American Surgical Association

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Topic: D. Clinical Cancer
Should R1 Liver Resection by Necessity be Blamed or Encouraged in the Treatment of Colorectal Metastases?
Robbert J de Haas, Dennis A Wicherts, Eduardo Flores, Daniel Azoulay, Denis Castaing, RenÚ Adam
H˘pital Paul Brousse, Villejuif, France

OBJECTIVE(S)
Complete macroscopic resection with negative margins (R0) is the gold standard recommendation in the surgical treatment of colorectal liver metastases (CLM). However, owing to vascular proximity or multinodularity, complete macroscopic resection can sometimes only be performed through R1-resection (positive margins). As increasingly efficient chemotherapy may have changed the spectrum of this particular situation, we compared long-term outcome of R0- and R1-resections with an aggressive approach combining chemotherapy and repeat surgery, to assess the validity of this policy.
METHODS
All resected CLM-patients (R0 or R1) at our institution between 1990 and 2006 were prospectively evaluated. We aimed to resect all identified metastases with negative margins. However, when safe margins could not be obtained, resection was still performed provided complete tumor removal. Overall(OS) and disease-free survival(DFS) were compared between groups, and prognostic factors were identified.
RESULTS
Of 436 included patients, 234 (54%) underwent R0-resection and 202 (46%) R1-resection, with demographics shown in the table. After a mean follow-up of 40 months, 5-year OS was 61% and 57% for R0- and R1-patients(P=0.27). Five-year DFS was 29% in the R0-group versus 20% in the R1-group(P=0.12). Preoperative CEA-level >10ng/ml and major hepatectomy, but not R1-resection, were independent predictors of poor OS.
CONCLUSIONS
Despite a higher recurrence rate, the contraindication of R1-resection should be revisited in the current era of effective chemotherapy, since survival is similar to that of R0-resection.

Metastases, operative, and long-term outcome features
VariableR0-group
N=234
R1-group
N=202
P
> 3 CLM at diagnosis59 (26%)84 (44%)<0.001
Preoperative chemotherapy157 (67%)164 (81%)0.001
Major hepatectomy (> 3 segments)96 (41%)115 (57%)0.001
Postoperative mortality (< 2 months)5 (2%)1 (1%)0.14
Postoperative chemotherapy182 (78%)178 (88%)0.002
RecurrenceIntrahepatic
Extrahepatic
Both
26 (17%)
74 (48%)
53 (35%)
42 (28%)
46 (31%)
61 (41%)
0.004
Intrahepatic recurrence siteMargin
Elsewhere
Both
12 (15%)
59 (75%)
8 (10%)
13 (12%)
79 (75%)
14 (13%)
0.72
Repeat hepatectomy53 (23%)46 (23%)0.38
Resection extrahepatic recurrence56 (24%)29 (14%)0.14


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