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The role of adjuvant therapy for biliary tract cancer is not clearly defined with conflicting results demonstrated across nonrandomized and randomized studies. We report a systematic review and meta-analysis to delineate the effect of AT on overall survival.Eligible studies were identified from MEDLINE, EMBASE, Cochrane and PubMed. Studies comparing adjuvant chemotherapy or chemoradiotherapy after curative-intent surgery with curative surgery only for biliary tract cancer were included. Data pertaining to tumours of the gallbladder and bile ducts were included. The primary outcome assessed was overall survival. Random-effects meta-analysis was performed, as well as pooling of unadjusted Kaplan-Meier curve data.35 studies involving 42,917 patients were analysed. There was a significant improvement in overall survival with any adjuvant therapy after surgery compared with surgery only (HR 0.74; 95% CI, 0.67 to 0.83; P 0.001). There was a significant benefit for adjuvant therapy in those with margin positive surgery (RR, 0.83; 95% CI, 0.77 to 0.91; P0.001) and node-positive disease (RR 0.82; 95% CI 0.76 to 0.89; P 0.001) CONCLUSION: Our review advocates the use of adjuvant therapy in bile duct cancer after curative intent resection. Further prospective studies are needed to determine the optimal regime and timing of an adjuvant approach.

To investigate the influence of clear surgical resection margin width on disease recurrence rate after intentionally curative resection of colorectal liver metastases.There is consensus that a histological positive resection margin is a predictor of disease recurrence after resection of colorectal liver metastases. The dispute, however, over the width of cancer-free resection margin required is ongoing.Analysis of observational prospectively collected data for 2715 patients who underwent primary resection of colorectal liver metastases from 2 major hepatobiliary units in the United Kingdom. Histological cancer-free resection margin was classified as positive (if cancer cells present at less than 1 mm from the resection margin) or negative (if the distance between the cancer and the margin is 1 mm or more). The negative margin was further classified according to the distance from the tumor in millimeters. Predictors of disease-free survival were analyzed in univariate and multivariate analyses. A case-match analysis by a propensity score method was undertaken to reduce bias.A 1-mm cancer-free resection margin was sufficient to achieve 33% 5-year overall disease-free survival. Extra margin width did not add disease-free survival advantage (P0.05). After the propensity case-match analysis, there is no statistical difference in disease-free survival between patients with negative narrow and wider margin clearance [hazard ratio (HR) 1.0; 95% (confidence interval) CI: 0.9-1.2; P = 0.579 at 5-mm cutoff and HR 1.1; 95% CI: 0.96-1.3; P = 0.149 at 10-mm cutoff]. Patients with extrahepatic disease and positive lymph node primary tumor did not have disease-free survival advantage despite surgical margin clearance (9 months for1-mm vs 12 months for ≥1-mm margin clearance; P = 0.062).One-mm cancer-free resection margin achieved in patients with colorectal liver metastases should now be considered the standard of care.

Background Intermittent clamping of the porta hepatis, or the intermittent Pringle manoeuvre (IPM), is often used to control inflow during parenchymal liver transection. The aim of this study was to determine whether IPM is associated with an adverse long-term outcome after liver resection for colorectal liver metastasis (CRLM). Methods All patients undergoing resection for CRLM in 1993–2006, for whom data on IPM were recorded, were included in the study. A total of 563 patients was available for analysis. Results IPM was performed in 289 (51·3 per cent) of the patients. The duration of IPM ranged from 2 to 104 (median 22) min. There were no differences in clinicopathological features or postoperative morbidity between patients who had an IPM and those who did not. The median survival of patients undergoing IPM was 55·7 months compared with 48·9 months in those not having an IPM (P = 0·406). There was no difference in median disease-free survival between the two groups (22·1 versus 19·9 months respectively; P = 0·199). Conclusion IPM is not associated with an adverse long-term prognosis in patients undergoing liver resection for CRLM.

There is increasing evidence that systemic inflammatory response has a positive correlation with a poorer outcome in patients undergoing resection for solid tumours. The aim of this study was to analyse the impact of an elevated C-reactive protein (CRP), an outcome following curative resection for colorectal liver metastases. One hundred and seventy patients who underwent curative resection for colorectal liver metastases were included in the study. Laboratory measurements of haemoglobin, white cell, platelets, albumin and CRP were taken on the day before surgery. Elevated CRP (10 mg l(-1)) was present in 54 (31.8%) patients. The median survival of patients with an elevated CRP was 19 months (95% CI 7.5-31.2 months) compared to 42.8 months (95% CI 33.2-52.5 months) for those with a normal CRP, P=0.004. Similarly, when assessing disease-free survival, patients with an elevated CRP had poorer disease-free survival (median of 11.8 months (95% CI 6.4-17.3) compared to median of 15.1 months (95% CI 11.1-19.1)), P=0.043. The result of the study showed that an elevated preoperative CRP is a predictor of poor outcome in patients undergoing curative resection for colorectal liver metastases.

