Resection For Metastatic Colorectal Carcinoma Research Articles

Combined Liver and Colorectal Resection for Metastatic Colorectal Carcinoma: Institutional Experience and Clinical Outcomes

Introduction: Many patients with colorectal carcinoma present with liver metastases. Resection of both colorectal carcinomas and hepatic metastases brings potential for cure, but no consensus supports the resections should be concomitant. This study was undertaken to evaluate our initial outcomes with combined colorectal and hepatic resections. Methods: With IRB approval, we prospectively followed 26 consecutive patients who underwent combined liver and colorectal resections. ‘Major liver resection’ was defined as resection of ≥ 3 contiguous Couinaud segments. For illustrative purposes, data are presented as median(mean±SD). Results: Patients were 64(63±14.0) years old, 73% men, BMI of 29(29±5.7) kg/m2; 54% had previous abdominal operation(s). 62% underwent major liver resection; 77% had a robotic resection (no conversions to ‘open’). EBL was 150(210±181.8) mL. Total operative duration was 446(463±93.6) minutes with duration for liver resections being 206(226±103.0) minutes. All margins were R0. 3 patients developed postoperative complications of Clavien-Dindo score ≥III: 1 anastomotic leak requiring ileostomy, 1 effusion requiring thoracentesis, and 1 ascites requiring large-volume paracentesis. Length of stay was 5(6±3.5) days with 3 perioperative readmissions: 1 pleural effusion, 1 port site infection, and 1 fluid collection requiring percutaneous drainage. There were no deaths within 90 days. There were no differences in any metrics between robotic and ‘open’ operations. Conclusion: Concomitant liver and colon resections have shown to be safe and efficacious either via ‘open’ or robotic approach. For patients with metastatic colorectal cancer, our initial outcomes support concomitant colon and liver resections and the robotic approach.

Combined liver and colorectal resection for metastatic colorectal carcinoma: institutional experience and clinical outcomes

Combined liver and colorectal resection for metastatic colorectal carcinoma: institutional experience and clinical outcomes

Intrabiliary Hepatic Metastasis of Colorectal Carcinoma Mimicking Primary Cholangiocarcinoma: A Case Report and Review of the Literature.

Intrabiliary metastasis from colorectal carcinoma (CRC) growing within or invading bile ducts is not a very common pattern. However, accurate diagnosis of metastatic lesions is very important for selection of adjuvant therapy and prognosis. We report a case of 71-year-old male who developed painless jaundice due to hepatobiliary obstruction. MRI demonstrated 1.4 cm intraductal mass at hepatic hilum with severe intrahepatic ductal dilation, consistent with cholangiocarcinoma. ERCP (endoscopic retrograde cholangiopancreatography) showed intraductal segmental biliary stricture. Biopsy from the lesion showed adenocarcinoma favoring primary cholangiocarcinoma due to the papillary morphology and location of the mass. His past history was significant for rectosigmoid carcinoma (pT1N0) ten years ago and liver resection for metastatic CRC four years ago. He subsequently underwent central hepatectomy with resection of common bile duct. Grossly, there was a 1.2 cm intraductal mass at the bifurcation of bile ducts with multiple nodules in liver parenchyma. Microscopic examination revealed intraductal carcinoma with papillary architecture colonizing bile duct epithelium with resultant dilation and tortuosity. Occasional liver parenchymal nodules show classical metastatic pattern resembling CRC. Because of two distinct morphologic patterns and patient's past history, immunostains were performed. CK7 stained uninvolved bile duct epithelium with no staining in intrabiliary metastatic growth. CK20 and CDX2 were positive, thus confirming intrabiliary growth as metastatic growth from CRC. In summary, findings from our case indicate that intrabiliary growth of metastatic CRC can easily be overlooked with major duct involvement. Pathologic evaluation with use of immunohistochemical stains is very important to achieve correct diagnosis.

