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One-Millimeter Cancer-Free Margin Is Curative for Colorectal Liver Metastases: A Propensity Score Case-Match Approach

Hamady, Zaed Z. R. PhD, FRCS*,†; Lodge, J. Peter A. MD, FRCS; Welsh, Fenella K. FRCS*; Toogood, Giles J. DM, FRCS; White, Alan MRCS; John, Timothy FRCS*; Rees, Myrddin FRCS*

doi: 10.1097/SLA.0b013e3182902b6e
Original Articles

Objective: To investigate the influence of clear surgical resection margin width on disease recurrence rate after intentionally curative resection of colorectal liver metastases.

Background: 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.

Methods: 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.

Results: 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 (P > 0.05). 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 for <1-mm vs 12 months for ≥1-mm margin clearance; P = 0.062).

Conclusion: One-mm cancer-free resection margin achieved in patients with colorectal liver metastases should now be considered the standard of care.

Cancer-free resection margin after colorectal liver metastases resection is mandatory to achieve long-term cure. Current study showed that 1-mm margin clearance is sufficient to predict long-term disease-free survival. Patients with extrahepatic disease have poor outcome despite complete surgical clearance.

*Department of Hepatobiliary surgery, Hampshire Hospitals, Basing-stoke, United Kingdom

Hepato-pancreato-biliary and Transplant Unit, St James's University Hospital, Leeds University, Leeds, United Kingdom.

Reprints: Zaed Z.R. Hamady, PhD, FRCS, Hepato-pancreato-biliary and Transplant Unit, St James's University Hospita, Leeds LS7 9TF, United Kingdom. E-mail:

Disclosure: The authors declare no conflict of interest.

© 2014 by Lippincott Williams & Wilkins.