Many colorectal liver metastasis patients are denied surgical resection on the basis of tumour size. The aim of this study was to explore the impact of metastasis size on modern liver resection.Using a prospectively collected database, this was a retrospective analysis of 484 consecutive patients who underwent liver resection for colorectal liver metastases between 1993 and 2003. The cohort was divided into two groups: smaller metastases (8 cm) and larger metastases (or = 8 cm). Those with larger metastases were then further stratified into big metastases (8-12 cm) and giant metastases (12 cm). Demographic, pathological, surgical technique and outcome data were compared between the groups.There were 88 (18%) patients with metastases measuring 8 cm or larger. There was an association between higher carcinoembryonic antigen (CEA) and cancer antigen (CA) 19-9 levels and larger metastases. The actuarial 5-year survival for patients with larger metastases was 38% compared with 42% for smaller metastases (not statistically significant). Patients with giant metastases had poorer overall and disease-free survival (both nonsignificant) compared with those with big metastases: 29% and 28% at 5 years, respectively.Patients with colorectal liver metastasis greater than 8 cm and up to 12 cm in size should not be treated differently from those with smaller lesions.

Aim We undertook this study to evaluate the influence of resection margin distance from metastases on survival and post-operative disease recurrence after hepatectomy for colorectal liver metastasis. Methods Between January 1993 and December 2001, 293 consecutive patients underwent primary liver resection for colorectal metastasis. Clinical, pathological and outcome data were analysed using a prospectively collected database. Cases were stratified into those with involved and non-involved resection margins. Different non-involved margin widths were analysed against survival, recurrence rate and pattern (hepatic, extra hepatic) of recurrence. Results The 1, 3, 5 and 10 years actuarial survival rates were 82, 58, 44 and 36%, respectively. The median survival was 46 months. The histological liver resection margin involvement was a significant predictor of survival and disease free survival after surgery. One, two, five and 10 millimetres disease free resection margin widths were found not to be significant in influencing patients' survival or recurrence rate. Conclusion A positive hepatic resection margin was associated with a higher incidence of post-operative recurrence and lower survival rate. The width of the resection margin did not influence the post-operative recurrence rate or pattern of recurrence. The ‘1 cm rule’ should be abandoned.

To analyze results of 70 patients undergoing left hepatic trisectionectomy and to clarify its current role.Left hepatic trisectionectomy remains a complicated hepatectomy, and few reports have described the long-term results of the procedure.Short-term and long-term outcomes of 70 consecutive patients who underwent left hepatic trisectionectomy from January 1993 to February 2004 were analyzed.Of the 70 patients, 36 had colorectal liver metastasis, 24 had cholangiocarcinoma, 4 had hepatocellular carcinoma, and the remaining 6 had other tumors. Overall morbidity, 30-day and 90-day mortality rates were 46%, 7%, and 9%, respectively. Multivariate analysis disclosed that preoperative jaundice and intraoperative blood transfusion were positive independent predictors for postoperative morbidity; however, there were no independent predictors for postoperative mortality. Postoperative morbidity (87% versus 35%, P0.001) and mortality (20% versus 5%, P = 0.108) were observed more frequently in patients with preoperative obstructive jaundice than in those without jaundice. Each survival according to tumor type was acceptable compared with reported survivals. Survival for patients with colorectal liver metastasis undergoing left hepatic trisectionectomy with concomitant partial resection of the remnant liver was similar to those without this concomitant procedure. This concomitant procedure was not associated with postoperative morbidity and mortality.Left hepatic trisectionectomy remains a challenging procedure. Preoperative obstructive jaundice considerably increases perioperative risk. Concomitant partial resection of the remaining liver appears to be safe and offers the potential for cure in patients with colorectal metastasis affecting all liver segments.