Pulmonary Metastasectomy for Colorectal Carcinoma

Purpose: Surgical resection is an important curative treatment for pulmonary metastases from colorectal adenocarcinoma. We analyzed the outcomes and the prognostic factors related to the post operative mortality after surgical resection for pulmonary metastases from colorectal adenocarcinoma. Materials and Methods: Between January 1994 and December 2009, 28 patients underwent complete pulmonary resection of metastatic colorectal carcinoma. We performed a retrospective review of the patient’s characteristics and the factors affecting survival. Survival was analyzed by the Kaplan-Meier method and comparison between groups was performed by a log-rank analysis. Results: The median survival was 53.07 months (Kaplan-Meier method). The number of pulmonary metastases (p=0.0151) and a prethoracotomy carcinoembryonic antigen (CEA) level over 5 ng/mL (p=0.0217) were significantly related with survival. Conclusion: The prethoracotomy CEA level and the number of metastases were significantly related with the survival rate. Resection of pulmonary metastatic lung lesion from colorectal cancer may improve the survival rate in a selected group of patients. (J Lung Cancer 2010;9(2):91 󰠏 96)

Pulmonary resection for metastases from colorectal carcinoma

A pulmonary resection of metastatic colorectal carcinoma is an accepted method of treatment. The purpose of this study was to confirm the role of resections for pulmonary metastases from colorectal carcinoma, and to determine the clinical course, outcome, and prognostic factors after surgery. A retrospective analysis was conducted of the records of all patients with pulmonary metastases from colorectal carcinoma who underwent a surgical resection between 1995 and 2008, at a single surgical center. The overall 5-year survival rate was 74%. Multivariate Cox analysis demonstrated that the number of pulmonary metastases (HR: 9.40, 95% confidence interval (CI): 1.08-82.2, P=0.0428) and prethoracotomy carcinoembryonic antigen (CEA) level (HR: 9.79, 95% CI: 1.11-86.8, P=0.0404) were statistically significant predictors of survival after the first pulmonary metastasectomy. In addition, a second resection for recurrent metastases was performed in eight patients, and a third resection was done in one patient. There were no major postoperative complications among the patients who underwent second or third resections. Pulmonary resections are considered to be a safe and effective treatment in selective patients.

Survival after Liver Resection for Metastatic Colorectal Carcinoma in a Large Population

Previous reports of liver resection for metastatic colorectal cancer (CRC) are typically from single centers and cannot account for selection or referral bias. We measured longterm survival after liver resection for metastatic CRC in the province of Ontario, Canada (population 12 million). The Ontario Cancer Registry is an administrative database that links all hospital records, pathology reports, and vital statistics for patients with a diagnosis of cancer. We used the Registry to identify and obtain information on all patients who underwent liver resection for metastatic CRC in calendar years 1996 to 2004. Pathology reports of the original CRC resection and subsequent liver resections were individually reviewed. Eight hundred forty-one resections were performed at 43 centers across Ontario during the 9-year period, including wedge resection (n = 303; 36%); lobectomy (n = 466; 55%); and trisectionectomy (n = 72; 9%). Ninety-one percent and 54% of resections were performed at teaching and high-volume centers (> 80 resections), respectively. Most liver resections were performed more than 120 days after original CRC operation (672 of 841; 80%). Perioperative mortality was 3%. Unadjusted 1-, 3-, and 5-year survival after liver resection was 88%, 59%, and 43%, respectively. Survival was improved when resection was performed for fewer than 2 tumor nodules, at high-volume centers, or in the years 2001 to 2004. Results in this population-based series are consistent with those of single-hospital series assessing longterm survival after liver resection for metastatic CRC. These findings support continued efforts to aggressively identify and resect CRC liver metastases.

151: Survival following liver resection for metastatic colorectal carcinoma in a large population

151: Survival following liver resection for metastatic colorectal carcinoma in a large population

Nodal Involvement at the Time of Pulmonary Metastasectomy: Experiences in 245 Patients

