Liver resection for colorectal liver metastases in older patients
Introduction
Life expectancy has increased dramatically over the last 100 years, and is now 75–77 years for men and 80–81 years for women in western society [1]. The demographics of these changes have important consequences for health care professionals in oncology. Currently, over half of all cancers are diagnosed in elderly patients, and 76% of all colorectal cancer patients are diagnosed between 65 and 85 years old [2], [3]. Although the prevalence of colorectal cancer in elderly patients is increasing, survival in this patient category has not improved accordingly. Age standardised survival rates are lower for elderly patients with colorectal cancer compared to younger ones, especially during the first year after diagnosis [2]. Elderly patients are less likely to undergo curative surgery, and less likely to be offered the option of metastasectomy when liver metastases are present [4].
Synchronous liver metastases are present in about 20% of patients found to have carcinoma of the colon and rectum [5], and metachronous liver metastases will subsequently appear in approximately 20–50% of patients [6], [7], [8], [9]. Hepatic resection is the only treatment offering long-term survival for these patients [8], [10], [11]. However, in studies reporting resection of colorectal liver metastases, only 8–20% [11], [12] of the patients are older than 70 years [13]. When balancing the benefits of surgical resection of liver metastases against the potential risks of surgery, many clinicians are still reluctant to advise in favour of surgical treatment in the elderly. Although such a minimalist approach might seem unacceptable, it is likely that concerns about postoperative morbidity and mortality in the elderly may have influenced the decision to not offer surgery to these patients.
Recent improvements in techniques of hepatic resection and anaesthetic interventions have evolved dramatically. Postoperative mortality has decreased over the past decades, and nowadays peri-operative care has improved with mortality rates varying between 0% and 11%, even for procedures combining colon resection with metastasectomy [14]. In addition, neoadjuvant chemotherapy is being used increasingly with the intention of improving disease-free survival post-liver resection, and also to bring patients with initially unresectable liver disease to potentially curative surgery. This study was therefore conducted to investigate the feasibility, short- and long-term outcomes of liver resection for colorectal liver metastases in patients over the age of 70.
Section snippets
Methods
Out of a consecutive series of 654 liver resections for colorectal metastases collected between August 1990 and April 2007 at our Unit, all patients over 70 years old were included in this study. Preoperative radiological investigations and clinical details of all patients were discussed at the hepatobiliary (HB) multidisciplinary team (MDT) meeting before proceeding to surgery data were collected prospectively, including: age, sex, site and staging of primary tumour, administration of
Results
Within the 17-year study period 181 liver resections were performed in 178 consecutive patients. The American Association of Anesthesiologists (ASA) grade was less than IV for all patients included. The median age of patients was 74 years (range 70–82 years). Patient characteristics are shown in Table 1.
Thirty-four patients (18.8%) received neoadjuvant chemotherapy prior to liver surgery. No patients received neoadjuvant chemotherapy prior to 2000, and all of those who received it thereafter
Discussion
Even with the recent advances in chemotherapy, 5-year survival in patients with colorectal liver metastases receiving only palliative chemotherapy is 0–4% and none are cured [16], [17]. The active treatment of elderly patients with metastatic colorectal cancer disease, with the intention of increasing life expectancy, presents us with a dilemma between the benefits and risks of surgery. Most studies reporting outcome after hepatic resection in the elderly deal with mixed caseloads (including a
Conflict of interest statement
No funding sources have been employed and there is no conflict of interest to be declared.
Reviewers
Professor Nicolas Demartines, Head, Department of Visceral Surgery, Centre Hospitalier Universitaire Vaudois CHUV, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland.
Nicola de Liguori Carino, M.D., Degree in Medicine and Surgery at University of Tor Vergata in Rome. Currently Surgical Senior Clinical Fellow in HPB and Transplant at St. James University Hospital, Leeds, UK.
References (31)
- et al.
Outcomes after major hepatectomy in elderly patients
J Am Coll Surg
(2006) - et al.
Outcome of patients undergoing orthotopic liver transplantation with elderly donors (over 60 years)
Transplant Proc
(1997) - et al.
Marginal donors in liver transplantation
Transplant Proc
(2004) - et al.
Surgical therapy for colorectal metastases to the liver
J Gastrointest Surg
(2007) - et al.
Perioperative chemotherapy with FOLFOX4 and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC Intergroup trial 40983): a randomised controlled trial
Lancet
(2008) - et al.
Perioperative complications in patients undergoing major liver resection with or without neoadjuvant chemotherapy
J Gastrointest Surg
(2003) - World Health Organisation. World Health Statistics. Anonymous. WHO Library Cataloguing-in-Publication Data,...
- et al.
A wide difference in cancer survival between middle aged and elderly patients in Europe
Int J Cancer
(2007) - et al.
Should we deny surgery for malignant hepato- pancreatico-biliary tumors to elderly patients?
World J Surg
(2005) - et al.
Use of surgery among elderly patients with stage IV colorectal cancer
J Clin Oncol
(2004)
Metastases:incidence, detection and evaluation without histologic confirmation
The natural history of primary and secondary malignant tumors of the liver
Cancer
Pattern of recurrence in liver resection for colorectal secondaries
World J Surg
Resection of colorectal liver metastases
World J Surg
Survival after resection of multiple hepatic colorectal metastases
Ann Surg Oncol
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Outcomes following potentially curative therapies for older patients with metastatic colorectal cancer
2021, European Journal of Surgical OncologyChanging outlook for colorectal liver metastasis resection in the elderly
2019, European Journal of Surgical OncologyCitation Excerpt :This likely relates to concerns regarding increased operative risk for the older patients, with expected shorter survival [8,12,13]. However, recent outcomes have suggested patients aged over seventy undergoing liver resection for CRLM will achieve a five-year survival of 21–44%, with postoperative morbidity and mortality rates of approximately 20–40% and 0–7% respectively [8,14–19]. These studies did not employ ERAS and CPET in patient management.
Personalized management of elderly patients with rectal cancer: Expert recommendations of the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology, and American College of Surgeons Commission on Cancer
2018, European Journal of Surgical OncologyCitation Excerpt :De Liguori Carino et al. analyzed data from liver resections performed on 178 consecutive senior adult patients. The overall survival (OS) rate at 5 years was 31·5% [126]. Similar results were reported by Nagano et al. who reported 34·1% 5-year survival rate in 202 elderly patients undergoing surgery for CRC with liver metastatic disease [127].
Hepatectomy for octogenarians with colorectal liver metastasis in the era of enhanced recovery
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2017, HPBCitation Excerpt :This is likely related to differences in the age cut-off studied and non-specific patient selection including both benign and malignant pathologies, ±underlying liver dysfunction and major and minor resections.13,15,19–21 However, even amongst studies specifically evaluating hepatectomy for CRLM, results differ.10,12,14,22–25 To date only two studies have exclusively evaluated outcomes among octogenarians undergoing hepatectomy.26,27
Nicola de Liguori Carino, M.D., Degree in Medicine and Surgery at University of Tor Vergata in Rome. Currently Surgical Senior Clinical Fellow in HPB and Transplant at St. James University Hospital, Leeds, UK.