N. BIRD ET AL.
316
ble) is the most effective treatment for colorectal liver
metastases in providing long term survival. There was a
survival benefit from oxaliplatin or irinotecan based
chemotherapy in patients who recurred after liver resec-
tion and these recurrences were inoperable. They were
therefore given palliative chemotherapy. Those patients
treated with 5-FU had a significantly poorer survival
than those treated with Oxaliplatin or Irinotecan. We
propose that unless the value of adjuvant post-hepatec-
tomy chemotherapy is clarified by a randomised study,
patients with resectable liver and/or lung metastases
should undergo surgical resection and re-resection with
or without pre-operative downsizing if required. The use
of oxaliplatin and irinotecan in the palliative setting
should be reserved for inoperable recurrences only. This
approach is likely to confer the highest chance of cure as
well as a significant prolongation of survival in those that
are inoperable and as a bonus, may render a small num-
ber of patients with inoperable recurrence to be subse-
quently operable.
We have described a consecutive series of patients
with colorectal liver metastasis who underwent liver
surgery (if suitable) or chemotherapy/best supportive
care (if unsuitable). Our analysis suffers from the limita-
tion that these groups of patients are probably not di-
rectly comparable because those patients who did not
undergo liver surgery due to distribution of disease or
fitness had, by definition, biologically aggressiv e disease
or a weak host and their survival would therefore be ex-
pected to be worse. Patients who had liver surgery fol-
lowed by inoperable recurrence and were treated with
two different kinds of chemotherapy were more compa-
rable and showed that modern drugs offer a clear sur-
vival benefit. What is not known is whether any su rvival
benefit was conferred by surgical resection of liver me-
tastasis for patients who later relapsed. A randomized
trial comparing chemotherapy alone versus surgery alone
in patients with resectable, low-volume liver involve-
ment may show the added benefit of surgical resection,
however the potential for long-term disease free survival
offered by liver resection may make recruitment to such
a trial difficult if not impossible. Wagner (1984) showed
that patients with resectable liver disease who were not
operated upon or given chemotherapy had a median sur-
vival of 21 months. Our results show modern liver sur-
gery and modern chemotherapy for metastatic colorectal
cancer can lead to a cure in up to a third of cases and
significantly prolong life in the rest.
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