Selection for hepatic resection of colorectal liver metastases: expert consensus statement

Abstract

Hepatic resection offers a chance of a cure in selected patients with colorectal liver metastases (CLM). To achieve adequate patient selection and curative surgery, (i) precise assessment of the extent of disease, (ii) sensitive criteria for chemotherapy effect, (iii) adequate decision making in surgical indication and (iv) an optimal surgical approach for pre-treated tumours are required. For assessment of the extent of the disease, contrast-enhanced computed tomography (CT) and/or magnetic resonance imaging (MRI) with gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) is recommended depending on the local expertise and availability. Positron emission tomography (PET) and PET/CT may offer additive information in detecting extrahepatic disease. The RECIST criteria are a reasonable method to evaluate the effect of chemotherapy. However, they are imperfect in predicting a pathological response in the era of modern systemic therapy with biological agents. The assessment of radiographical morphological changes is a better surrogate of the pathological response and survival especially in the patients treated with bevacizumab. Resectability of CLM is dependent on both anatomic and oncological factors. To decrease the surgical risk, a sufficient volume of liver remnant with adequate blood perfusion and biliary drainage is required according to the degree of histopathological injury of the underlying liver. Portal vein embolization is sometimes required to decrease the surgical risk in a patient with small future liver remnant volume. As a complete radiological response does not signify a complete pathological response, liver resection should include all the site of a tumour detected prior to systemic treatment.

Multivisceral Resection for Locally Invasive Colorectal Liver Metastases: Outcomes of a Matched Cohort Analysis

“…In fact, a recent systematic review commented on the non-randomized nature of current data with a lack of high-level evidence comparing similar patient groups making it difficult to draw conclusions from published data [12]. This is highlighted in current consensus guidelines, which remain ambiguous over the value of resection in the case of CRLM and EHD [13, 14]. The aim of this study is to review our experience of resecting hepatic and EHD in combination in the setting of CRLM, comparing these to outcomes in a 3: 1 matched cohort of isolated hepatic ­resections.…”

Laparoscopic parenchyma-sparing liver resection for colorectal metastases

“…While in the 1970s, resection was considered only in patients with solitary liver metastasis, nowadays resection of CLM is considered regardless of tumor size and number, provided that a resection with negative margins is possible, that stable disease can be achieved, that the remaining parenchyma is sufficient to prevent liver failure, and that there is no unresectable extrahepatic disease. 36 There are two known mechanisms for hepatic spread of colorectal cancer: metastasis from the primary tumor, and metastasis from other existing metastases. In contrast to hepatocellular carcinoma, tumor cells from CLM do not migrate into intrahepatic portal branches to form secondary intrahepatic metastases.…”

Recurrence of liver metastases from colorectal cancer and repeat liver resection

“…Patients with lung metastases in addition to liver metastases (4/34) underwent liver resection first and lung resection second (22).…”

“…However, not all patients are amenable to such resection, and appropriate selection is most important for a successful procedure. In the last few years, inclusion criteria have increased (15,16), and now the one criterion for resection is whole tumor resectability with safety margins and adequately functional liver remnant (17).…”