Although routine systematic mediastinal and hilar lymph node dissection contemporary with pulmonary metastasectomy has not been uniformly performed in many thoracic surgical centers, the value of this procedure needs to be investigated. Between 1996 and 2001, 245 patients (157 men, 88 women) underwent pulmonary resection of metastatic colorectal carcinoma, sarcoma, and renal cell carcinoma. Generally, systematic mediastinal and hilar lymph node dissection was performed concurrently with pulmonary metastasectomy. Patients were assessed for patterns of lymph node metastases. The frequency of lymph node involvement was determined. Patients and tumor characteristics were assessed to ascertain whether certain factors were likely to predict lymph node spread. Of the 245 patients (328 primary thoracic procedures), 165 had no lymph node involvement, 45 had pulmonary and hilar metastases, 22 had pulmonary, hilar, and mediastinal metastases, and 13 had only mediastinal involvement without pulmonary and hilar spread. Patients with more than one pulmonary metastasis or metachronous disease were more likely to have thoracic lymph node metastases. The risk for mediastinal lymph node involvement was even more likely for patients who had already pulmonary or hilar lymph node spread; the odds ratios (with 95% confidence intervals) were 1.30 (0.71 to 2.36), 1.32 (0.59 to 2.99), and 5.87 (2.73 to 12.6), respectively. Median survival for the group of patients after complete resection was 54.8 months (95% CI: 40.9 to 68.7); and for the patients with no lymph node involvement, it was 63.9 months (95% CI: 45.3 to 82.6); with N1 disease, 32.7 months (95% CI: 9.2 to 56.2); and with N1 + N2 disease, 20.6 months (95% CI: 5.1 to 36.1). The log-rank test revealed significance between N0 and N1 (p = 0.018) and N0 versus N1, 2 (p = 0.001). We conclude that systematic mediastinal and hilar lymph node dissection contemporary with pulmonary metastasectomy offers a further understanding of metastatic disease and provides important information for complete surgical staging.

Resection of 'recurrent' colorectal metastases to the liver.

Hepatic resection is the only treatment for patients with colorectal cancer metastatic to the liver that has resulted in long-term survival. This apparent efficacy of hepatectomy has prompted efforts to expand the surgical approach for disease progression within the liver. A review of personal experience and of the literature was performed in an attempt to define the role of surgery for disease progression. Twenty-one patients who underwent hepatic resection between 1983 and 1991 for isolated disease progression in the liver were retrospectively reviewed. The median follow-up of patients still alive was 1.7 years (range 4 months to 4.5 years). The median survival from the date of repeat hepatic resection was 3.4 years with an estimated actuarial survival rate of 43 per cent at 4 years. These patients experienced no significant morbidity and the mortality rate was 5 per cent. Hepatic resection of metastatic colorectal carcinoma can produce long-term survival without prohibitive risk. These findings support an aggressive surgical approach for metastatic progression in the liver from colorectal carcinoma.

Outcome of colorectal carcinoma in patients under 40 years of age

Colorectal carcinoma in patients under 40 years of age usually has a poor prognosis. Controversies still exist regarding the features and the prognosis of colorectal cancer in young patients. The records of 45 patients with histologically confirmed colorectal carcinoma treated between 1992 and 2002 at the Division of Oncology at Taipei Veterans General Hospital were reviewed. The relevance of sex, duration of symptoms, tumor site, histological type, lymph node involvement, Karnofsky performance status (KPS), carcinoembryonic antigen (CEA) and lactate dehydrogenase (LDH) levels at the diagnosis and tumor stage to overall survival (OS) were determined by univariate analysis, and their independent significance were tested by multivariate analysis. Most patients presented with an advanced tumor stage (24% Dukes' C and 66% Dukes' D). Colon carcinoma constituted 76% of the colorectal tumors. Family history was present in two patients and did not affect the OS. Two patients were found to have colon carcinoma during pregnancy. The 5-year survival rate in patients with Stage B, C, and D were 25, 16 and 0%, respectively. With aggressive treatment, patients with early stage carcinoma achieved longer survival. Eleven patients received resection of metastatic carcinoma of the liver, lung and ovary. Adjuvant chemotherapy with irinotecan/5-fluorouracil-based chemotherapy seemed to improve the OS in such patients, though the OS was still poorer than in patients with early stage tumors. In univariate analysis, KPS (P = 0.0001), lymph node involvement (P = 0.0024), CEA (P = 0.0423) and LDH levels (P = 0.0126) at the diagnosis and tumor stage (P = 0.0122) proved to be significant predictors of overall survival. Multivariate analyses revealed that KPS > or =70% (P = 0.007) and normal LDH levels at diagnosis (P = 0.004) were predictive of overall survival in this population. The present study shows that performance status and preoperative LDH levels were the major determinants for survival in patients with colorectal carcinoma under 40 years of age and the present series also suggests that surgical resection of metastatic colorectal carcinoma followed by adjuvant chemotherapy might be beneficial in certain patients. The data also suggests that current treatment modalities for young patients with advanced colorectal cancer might not be effective and more effective therapeutic regimens might be needed. Thus, it is important for surgeons to recognize the potential for colorectal cancer in young patients and to take an aggressive approach to the diagnosis and early treatment of the disease.

