Long-term survival after hepatic cryosurgery versus surgical resection for metastatic colorectal carcinoma: A critical review of the literature

OBJECTIVE: To critically assess the evidence for long-term survival after hepatic resection and hepatic cryosurgery for metastatic colorectal cancer. The purpose of this review is to determine if a randomized controlled trial comparing these two treatment modalities is justified. DATA SOURCES: A review of the medical literature from 1973 to 1995 using the MEDLINE and CANCERLIT databases. References were also retrieved from the bibliographies of identified articles and from experts in the field of hepatobiliary and pancreatic surgery. STUDY SELECTION: One hundred and seventy-eight studies were reviewed. Studies presenting original data on the results of hepatic resection or cryotherapy for colorectal liver metastases were selected. Studies were excluded if they did not present survival data longer than 2 years. Studies pertaining to resection for fewer than 60 patients with colorectal metastases to the liver were excluded. DATA EXTRACTION: Data forms were designed before studies were examined in detail. All studies that met the inclusion and exclusion criteria were reviewed and the identified data extracted and tabulated. DATA SYNTHESIS: No controlled studies were identified, only case series. Four reports on hepatic cryosurgery and 9 on hepatic resection met the study criteria. The cryosurgery studies were methodologically poor; the resection studies were larger and more methodologically sound. The median follow-up for cryosurgery ranged from 12 to 28.8 months, that for resection 21 to 69 months. There is clear evidence that hepatic cryosurgery has a role in the management of selected patients with colorectal metastases to the liver. However, valid conclusions cannot be made about the 5-year survival rate. The results of the studies on hepatic resection in patients with colorectal metastases to the liver have greater validity and consistency, with 5-year survival rates of 20% to 40%. CONCLUSIONS: Although hepatic cryosurgery offers some unequivocal and other potential advantages over surgical resection for colorectal metastases to the liver, the published data do not support its use in patients with resectable disease outside a clinical trial, and do not yet justify a randomized trial. A study that collects prospective data on 2 groups of patients (resectable v. unresectable) who differ only in the anatomic location of their metastases within the liver is needed.