Current status of surgical treatment of colorectal liver metastases

Abstract

Liver metastasis (LM) is one of the major causes of death in patients with colorectal cancer (CRC). Approximately 60% of CRC patients develop LM during the course of their illness. About 85% of these patients have unresectable disease at the time of presentation. Surgical resection is currently the only curative treatment for patients with colorectal LM (CRLM). In recent years, with the help of modern multimodality therapy including systemic chemotherapy, radiation therapy, and surgery, the outcomes of CRLM treatment have significantly improved. This article summarizes the current status of surgical treatment of CRLM including evaluation of resectability, treatment for resectable LM, conversion therapy and liver transplantation for unresectable cases, liver resection for recurrent CRLM and elderly patients, and surgery for concomitant hepatic and extra-hepatic metastatic disease (EHMD). We believe that with the help of modern multimodality therapy, an aggressive oncosurgical approach should be implemented as it has the possibility of achieving a cure, even when EHMD is present in patients with CRLM.

Historical perspective: Two decades of progress in treating metastatic colorectal cancer

“…The current accepted criteria for resection include any tumor number with any distribution within the liver, stable or resectable extrahepatic disease, an appropriate FLR, venous involvement amenable to resection or reconstruction, and ability to achieve a tumor‐free margin …”

“…To improve the size of the FLR, techniques such as portal vein embolization (PVE) and portal vein ligation (PVL) were brought into clinical practice; such techniques induce atrophy of the liver segments to be resected and hypertrophy of the contralateral FLR. These techniques can be used in patients with resectable CRLM but inadequate FLR . Contralateral liver hypertrophy occurs over a 4 to 6 week period after embolization or ligation, and there has been some controversy as to whether this lag time before resection has oncologic significance.…”

“…In the first stage, small metastatic lesions in the FLR are resected with concomitant PVL or postoperative PVE. After hypertrophy of the FLR, the second stage is performed . Patients who complete the two‐stage therapy have an overall survival of approximately 52 months from the first liver surgery and 5‐year overall survival of 35% .…”

“…Liver transplantation remains controversial in the treatment of colorectal cancer liver metastases, especially given the limited availability of organs and the likelihood of tumor progression and death while awaiting transplantation, as well as the chance of recurrence and death after transplantation. Several studies are ongoing to address transplantation as a treatment option for unresectable liver metastases and to create risk stratification and aid in patient selection . Finally, the role of HIPEC for peritoneal metastases for CRC will be better defined and the results of ongoing studies are published.…”

“…With the advent and availability of more effective systemic therapies in the form of biologic therapeutics specifically, the pool of patients The current accepted criteria for resection include any tumor number with any distribution within the liver, stable or resectable extrahepatic disease, an appropriate FLR, venous involvement amenable to resection or reconstruction, and ability to achieve a tumor-free margin. 98,99 As the effectiveness and use of neoadjuvant chemotherapy increased, so did the concern regarding the size and quality of the FLR. Studies showed that receipt of 12 or more weeks of neoadjuvant chemotherapy was associated with the increased hepatotoxicity in the form of steatohepatitis or hepatic sinusoidal obstruction, depending on the chemotherapy regimen.…”