Prognostic factors and survival after complete resection of pulmonary metastases from colorectal carcinoma: Experiences in 167 patients

ObjectiveSurgical resection is an important form of treatment for pulmonary metastases from colorectal carcinoma. We analyzed the clinical course, outcome, and prognostic factors after surgery. MethodsBetween 1985 and 2000, 167 patients (103 men, 64 women) underwent complete pulmonary resection of metastatic colorectal carcinoma. Only patients who met the criteria for potentially curative operation, in particular, control of the primary tumor, ability to resect all metastatic disease, and no other extrapulmonary metastases, were included. ResultsThe overall 5-year survival was 32.4%. A significantly longer survival was observed in multivariate analysis in patients without lymph node involvement compared with patients with pulmonary or mediastinal lymph node metastases or both. The number of pulmonary metastases significantly influenced survival. In patients with a solitary metastasis, we observed a 5-year survival of 45%, whereas the rate was 19.8% in patients with more than a single metastasis. In multivariate analysis, we also found the prethoracotomy carcinoembryonic antigen serum level to be an independent significant prognostic factor for survival. In patients with a serum carcinoembryonic antigen level exceeding 5 ng/mL and in patients with a serum carcinoembryonic antigen level in the normal range, the 5-year survivals were 22.7% and 48.3%, respectively. ConclusionsWe conclude that pulmonary resection of metastatic colorectal carcinoma is safe and results in long-term survival. Thoracic lymph node metastases, serum carcinoembryonic antigen level before metastasectomy, and the number of pulmonary metastases were identified as prognosis-related criteria for surgery.

Pulmonary metastasectomy for 165 patients with colorectal carcinoma: A prognostic assessment

Objective: The purpose of this study was to analyze our entire experience with pulmonary resection for metastatic colorectal carcinoma to determine prognostic factors and critically evaluate the potential role of extended metastasectomy. Methods: We analyzed the postoperative survival of 165 patients who underwent curative pulmonary surgery at eight institutions in the Kansai region of western Japan (Kansai Clinical Oncology Group) from 1990 to 2000. Results: Overall survivals at 5 and 10 years were 39.6% and 37.2%, respectively. Cumulative survival of patients who underwent simultaneous bilateral metastasectomy was significantly lower than that of the patients who underwent unilateral metastasectomy or sequential bilateral metastasectomy (P =.048). Five-year survival was 53.6% for patients without hilar or mediastinal lymph node metastasis, versus 6.2% at 4 years for patients with metastases (P <.001). Five-year survival of patients with a prethoracotomy carcinoembryonic antigen level less than 10 ng/mL was 42.7%, versus 15.1% at 4 years for patients with a carcinoembryonic antigen level 10 ng/mL or greater (P <.0001). Twenty-one patients underwent a second or third thoracotomy for recurrent colorectal carcinoma. Overall 5-year survival from the date of the second thoracotomy was 52.1%. The 34.1% 10-year survival for the 26 patients with hepatic metastasis resected before thoracotomy did not differ significantly from that of patients without hepatic metastases (P =.38). Conclusions: The status of the hilar or mediastinal lymph nodes and prethoracotomy carcinoembryonic antigen level were significant independent prognostic factors. Patients with pulmonary metastases potentially benefit from pulmonary metastasectomy even when there is a history of solitary liver metastasis. Careful follow-up is warranted, because patients with recurrent pulmonary metastases can undergo repeat thoracotomy with acceptable long-term survival. Simultaneous bilateral metastasectomy confers no survival benefit. Prospective studies may determine the significance of this type of pulmonary metastasectomy.J Thorac Cardiovasc Surg 2002;124:1007-13

