Survival after liver resection for colorectal metastases in a large population

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Slide 1 : Survival following liver resection for metastatic colorectal carcinoma in a large population Shimul A. Shah1,2, Rudy Bromberg2, Angela Coates3, Marko Simunovic3, Steven Gallinger2 Departments of Surgery, 1University of Massachusetts Medical School, Worcester, MA, 2University Health Network, University of Toronto, Toronto, 3Hamilton Health Sciences, McMaster University, Hamilton, Canada.
Slide 2 : Liver metastases from colorectal cancer (CRC) Hematogenous spread common Incidence 40-60% Resection for liver metastases 5-yr survival 30-50% Improved diagnostic accuracy Surgical technique – low morbidity Sheele J et al. Br J Surg 1990 Abdalla EK et al. Ann Surg 2004 Fong Y et al Ann Surg 2002 Shah SA et al. J Am Coll Surg 2006
Slide 3 : Liver resection for metastatic colon cancer Most series – single institution reports Selection bias Referral patterns Few registry studies to date Burgundy, Melbourne, Auckland, Caen No population based study of resection for liver metastases from CRC reported in North America.
Slide 4 : Volume-outcome relationship Positive influence in other cancer models Breast Colon Lung Number of liver resections increasing Improved perioperative mortality after liver resection in high-volume centers (>25 cases / year) 4% vs. 9% Dimick JA et al. JACS 2004 Fong Y et al. Ann Surg 2006
Slide 5 : Purpose Assess long-term survival after liver resection for metastatic CRC in a large population (Ontario, Canada; 12 million). Determine if a positive hospital volume – patient survival relationship exists.
Slide 6 : Methods Ontario Cancer Registry All patients who underwent liver resection for metastatic CRC 1996-2004 identified. Pathology reports reviewed. Hospital volume cut points Teaching hospitals affiliated with a medical school Primary endpoint: patient survival after liver resection
Slide 7 : Liver resections performed by year
Slide 8 : 43 centers performed 863 resections. High volume: 5 centers performed > 80 resections. Median follow-up: 24 months after liver resection Hospital volume distribution
Slide 9 : Patient demographics
Slide 10 : Tumor characteristics
Slide 11 : Volume effects
Slide 12 : n=863 Patient survival after liver resection Survival 1 year – 88% 3 year – 59% 5 year – 43% Perioperative mortality – 3.2%
Slide 13 : 120 100 80 60 40 20 0 Months after liver resection 1.0 0.8 0.6 0.4 0.2 0.0 Cumulative Survival low volume (n=390) high volume (n=473) Hospital volume – patient survival p=0.002
Slide 14 : Cox regression survival analysis
Slide 15 : Cox regression survival analysis
Slide 16 : Summary The 5-year survival after liver resection for metastatic CRC in this series was 43%. These results parallel single-center series. Long-term survival for patients undergoing liver resection for metastatic CRC was superior in high versus low volume hospitals. Survival advantage at high volume centers was not lost after the post-operative period.
Slide 17 : Conclusion These findings support continued efforts to aggressively identify liver metastases following CRC resection. Efforts to improve the quality of surgical care, whether through increased regionalization or hospital level projects, should include on-going data monitoring at the population level.

 


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