Surgical management and outcomes of colorectal cancer liver metastases

Introduction Selected patients with colorectal cancer liver metastases (CRLM) and synchronous extrahepatic disease (EHD) are considered for surgery. Objectives To evaluate the change in surgical management and long-term survival (disease-free survival [DFS] and overall survival [OS]) for patients with CRLM and EHD who undergo positron emission tomography combined with computed tomography (PET-CT) vs no PET-CT. Methods Patients with CRLM were enrolled in a trial evaluating the effect of PET-CT (vs no PET-CT) on surgical management, DFS, and OS. This is a sub-study of the trial, including only patients with synchronous EHD. Cox proportional hazard models were used to calculate risks for recurrence and death. Survival were described by Kaplan-Meier method and compared with log-rank test. Results Of 25 patients with EHD (PET-CT arm: 14/270 (5%) and no PET-CT arm: 11/134 (8%)), PET-CT changed surgical management in 14%, all of which avoided liver resection due to more extensive disease. Complete metastasectomy was achieved in 36% (5/14) and 72% (8/11), respectively. Respectively, PET-CT vs no PET-CT had statistically similar median DFS, 5.6 months (95% confidence interval (CI) 3.6-18) vs 7.6 months (95% CI 2.9-15) and median OS, 42 months (95% CI 25-48) vs 29 months (95% CI 17-41). EHD was associated with worse DFS (hazard ratio HR = 1.89, 95% CI 1.41-2.52) and OS (HR = 2.47, 95% CI 1.6-3.83). Conclusions Preoperative PET-CT for the management of resectable CRLM did not improve long-term outcomes among patients who had synchronous EHD; however, it changed surgical management in a relatively significant proportion of patients.

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Effect of PET-CT on disease recurrence and its management in patients with potentially resectable colorectal cancer liver metastases: The long-term results of a randomized control trial.

Journal of Clinical Oncology ◽

10.1200/jco.2018.36.4_suppl.562 ◽

2018 ◽

Vol 36 (4_suppl) ◽

pp. 562-562

Author(s):

Pablo Emilio Serrano Aybar ◽

Chu-Shu Gu ◽

Mohamed Husien ◽

Diederick Jalink ◽

Guillaume Martel ◽

...

Keyword(s):

Colorectal Cancer ◽

Liver Metastases ◽

Surgical Management ◽

Disease Recurrence ◽

Long Term Results ◽

Colorectal Cancer Liver Metastases ◽

Pet Ct ◽

Risks Factors

562 Background: The PETCAM randomized trial evaluated the effect of preoperative PET-CT (vs. no PET-CT) on surgical management in patients with colorectal cancer liver metastases. In this study, 8% of patients had a change in surgical management, including a higher proportion of major liver resections in the PET-CT arm. The current study compares the intervention groups for 5-year disease free (DFS) and overall survival (OS), and evaluated their long-term clinical course, i.e. sites of recurrence and management of disease recurrence. Methods: Recruitment to the trial occurred between 2005-2010, with last follow-up in 2013. Data on recurrence, management of recurrence and mortality from 2013-2017 was collected from patient’s charts. Recurrences according to site and management were described. Cox proportional Hazard Models were used to calculate the risk for recurrence and death. OS was calculated with Kaplan-Meir method and compared with log-rank test. Results: At 5 years, 157 of 404 (39%) patients were still alive and 19 patients were lost to follow-up. Median follow-up is 4.2 years. There were no differences in DFS (HR: 1.12, 95%CI: 0.88-1.42) or OS (HR: 0.97, 95%CI: 0.74-1.28) between groups. The median DFS for the 372 patients who had surgery was 17 months, 95%CI: 14.7-19.4. Risks factors for recurrence were: extrahepatic disease, liver tumour size, and nodal stage. The median OS for all patients was 50 months, 95%CI: 43.5-64.3. Risks factors for death also included age and prior use of chemotherapy. During the follow-up period, 287/404, 71% patients recurred (mostly liver and lung); 137 (48%) were treated solely with chemotherapy and 35% were treated with surgery with curative intent. Of these, the majority recurred (109/116, 94%). The median OS following first recurrence was 27.5 months, 95%CI: 23-30. Conclusions: PET-CT did not improve DFS or OS. Survival following liver resection is similar to previous reports, however most patients experience disease recurrence. A substantial proportion of patients who recur undergo surgery, however it is likely that they will recur again.

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PET-CT compared to no PET-CT in the management of potentially resectable colorectal cancer liver metastases: The costs implications of a randomized controlled trial.

Journal of Clinical Oncology ◽

10.1200/jco.2016.34.4_suppl.296 ◽

2016 ◽

Vol 34 (4_suppl) ◽

pp. 296-296 ◽

Cited By ~ 2

Author(s):

Pablo Emilio Serrano Aybar ◽

Amiram Gafni ◽

Chu-Shu Gu ◽

Jim A. Julian ◽

Carol-anne Moulton ◽

...

Keyword(s):

Colorectal Cancer ◽

Cost Analysis ◽

Liver Metastases ◽

Surgical Management ◽

Credible Interval ◽

Cost Driver ◽

Care Utilization ◽

Colorectal Cancer Liver Metastases ◽

Pet Ct ◽

Mean Cost

296 Background: PETCAM was a randomized trial evaluating the effect of PET-CT compared to conventional imaging (control) on the surgical management of patients with resectable colorectal cancer liver metastases (CRLM). It concluded that PET-CT did not result in frequent change in surgical management (8·0%, 21/263) with only 2·7% (7/263) avoidance of liver resections. In this study we conducted a cost analysis of these two arms up to one year following randomization. Methods: Health care utilization was collected for all study participants. Unit costs for hospitalization, physician services, chemotherapy and outpatient radiological and endoscopic procedures were obtained from administrative databases. Cost analysis was undertaken from the perspective of a third-party payer (i.e., Ministry of Health). Mean cost with its 95% credible interval was estimated using a Bayesian approach. Results: The estimated mean cost per patient in the PET-CT arm was CAN $45,454 (min-max: 1,340-181,420) and in the control arm, CAN $40,859 (min-max: 279-293,558), with a net difference of CAN $4,327, 95% credible interval -2,207 to 10,614. The primary cost driver was cost of hospitalization for liver surgery (+ $2,997 CAN for the PET-CT arm), mainly due to a longer length of hospital stay for the PET-CT arm compared to control (median 7 days vs. 6 days, P= 0·034) and a higher rate of postoperative complications (52/255, 20% vs. 13/128, 10%, P = 0·014). Baseline characteristics were similar between groups, including a similar number of liver segments involved with cancer, number of segments resected and type of liver resection performed. Conclusions: PET-CT does not appear to provide a significant clinical benefit in the surgical management of patients with resectable CRLM and it is not cost saving compared to control.

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