Fibrous pseudocapsule of metastatic liver tumors from colorectal carcinoma

BACKGROUND The presence of pseudocapsules of liver tumors has been recognized in hepatocellular carcinoma and is known to be a favorable prognostic factor. Although several studies have reported pseudocapsules around metastatic liver tumors, to the authors' knowledge there have been few evaluations of the clinical significance of such features in patients with metastatic colorectal carcinoma. METHODS A clinicopathologic study was conducted in 152 patients who underwent initial hepatic resection for metastatic colorectal carcinoma. RESULTS The presence of fibrous tissue between the tumor and the surrounding hepatic parenchyma was noted in 93 of the 152 patients (61%) with colorectal liver metastases. These patients were classified as having a thin pseudocapsule (n = 46) or a thick pseudocapsule (n = 47), according to the number of collagen bundles (< 10 or ≥ 10) between the tumor and the hepatic parenchyma in histologic sections. Pathologically, the presence and thickness of the fibrous pseudocapsule were related closely to less invasiveness into adjacent vessels (P = 0.004) and the presence of macroscopic intrabile ductal invasion (P = 0.008). The postresection survival was significantly better in patients with thick or thin pseudocapsules than in those without a pseudocapsule (3-year and 5- year cumulative survival rates of patients with no, thin, and thick pseudocapsules were 41% and 31%, respectively, 71% and 64%, respectively, and 88% and 88%, respectively; P < 0.001). In a multivariate analysis using the Cox proportional hazards model, after adjusting for other potential prognostic factors (vascular invasion, bile ductal invasion, number of tumors, tumor size, and curativeness of surgery), the presence of a fibrous pseudocapsule was an independent predictor of a favorable outcome after hepatic resection. CONCLUSIONS The presence of fibrous tissue between the tumor and the liver parenchyma was a promising indicator of a better prognosis after resection in patients with colorectal liver metastases. Cancer 2000;89:267–75. © 2000 American Cancer Society.

Benefits and safety of hepatic resection for colorectal metastases

Background: Metastatic colorectal carcinoma to the liver is a potentially curable disease. The purpose of this study was to determine the safety and efficacy of hepatic resection for metastatic colorectal carcinoma. Methods: One hundred twenty-one consecutive hepatic resections in 110 patients with metastatic colorectal cancer between January 1978 and September 1998 performed by a single surgeon were reviewed. Results: The actuarial 5-year survival for all patients in the series was 46%. Of the patients operated on before 1993, the actual 5-year survival was 43% and actual disease-free 5-year survival was 28%. The actual 10-year survival was 27%, and of all patients operated on in the last 20 years, 48% are alive today. When comparing initial regional lymph node status, the 5-year survival was 54% for the patients with negative lymph nodes and 40% for patients with positive nodes. Only 18% of patients required a perioperative blood transfusion, and the median length of stay was 7 days. There were complications in 34% of cases, and the operative mortality was 4%. Conclusions: Hepatic resection for metastatic colon cancer is safe, and significant longevity and cure can be obtained after resection.

Surgical margin in hepatic resection for colorectal metastasis: a critical and improvable determinant of outcome.

To update the analysis of technical and biologic factors related to hepatic resection for colorectal metastasis in a large single-institution series to identify important prognostic indicators and patterns of failure. Surgical therapy for colorectal carcinoma metastatic to the liver is the only potentially curable treatment. Careful patient selection of those with resectable liver-only metastatic disease is crucial to the success of surgical therapy. Two hundred forty-four consecutive patients undergoing curative hepatic resection for metastatic colorectal carcinoma were analyzed retrospectively. Variables examined included sex, stage of primary lesion, size of liver lesion(s), number of lesions, disease-free interval, ploidy, differentiation, preoperative carcinoembryonic antigen level, and operative factors such as resection margin, use of cryotherapy, intraoperative ultrasound, and blood loss. Surgical margin, number of lesions, and carcinoembryonic antigen (CEA) levels significantly control prognosis. Patients with only one or two liver lesions, a 1-cm surgical margin, and low CEA levels have a 5-year disease-free survival rate of more than 30%. Disease-free interval, original stage, bilobar involvement, size of metastasis, differentiation, and ploidy were not significant predictors of recurrence. The pattern of failure correlates with surgical margin. Routine use of intraoperative ultrasound resulted in an increased incidence of negative surgical margin during the period examined. Surgical resection or cryotherapy of hepatic metastasis from colorectal cancer is safe and curable in appropriately selected patients. Biologic factors, such as number of lesions and carcinoembryonic antigen levels, determine potential curability, and surgical margin governs the patterns of failure and outcome in potentially curable patients. Optimization of selection criteria and surgical resection margins will improve outcome.

