Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer: analysis of 1001 consecutive cases

Abstract

Objective: There is a need for clearly defined and widely applicable clinical criteria for the selection of patients who may benefit from hepatic resection for metastatic colorectal cancer. Such criteria would also be useful for stratification of patients in clinical trials for this disease.

Methods: Clinical, pathologic, and outcome data for 1001 consecutive patients undergoing liver resection for metastatic colorectal cancer between July 1985 and October 1998 were examined. These resections included 237 trisegmentectomies, 394 lobectomies, and 370 resections encompassing less than a lobe. The surgical mortality rate was 2.8%.

Results: The 5-year survival rate was 37%, and the 10-year survival rate was 22%. Seven factors were found to be significant and independent predictors of poor long-term outcome by multivariate analysis: positive margin (p = 0.004), extrahepatic disease (p = 0.003), node-positive primary (p = 0.02), disease-free interval from primary to metastases <12 months (p = 0.03), number of hepatic tumors >1 (p = 0.0004), largest hepatic tumor >5 cm (p = 0.01), and carcinoembryonic antigen level >200 ng/ml (p = 0.01). When the last five of these criteria were used in a preoperative scoring system, assigning one point for each criterion, the total score was highly predictive of outcome (p < 0.0001). No patient with a score of 5 was a long-term survivor.

Conclusion: Resection of hepatic colorectal metastases may produce long-term survival and cure. Long-term outcome can be predicted from five criteria that are readily available for all patients considered for resection. Patients with up to two criteria can have a favorable outcome. Patients with three, four, or five criteria should be considered for experimental adjuvant trials. Studies of preoperative staging techniques or of adjuvant therapies should consider using such a score for stratification of patients.

Figures

Figure 1. Changes in pattern of practice of liver resection for metastatic colorectal cancer. Bar graph represents the number of resections per year.

Figure 2. Survival after treatment for metastatic colorectal cancer to the liver. Bottom curve depicts survival as calculated from the time of liver resection. Top curve represents survival calculated from the time of resection of the primary colorectal cancer.

Figure 3. Survival after hepatic resection as related to clinical risk score. Open box: score = 0 (n = 52); filled triangle: score = 1 (n = 262); open circle: score = 2 (n = 350); filled circle: score = 3 (n = 243); filled box: score = 4 (n = 80); open triangle: score = 5 (n = 14). p

Figure 4. Survival after hepatic resection for colorectal metastases as related to number of liver tumors. p = 0.004. Open squares: number = 1 (n = 517); filled triangles: number = 2 or 3 (n = 330); filled squares: number = ≥4 (n = 154).

Figure 5. Predictors of long-term outcome. (A) Correlation of clinical risk score to median survival (square) (r2 = 0.92, m = −10.3) and to 5-year survival (triangle) (r2 = 0.92, m = −9.1). (B) Correlation of number of tumors to median survival (square) (r2 = 0.81, m = −7.3) and to 5-year survival (triangle) (r2 = 0.80, m = −4.4).

Figure 6. Prediction of long-term outcome for small (