High Survival Rate After Two-Stage Resection of Advanced Colorectal Liver Metastases: Response-Based Selection and Complete Resection Define Outcome

TLDR

Survival after two‑stage resection of advanced colorectal liver metastases may stem from selecting patients who respond best to chemotherapy, yet the benefit of complete resection in this well‑selected group remains controversial, as shown by a prospective collection of 890 resected and 879 chemotherapy‑only patients. The study employed an intent‑to‑treat analysis of 65 patients undergoing first‑stage two‑stage resection and a matched cohort of 62 nonsurgically treated patients with liver‑only disease, objective chemotherapy response, and survival beyond one year. Among the TSR group, 72 % completed the second stage, and after a median 50‑month follow‑up the 5‑year survival was 51 % versus 15 % in the medical group, with noncompletion and major complications independently predicting worse survival, demonstrating that TSR yields excellent outcomes through selection and complete resection.

Abstract

Prolonged survival after two-stage resection (TSR) of advanced colorectal liver metastases (CLM) may be the result of selection of best responders to chemotherapy. The impact of complete resection in this well-selected group is controversial.Data on 890 patients undergoing resection and 879 patients who received only chemotherapy for CLM were collected prospectively. We used intent-to-treat analysis to evaluate the survival of patients who underwent TSR. Additionally, we evaluated a cohort of nonsurgically treated patients selected to mirror the TSR population: colorectal metastases with liver-only disease, objective response to chemotherapy, and alive 1 year after chemotherapy initiation.Sixty-five patients underwent the first stage of TSR; 62 patients fulfilled the inclusion criteria for the medical group. TSR patients had a mean of 6.7 ± 3.4 CLM with mean size of 4.5 ± 3.1 cm. Nonsurgical patients had a mean of 5.9 ± 2.9 CLM with mean size of 5.4 ± 3.4 cm (not significant). Forty-seven TSR patients (72%) completed the second stage. Progression between stages was the main cause of noncompletion of the second stage (61%). After 50 months median follow-up, the 5-year survival rate was 51% in the TSR group and 15% in the medical group (P = .005). In patients who underwent TSR, noncompletion of TSR and major postoperative complications were independently associated with worse survival.TSR is associated with excellent outcome in patients with advanced CLM as a result of both selection by chemotherapy and complete resection of metastatic disease.