• Georgios A Margonis, Stefan Buettner, Nikolaos Andreatos, Kazunari Sasaki, Jan N M Ijzermans, Jeroen L A van Vugt, Timothy M Pawlik, Michael A Choti, John L Cameron, Jin He, Christopher L Wolfgang, and Matthew J Weiss.
• *Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD †Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, the Netherlands ‡Department of Surgery, Ohio State University Wexner Medical Center, Columbus, OH §Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
• Ann. Surg. 2017 Oct 1; 266 (4): 641-649.

ObjectiveTo investigate the potential clinical advantage of anatomical resection versus nonanatomical resection for colorectal liver metastases, according to KRAS mutational status.BackgroundKRAS-mutated colorectal liver metastases (CRLM) are known to be more aggressive than KRAS wild-type tumors. Although nonanatomical liver resections have been demonstrated as a viable approach for CRLM patients with similar oncologic outcomes to anatomical resections, this may not be the case for the subset of KRAS-mutated CRLM.Methods389 patients who underwent hepatic resection of CRLM with known KRAS mutational status were identified. Survival estimates were calculated using the Kaplan-Meier method, and multivariable analysis was conducted using the Cox proportional hazards regression model.ResultsIn this study, 165 patients (42.4%) underwent nonanatomical resections and 140 (36.0%) presented with KRAS-mutated CRLM. Median disease-free survival (DFS) in the entire cohort was 21.3 months, whereas 1-, 3-, and 5-year DFS was 67.3%, 34.9%, and 31.5% respectively. Although there was no difference in DFS between anatomical and nonanatomical resections in patients with KRAS wild-type tumors (P = 0.142), a significant difference in favor of anatomical resection was observed in patients with a KRAS mutation (10.5 vs. 33.8 months; P < 0.001). Five-year DFS was only 14.4% in the nonanatomically resected group, versus 46.4% in the anatomically resected group. This observation persisted in multivariable analysis (hazard ratio: 0.45; 95% confidence interval: 0.27-0.74; P = 0.002), when corrected for number of tumors, bilobar disease, and intraoperative ablations.ConclusionsNonanatomical tissue-sparing hepatectomies are associated with worse DFS in patients with KRAS-mutated tumors. Because of the aggressive nature of KRAS-mutated CRLM, more extensive anatomical hepatectomies may be warranted.

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