Analysis of prognostic risk factors in hepatic resection for metastatic colorectal carcinoma with special reference to the surgical margin

Analysis of prognostic risk factors in hepatic resection for metastatic colorectal carcinoma with special reference to the surgical margin

Analysis of prognostic risk factors in hepatic resection for metastatic colorectal carcinoma with special reference to the surgical margin

Liver resection for metastatic colorectal cancer has been established. Nevertheless, it is still controversial whether the surgical margin from the tumour edge to the cut surface of the liver is a significant prognostic factor in hepatic resection for colorectal metastatic liver cancer. To clarify the prognostic risk factors in hepatic resection for colorectal metastasis, univariate and multivariate analyses were performed. Between April 1985 and April 1995, 31 patients underwent curative hepatic resection for metastatic colorectal cancer. The clinical and pathological factors were examined retrospectively. Overall 1-, 3- and 5-year survival rates of the patients were 92, 42 and 39 per cent respectively. Pathological study of 16 resected specimens with a solitary liver tumour revealed hepatic vein invasion by cancer cells in two of 16 cases, portal vein invasion in three, microsatellite lesions in two and biliary tract invasion in six cases. In resected specimens with a solitary tumour measuring less than 4 cm in diameter, one of these factors was observed in only two of nine cases, whereas in specimens with a solitary tumour measuring more than 4 cm in diameter, these factors were observed in six of seven patients (P < 0.05). The distance from the tumour edge to the intrahepatic invasion was less than 10 mm. With univariate analysis, tumour size of 4 cm or more in diameter, an interval of 6 months or less between colorectal and hepatic resection, four or more gross tumours, bilobar involvement and a resection margin from the tumour of less than 10 mm were found to be significant factors indicating a poor prognosis. Cox's proportional hazards model identified a tumour of 4 cm or more in diameter and a resection margin from the tumour of less than 10 mm as poor prognostic factors (P < 0.05). In treating metastatic colorectal cancer to the liver, the surgical margin should be more than 10 mm because occult intrahepatic invasion was always found to be located within 10 mm from the edge of the tumour.

Factors influencing survival following pulmonary resection for metastatic colorectal carcinoma.

The results of pulmonary resection and clinical factors relating to long-term survival were evaluated in 29 patients with histologically proven pulmonary metastasis from colorectal carcinoma. The patients were followed up from 4 months to 120 months, with an average of 43.7 months. Overall 5- and 10-year survival rates were 41% and 34% respectively. The 5- and 10-year survival rates in patients with metastatic nodules 30 cm or less in diameter were 77% and 58%, respectively, a significantly better result than in those with metastatic nodules over 30 mm in diameter. Survival in patients without nodal involvement was significantly better than that in patients with lymph node metastases. Multivariate analysis according to Cox proportional hazards model demonstrated that the size of the metastasis was an independent prognostic factor.

Surgical resection of pulmonary metastases from colorectal carcinoma. Five-year survival and main prognostic factors.

Between 1986 and 1994, 19 patients underwent pulmonary resection for metastatic colorectal carcinoma. The mean interval between colon resection and appearance of pulmonary metastasis was 41 +/- 21 months. All the patients had no more than two metastases. Wedge resection alone or associated with lobectomy was performed in four patients, lobectomy in ten, and pneumonectomy in five. One patient died within the month after surgery. Mean follow-up was 35 +/- 26 months. The 5-year survival rate was 38.7%. Repeat thoracotomy for recurrent metastases was performed in one patient. The disease-free interval, the size of metastases, the type of pulmonary resection, and the location and the stage of primary cancer had no apparent influence on survival, but the survival rate at 4 years was 25% for patients with high carcinoembryonic antigen (CEA) level versus 80% for those with low CEA level. We conclude that, at least when the number of metastases is less than two, resection of colorectal lung metastasis is safe and effective.

Redo hepatic resection for metastatic colorectal carcinoma.

Redo hepatic resection for recurrent colorectal metastasis was performed in eight patients. There was no operative mortality; major morbidity occurred in 25% and minor morbidity in 13% of patients. Four patients are alive and disease-free at 9, 23, 39, and 49 months, respectively, after their repeat hepatic resection. Four patients have died of recurrent disease, with a median time to recurrence of 6 months and median survival of 15 months. Patterns of failure include hepatic failure alone in two patients and pulmonary and hepatic failure in two. Repeat liver resection can be performed safely and may be beneficial in some patients with recurrent metastases confined to the liver after previous hepatic metastasectomy.