Prognosis of Rectal Cancer with Hepatic Metastases
For adult patients with rectal cancer and hepatic metastases, prognosis depends critically on resectability: with modern systemic chemotherapy alone, median overall survival is approximately 19-24 months, but if liver metastases become resectable after treatment, 5-year survival improves dramatically to 20-45% following complete surgical resection. 1
Baseline Prognosis Without Liver Resection
Without treatment, metastatic colorectal cancer to the liver carries a poor prognosis with most patients succumbing within one year, and the liver represents the most common site of metastatic disease with more than half of patients who die from colorectal cancer having liver metastases at autopsy. 1
With modern systemic chemotherapy regimens including combination chemotherapy and targeted therapies, median overall survival improves to approximately 19-24 months, with 5-year survival rates of 10-20% possible. 1
Current chemotherapeutic regimens lead to 2-year survival of approximately 60% in patients with unresectable liver metastases. 2
Prognosis With Surgical Resection
Liver resection is currently the treatment that offers the highest cure rate in patients with colorectal liver metastases, with overall 5- and 10-year survival rates ranging from 16-74% (median 38%) and 9-69% (median 26%), respectively. 3
If metastases become resectable after chemotherapy response, long-term survival or even cure can be attained in 20-45% of patients who undergo complete surgical resection or ablation of their metastases. 1
Resection of liver metastases offers 5-year disease-free survival rates of approximately 20% in carefully selected patients. 1
In elderly patients specifically, liver resection for colorectal liver metastases is safe treatment with 5-year survival rates reaching up to 40%. 3
Critical Prognostic Factors
Resectability Status
Approximately 25% of colorectal cancer cases present with simultaneous liver metastases, and 85% of these lesions are not resectable at diagnosis. 3
Conversion chemotherapy can render lesions resectable in approximately 13% of patients with initially unresectable colorectal liver metastases, with 5-year overall survival rates of 30% comparable to patients with initially resectable disease. 3
Synchronous vs. Metachronous Disease
Synchronous liver metastases generally carry a worse prognosis than metachronous metastases, indicating more disseminated disease at presentation. 1
Patients with rectal primaries present most commonly with higher metastatic liver load compared to colon cancer. 3
Age-Related Outcomes
Elderly patients aged >70 years have weighted 5-year overall survival of 32% compared to 40% in younger counterparts (P < 0.001), although 5-year disease-free survival is comparable between age groups. 3
In elderly patients aged >75 years undergoing liver resection, perioperative mortality is almost doubled and overall morbidity rate is higher, though disease-free survival remains equivalent to younger patients. 3
Postoperative mortality is higher in patients aged >70 years (4% vs. 2%, P = 0.01) and in patients aged >75 years (6% vs. 1%, P = 0.02). 3
Treatment Approach Impact on Prognosis
Surgical Strategy
Simultaneous and staged colorectal and hepatic resections for synchronous liver metastases have comparable postoperative morbidity and mortality, recurrence rate, and 5-year overall survival. 3
The liver-first approach is increasingly used in rectal cancer patients with synchronous colorectal liver metastases, specifically in those with rectal primaries and high metastatic disease burden. 3
Patients undergoing primary rectal resection only have shorter median survival than those undergoing either staged or synchronous liver resection (31 vs. 47 vs. 46 months, respectively). 2
Chemotherapy Regimens
In the landmark AVF2107g trial, addition of bevacizumab to bolus-IFL improved median overall survival from 15.6 months to 20.3 months (HR 0.66,95% CI: 0.54-0.81, p<0.001). 4
In the E3200 trial for previously treated patients, addition of bevacizumab to FOLFOX4 resulted in median overall survival of 13.0 months versus 10.8 months with FOLFOX4 alone (HR 0.75,95% CI: 0.63-0.89, p=0.001). 4
Neoadjuvant chemotherapy followed by rectal resection and then hepatic resection is associated with median survival of 41.4 months, with overall survival of 59% at 3 years and 39% at 5 years. 5
Recurrence Patterns
Approximately 60% of patients develop recurrence after hepatic resection, with 20% having liver-only recurrence amenable to re-resection. 6
The liver remains the most frequent site of first progression following treatment of rectal cancer with hepatic metastases. 7
Special Considerations for Poorly Differentiated Tumors
Patients with poorly differentiated metastatic rectal carcinoma have median overall survival of approximately 6-10 months with standard chemotherapy, though this can extend to 13-20 months with modern combination regimens including biologics in selected cases. 8
Poorly differentiated histology specifically confers worse outcomes compared to well or moderately differentiated tumors. 8