hepatectomy. Like the surgical management of primary colorectal cancer, the ultimate goal must be a complete excision of all macroscopic disease (R0 resection).
Although few patients with portal lymphatic metastases will survive 5 years, many do survive for 3 years.4,5 Recent advances in adjuvant chemotherapy in patients with metastatic colorectal cancer following hepatic resection (without nodal metastases) have decreased the recurrence rate and significantly improved survival.6 Hopefully, this adjuvant therapy will also help patients with nodal disease that undergo an R0 resection. In addition, the mortality for hepatic resection continues to decline and currently is <2%, and the morbidity is <10% for most hepatic surgeons. So, with a small operative risk and the chance to enjoy life for several more years, should we begin to offer combined excision of liver and portal nodal metastases?
Received for publication April 22, 2002. Accepted for publication April 22, 2002.
REFERENCES
This article has been cited by other articles:
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  V. P. Khatri, N. J. Petrelli, and J. Belghiti Extending the Frontiers of Surgical Therapy for Hepatic Colorectal Metastases: Is There a Limit? J. Clin. Oncol., November 20, 2005; 23(33): 8490 - 8499. [Abstract] [Full Text] [PDF]
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