Hepatic and Extrahepatic Colorectal Metastases: When Resectable, Their Localization Does Not Matter, But Their Total Number Has a Prognostic Effect Dominique Elias, MD, PhD, 1 Gabriel Liberale, MD, 1 De´wi Vernerey, MSc, 2 Marc Pocard, MD, PhD, 1 Michel Ducreux, MD, PhD, 3 Vale´rie Boige, MD, 3 David Malka, MD, PhD, 3 Jean-Pierre Pignon, MD, PhD, 2 and Philippe Lasser, MD 1 1 Department of Surgical Oncology, Institut Gustave Roussy, Comprehensive Cancer Center, 39 Rue Camille Desmoulins, 94805 Villejuif Ce´dex, France 2 Department of Medical Statistics, Institut Gustave Roussy, Comprehensive Cancer Center, 39 Rue Camille Desmoulins, 94805 Villejuif Ce´dex, France 3 Department of Medical Oncology, Institut Gustave Roussy, Comprehensive Cancer Center, 39 Rue Camille Desmoulins, 94805 Villejuif Ce´dex, France Background: The presence of extrahepatic disease (EHD) is considered a contraindication to hepatectomy in patients with colorectal liver metastases. After resection, the prognosis is based more on the total number of resected metastases (located inside and outside the liver) than on the site of these metastases (only inside the liver or not). Methods: A total of 308 patients with colorectal cancer underwent hepatectomy, and 84 (27%) also underwent resection of miscellaneous EHD. The study was a prospective data registration and retrospective analysis. When considering the total number of resected metastases, each liver metastasis and each EHD location was counted as one lesion. Uni- variate and multivariate analyses were performed. Results: The median follow-up was 99 months. The overall 5-year survival rate was 32%.In the multivariate analysis, the total number of metastases (inside or outside the liver) had a greater prognostic value than the criterion ‘‘presence or absence of EHD.’’ Considering the total number of resected metastases (whatever their site), 5-year survival rates were 38% (SD: 4%) in the group with one to three metastases, 29% (SD: 5%) in patients with four to six metastases, and 18% (SD: 5%) in patients with more than six metastases (P = .002). A very simple prognostic score based on sex and the total number of metastases is proposed. Conclusions: EHD, when resectable, is no longer a contraindication to hepatectomy. More importantly, the total number of the metastases, whatever their location, has a stronger prognostic effect than the site of these metastases. Key Words: Colorectal cancer—Liver metastases—Extrahepatic disease. Hepatic resection is traditionally the sole treatment that produces long-term survival in patients with colorectal liver metastases (LM), with a 25% to 40% 5-year survival rate. 1–10 Extrahepatic disease (EHD) has been considered a contraindication to hepatec- tomy because subgroup analyses of large series pub- lished before 1990 showed a very unfavorable prognosis. 1–6 Similarly, lung metastases were rarely resected even when they were technically resectable, and peritoneal carcinomatosis was never considered as potentially curable. 11,12 However, over the last few years, some series reported interesting 5-year survival Received January 19, 2005; accepted June 28, 2005; published online September 26,2005. Address correspondence and reprint requests to: Dominique Elias, MD, PhD; E-mail: elias@igr.fr Published by Springer Science+Business Media, Inc. Ó 2005 The Society of Surgical Oncology, Inc. Annals of Surgical Oncology, 12(11): 900)909 DOI: 10.1245/ASO.2005.01.010 900