Introduction Liver metastases occur in ∼50% of patients with colorectal cancer. Only 20% of patients present with disease that is suitable for resection, the only hope of cure. In selected patients, chemotherapy may downstage inoperable liver-limited disease such that potentially curative resection becomes feasible.
Methods All patients referred to the regional Multi-Disciplinary Team (October 2001–June 2008) were considered for downstaging chemotherapy if they had inoperable liver-limited disease and were fit enough for resection. Two-weekly FOLFOX chemotherapy was administered and response assessed by 3 monthly CT scan. Disease having a partial response but remaining unresectable received further chemotherapy and reassessment by CT. Patients in whom R0 resection was thought feasible were offered surgery. Morbidity and mortality data were collected. Mortality was cross-referenced with the Cancer Registry. Overall (OS), post-operative (POS) and disease free survival (DFS) were calculated using SPSS (medians/range/Kaplan–Meier survival curves). OS was calculated from the onset of chemotherapy and based on intention to treat. Additional univariate analysis has been performed.
Results 104 patients commenced downstaging chemotherapy (median six cycles): one died after the 3rd cycle (cardiac), 28 had no response, 56 had a degree of response and 19 had near complete regression. Eventually, 56 patients remained unresectable and 47 had a disease response deemed resectable and were offered surgery. Of these 47 patients, seven declined or became unfit for surgery and 40 proceeded to an operation, of which 36 underwent resection. In four, liver resection was abandoned due to additional disease found at surgery. Peri-operative morbidity was 63% and 30-day mortality was zero. Mortality of patients receiving only chemotherapy was 100% and median OS 14 months (range 3–64 months) compared to a median OS for the 40 patients undergoing laparotomy of 39 months (10–98) with an estimated 20% 5-year survival rate. The 10 surviving patients (25%) have been followed up for a median of 63.5 months (36–90). 7/36 patients (19.4%) remain disease free with median OS 85 months (40–98). 29/36 patients (80.6%) have recurred, all within 24 months of surgery (median DFS 7 months) but with median OS 35 months (10–73) and 4/29 (14%) surviving >5 years.
Conclusion Liver resection after downstaging chemotherapy is safe, feasible and improves median survival. 80% of patients had recurring disease, all within 2 years, however a significant survival benefit occurred in this group compared to patients who could not be offered surgery. The proportion of patients remaining disease free (19.4%) is lower than would be expected in a group with initially resectable disease.
Competing interests None declared.