Gastrointestinal Cancer
Are There Any Prognostic Factors for Peri-operative and Long-term Outcomes? The results of liver resection for CRLM in well-selected elderly patients are favourable, thus the next step would be to determine whether there are prognostic factors that predict better or worse outcomes of resection in these patients. Proposals for a prognostic model in this select group of patients have been made, but to date none has been validated.
Zacharias et al.11
noted three independent risk factors that influence the OS and the DFS at multivariate analysis: presence of extrahepatic disease, presence of three or more liver metastases and a high pre- operative carcinoembryonic antigen (CEA) level (>200ng/ml). Patients without these risk factors had a three- and five-year OS of 59 and 36%, respectively, and a median OS of 42 months. Three- and five-year DFS rates were 33%. With one risk factor, three-year OS was 47% and median OS was 33 months, while three-year DFS was 14%. With two or three risk factors, the three-year OS was 20% and median OS was 14 months, with disease recurrence in all patients within the first year.
In a study by Fong et al.,15 male sex and American Society
of Anesthesiologists (ASA) class were significant predictors of complications after liver resection. The extent of resection, operative blood loss and operating time did not emerge as significant factors in multivariate analysis, although they were significant at univariate analysis.
In our study,18
univariate analysis identified eight pre-operative variables influencing survival: more than three metastases at diagnosis, bilateral metastases, a larger number of pre-operative chemotherapy cycles, non-curative liver resection, ‘globally non- curative’ resection (presence of extrahepatic disease), combined treatment modalities to improve resectability (radiofrequency ablation, cryosurgery or both used to treat all metastases during surgery), total number of hepatectomies and concomitant extrahepatic disease.
However, at multivariate analysis, three pre-operative variables merged as independent prognostic factors: more than three metastases at diagnosis, bilateral metastases and concomitant extrahepatic disease. In addition, no post-operative chemotherapy independently predicted poor survival. All are well-known poor prognostic factors as they reflect more advanced disease.9,25,26,55–57
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43%, respectively, for patients without any risk factors and ranged from 49.4 to 54.7% and 26 to 32%, respectively, when one factor was present. When two risk factors were present, the OS was 33.7–39.5% and 13–17%, respectively, at three and five years, whereas in the presence of all three risk factors the OS was only 22.3 and 6%, respectively. Our proposed prognostic model is indicative and could be used as a guide, but since it has not yet been validated, it should not be used as a unique cut-off decision-making tool.
Conclusion
Liver resection for CRLM in elderly patients is feasible and results in acceptable peri-operative and long-term outcomes that are similar to those in younger patients. The use of optimal chemotherapy further improves long-term survival. No upper age limit should contraindicate optimal treatment, and well-selected elderly patients can be offered a similar chance of DFS and OS. Although potential co-morbidities should be identified carefully to minimise peri-operative mortality, hepatectomy for CRLM as well as active chemotherapy should not be denied on the basis of age alone. n
Prashant Bhangui is a Clinical and Research Fellow in hepatobiliary (HPB) surgery and liver transplantation at the Hepatobiliary Centre at the Paul Brousse Hospital in France. He works in the specialised field of HPB surgery with a special interest in liver malignancies and transplantation. He received the Goa Scholar award in recognition of his academic and co-curricular achievements and for pursuance of advanced studies in HPB surgery and liver transplantation. He completed his
post-graduate studies in surgery at Goa Medical College, India, where he received the University Gold Medal.
Rene Adam is a Professor of Surgery in the Faculty of Medicine at Paris South University. He is President of the Medical Board and Head of the Onco-surgical Unit of the Hepatobiliary Centre at Paul Brousse Hospital in Villejuif in France. He is actively involved in clinical activity and research into the treatment of hepatocellular carcinoma and liver metastases. He chairs the European Liver Transplant Registry (ELTR) and LiverMetSurvey, an international Registry of Colorectal liver metastases.
Professor Adam is on the Editorial Board of The Oncologist and a member of several international societies, including the American Society of Clinical Oncology (ASCO), the European Society of Surgical Oncology (ESSO), the European Society of Organ Transplantation (ESOT), the European Surgical Association (ESA) and the International Hepato-Pancreatic and Biliary Association (IHPBA). He has given more than 600 lectures worldwide, and has more than 200 articles published in peer-reviewed journals.
OS at three and five years was 64.6 and
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