Liver Resection for Colorectal Cancer Metastases

Abstract

These recommendations apply to patients with liver metastases from crc who have had or will have a complete (R0) resection of the primary cancer and who are being considered for resection of the liver, or liver plus specific and limited ehms, with curative intent. 1(a). Patients with liver and lung metastases should be seen in consultation with a thoracic surgeon. Combined or staged metastasectomy is recommended when, taking into account anatomic and physiologic considerations, the assessment is that all pulmonary metastases can also be completely removed. Furthermore, liver resection may be indicated in patients who have had a prior lung resection, and vice versa. 1(b). Routine liver resection is not recommended in patients with portal nodal disease. This group includes patients with radiologically suspicious portal nodes or malignant portal nodes found preoperatively or intraoperatively. Liver plus nodal resection, together with perioperative systemic therapy, may be an option-after a full discussion with the patient-in cases with limited nodal involvement and with metastases that can be completely resected. 1(c). Routine liver resection is not recommended in patients with nonpulmonary ehms. Liver plus extrahepatic resection, together with perioperative systemic therapy, may be an option-after a full discussion with the patient-for metastases that can be completely resected. 2(a). Perioperative chemotherapy, either before and after resection, or after resection, is recommended in patients with resectable ABSTRACT Questions1. Should surgery be considered for colorectal cancer (crc) patients who have liver metastases plus (a) pulmonary metastases, (b) portal nodal disease, or (c) other extrahepatic metastases (ehms)? 2. What is the role of chemotherapy in the surgical management of crc with liver metastases in (a) patients with resectable disease in the liver, or (b) patients with initially unresectable disease in the liver that is downsized with chemotherapy ("conversion")? 3. What is the role of liver resection when one or more crc liver metastases have radiographic complete response (rcr) after chemotherapy? PerspectivesAdvances in chemotherapy have improved survival in crc patients with liver metastases. The 5-year survival with chemotherapy alone is typically less than 1%, although two recent studies with folfox or folfoxiri (or both) reported rates of 5%-10%. However, liver resection is the treatment that is most effective in achieving long-term survival and offering the possibility of a cure in stage iv crc patients with liver metastases. This guideline deals with the role of chemotherapy with surgery, and the role of surgery when there are liver metastases plus ehms. Because only a proportion of patients with crc metastatic disease are considered for liver resection, and because management of this patient population is complex, multidisciplinary management is required. MethodologyRecommendations in the present guideline were formulated based on a prepublication version of a recent systematic review on th...

Survival Outcomes of Liver Metastasectomy in Colorectal Cancer Cases: A Single-Center Analysis in Turkey

“…Despite positive results relating to metastasectomy in the literature, approximately two-thirds of metastatic colorectal cancer patients exhibit no long-term survival benefits. The factors that influence survival include poor tumor differentiation, increasing size and number of metastases, tumor staging, presence of extra-hepatic metastasis, elevated carcino embryonic antigen (CEA) levels and positive nodal status (Chua et al, 2011;Gallinger et al, 2013). The median survival rates depend on the presence or absence of these factors.…”

“…Five-year survival after curative resection ranges 30%-40% (up to 60% in selected series), whereas less than 2% of patients are alive 5 years after diagnosis without surgical therapy (Castaing et al, 2009;Hsu et al, 2011). Various factors associated with survival after surgery for CRC liver metastases have been identified, including tumor-free surgery margin, TNM stage of primary tumor, disease-free survival, number of metastasis and preoperative CEA level (Gallinger et al, 2013). Recently, with the addition of new chemotherapy drugs and targeted therapies, a positive correlation between the tumor response rate and metastatic complete resection rate has been demonstrated in mCRC patients (Chua et al, 2011).…”

Pooled analysis of the surgical treatment for colorectal cancer liver metastases

“…The authors state that heterogeneity and poor quality of the evidence were incompatible with a meta-analysis comparing different sequences of CT. The CCO guidelines are based on this last review [4]. In conclusion, neo adjuvant and adjuvant CT have not been compared directly.…”

“…An initial search and critical appraisal of guidelines on CRC performed in September 2012 yielded 5 guidelines: a 2006 guideline by IKNL on liver metastases [8], a 2008 guideline by IKNL that did not address treatment of liver metastases [12], a 2011 guideline by the Scottish Intercollegiate Guidelines Network (SIGN), a 2011 guideline by the National Institute for Health and Care Excellence, UK (NICE) [5] and a 2012 guideline by Cancer Care Ontario, Canada (CCO) [4]. We decided to update the literature from the search date of the IKNL 2006 guideline.…”

“…Based on these observations, recent guidelines recommend attempting curative resection of CRC liver metastases, sometimes in combination with other local treatment modalities such as radiofrequency ablation (RFA) despite lack of evidence from randomised controlled trials (RCT) [4][5][6]. A recent review reports that 15-30% of patients with liver metastases may be appropriate for curative resection.…”