Objectives To evaluate the effect of inter-institutional surgical pathology review of thyroid cancer on patients' treatment and prognosis. Methods All cases referred to the Institute of Pathology at Leeds for thyroid pathology review between January 2001 and March 2003 were included. The referring pathologists reports were compared to those produced in the MDT meeting by the expert pathologist. Whenever there was disagreement a third expert opinion was sought who was blinded for both diagnoses. Effects on management and prognosis were evaluated if there was disagreement. Results Of the 66 patients reviewed, 12 (18%) had a different pathological diagnosis ( κ =0.33). Two had their diagnosis changed from malignant to benign and a further two from benign to malignant. Eight patients had their prognosis downgraded and four upgraded after histopathological review. Five patients had their management affected by the new pathological diagnosis. Conclusion A second opinion of surgical pathology for thyroid tumours can result in major therapeutic and prognostic modifications. All cases of suspected thyroid cancers should be reviewed in a multidisciplinary meeting supported by pathologist with experience in thyroid pathology.

Background Non-anatomical liver resections have become more common in the management of colorectal liver metastases. This study examined survival and patterns of recurrence following surgery for colorectal liver metastases. Methods Data were collected prospectively on all patients who had hepatic surgery for colorectal liver metastases at St James' University Hospital, Leeds between 1993 and May 2003, and analysed with respect to type of resection. Results A total of 96 patients underwent non-anatomical liver resection, 280 patients had an anatomical resection, and 108 patients had a combined procedure. There was no significant difference in overall survival between the anatomical and non-anatomical groups (hazard ratio 1·14 (95 per cent confidence interval 0·60 to 2·17); P = 0·691). Intrahepatic recurrence was significantly less common in the anatomical group, whereas morbidity and mortality rates were lower in the non-anatomical group. On multivariable analysis, multiple metastases and poorer primary T stage predicted poorer overall survival and a positive resection margin predicted poorer disease-free survival. Conclusion Non-anatomical resection can be performed with lower rates of surgical morbidity and mortality than anatomical resection, and does not disadvantage the patient in terms of overall survival.

Aims The aim of this study was to report the results of surgery for multiple colorectal liver metastases on patient outcome. Methods This was a review of 484 consecutive patients who underwent liver resection for colorectal liver metastases between 1993 and 2003. The cohort was divided into 2 groups, those with 1–3 metastases and those with “multiple” metastases, namely 4 or more lesions. The later group was subdivided into those with less than 8 (“several”) or 8 or more (“numerous”) separate lesions. Main outcome measures: the post-operative hospital stay was calculated and morbidity and mortality were assessed. Results On multivariate analysis the presence of multiple metastases was the only predictor for both poorer overall survival ( p = 0.007) and disease-free survival ( p = 0.031). However, when patients with multiple metastases are analysed in detail this survival disadvantage appears to be only present in patients with numerous (8 or more) lesions. Conclusion Although patients with multiple metastases appear to have a poorer outcome, significant number of patients with multiple metastases survive to 5 years or more and should not be denied surgery. Patients with numerous (8 or more) metastases showed a poorer survival disadvantage. These patients need alternative treatment speculatives.

Aim Our aim was to determine independent predictors of survival after second liver resection and to confirm whether the type of first resection influences survival after repeat resection. Methods Fifty-four patients who underwent a second liver resection for colorectal liver metastases were analyzed. To find independent predictors of survival, possible prognostic factors regarding the primary tumor, and the first and second resections were used in the Cox regression analysis. Results There were three postoperative deaths within 90 days of surgery. The 3- and 5-year overall survival rates were 53% and 46%, respectively. The size of the tumor (>50 mm) ( p = 0.005), serum carcinoembryonic antigen level (>30 μg/L) ( p = 0.002), and the presence of a positive surgical margin at the second resection ( p = 0.006) were independent predictors of poor survival following the second resection. The type of first resection was not associated with survival but was associated with the ability to achieve a histological negative surgical margin at the second liver resection ( p = 0.01). Conclusion Three independent predictors of survival were identified. Major initial liver resection was associated with a reduced ability to achieve surgical clearance at the second resection. For colorectal liver metastases, major resection should only be performed if a negative margin cannot be achieved by minor resection.

Colorectal cancer remains the second most common cause of cancer death in the West. Every year in the UK alone, around 14 000 patients develop secondary hepatic deposits from a primary colorectal cancer. Surgery remains the mainstay of treatment for liver metastases. Although not every patient is a candidate for surgery, earlier referral and rapid assessment are required to improve outcome. With the use of most recent technologies and radical surgery, increasing numbers of patients should have therapy with curative intent. This paper reviews preoperative patient evaluation and selection, surgical strategies, adjuvant therapy and postoperative follow-up. Other treatment modalities to increase tumour resectability are also described.