Curative resection for the treatment of colorectal liver metastases remains the only cure for patients with colorectal liver metastases. Surgery has shown the best survival in these patients. Even though there has been an advancement in diagnostic imaging, still only 10 to 20% of patients are amenable to surgical resection.
During the past decade, multiple therapeutic strategies have been established to benefit long term survival. Of these, neoadjuvant chemotherapy, radiofrequency ablation, cryotherapy and portal embolization have been studied and implemented worldwide in specialized centers.
Colorectal liver metastases carry a bad prognosis, but currently, multiple centers have reported a 45% 5 year survival, in contrast to non-surgical management, which the 5 year survival is almost nil.
The management of these metastases is in fact directed to residual lesions after chemotherapy. This means that a multidisciplinary approach should always be implemented.
Preoperative evaluation
Every patient must have a complete ocological study. This means, search for other metastatic sites and of contraindications for surgery.
Every patient must have a full anatomical work-up with imaging studies (CT scan, MRI, US and/or angiography) to determine exactly the number of lesions, their precise localization, their relationship with pedicular elements and to better plan the surgical strategy.
The presence of pulmonary metastases does not contraindicate a liver resection, as demostrated by multiple centers in Europe and Asia, as long as they are amenable to resection.
Colonoscopy is mandatory, this because recurrent pericolic tumors are the most frequent, and sometimes not diagnosed. Liver tests, tumor markers and tests that show the liver’s functional capacity (indocyanine green clearance) are obligatory as well.
Current approach
A patient with a single metastases in a single liver segment should undergo a surgical resection. The difficulty comes with those patients who have more than one lesion, and more than one segment involved.
The new startegies are specifically adapted to four groups of patients:
1. Patients with a large single lesion, to which resection would leave an insufficient amount of liver parenchyma
2. Patients with bilobar metastases
3. Patients with recurrent metastases after resection
4. Patients with a primary colorectal tumor and synchronous liver metastases
Large single Colorectal Liver Metastases
This patients are initially not amenable to undergo surgical resection, but two therapeutic alternatives can be proposed.
Tumor downsizing with systemic or locoregional chemotherapy
Adam et al, at the Paul Brousse Hospital, have one of the largest series of patients treated with this approach. They concluded that patients benefit from tumor downsizing either with systemic chemotherapy or using transarterial chemotherapy and can undergo surgical resection with similar 5 year survival rates.
Compensatory Hypertrophy of the Non-Tumoral Liver
Portal embolization either operative or percutaneous (reviewed in later blogs) can help in augmenting the liver parenchyma through hypertrophy of the non-tumoral liver to make a resection possible without the risk of having a postoperative liver insufficiency.
Bilobar Metastases
Two Stage Hepatectomy with Portal Embolization
This surgical strategy has been developed in the last decade for patients with bilobar metastases that would make a resection impossible because of putting the patient at risk of hepatocellular insufficiency.
Because of the fact that growth of liver metastases has been reported in the liver not embolized, a startegy consisting of resection or ablation of the lesions in the future remaining liver, and a portal embolization of the most affected hemiliver to obtain a hypertrophied remaining organ. On a second stage, a resection of the embolized liver can be performed, being sure that an appropiate amount of parenchyma will rest in place.
Two Stage Hepatectomy
This technique described by Rene Adam et al, at the Paul Brousse Hospital, consists of resecting a large number of lesions in the first stage, and after a few weeks, after liver regeneration has taken place, resecting the rest of the metastases in a second procedure. Patients receive chemotherapy in between the two surgical interventions. The reported survival at 3 years is 35%.
Hepatectomy plus Local Destruction of Colorectal Liver Metastases
This strategy consists of resecting the largest lesions of one lobe and ablate the smallest lesions in the remaining liver, either with radiofrequency or cryotherapy. The sole conditions is that the largest lesions must be localized to one lobe, for the fact that 30% of liver parenchyma must be left in place to prevent hepatocellular insufficiency.
Two Stage Hepatectomy after Chemotherapy
The goal is to obtain tumor downsizing with chemotherapy and then perform a one or two stage hepatectomy. The current results establish a 5 year survival similar to those patients with initially resectable lesions.
Recurrence after Resection
The most important concept to grasp is that surgical resection remains the only cure for these patients. Resection of either hepatic or extrahepatic recurrences, provide survivals equal to patients without recurrence.
The indications can be widened with the use of local ablative procedures such as RFA or cryotherapy in association to surgical resection.
Resection in patients with Colorectal Tumor and Synchronous Metastases
The results at the Paul Brousse Hospital demonstrated that patients with a simultaneous resection of the colorectal tumor and synchronous liver metastases have the same morbidity and mortality as those with a differed procedure. The 1, 3 and 5 year survival is also similar in both groups.
During the past decade, multiple therapeutic strategies have been established to benefit long term survival. Of these, neoadjuvant chemotherapy, radiofrequency ablation, cryotherapy and portal embolization have been studied and implemented worldwide in specialized centers.
Colorectal liver metastases carry a bad prognosis, but currently, multiple centers have reported a 45% 5 year survival, in contrast to non-surgical management, which the 5 year survival is almost nil.
The management of these metastases is in fact directed to residual lesions after chemotherapy. This means that a multidisciplinary approach should always be implemented.
Preoperative evaluation
Every patient must have a complete ocological study. This means, search for other metastatic sites and of contraindications for surgery.
Every patient must have a full anatomical work-up with imaging studies (CT scan, MRI, US and/or angiography) to determine exactly the number of lesions, their precise localization, their relationship with pedicular elements and to better plan the surgical strategy.
The presence of pulmonary metastases does not contraindicate a liver resection, as demostrated by multiple centers in Europe and Asia, as long as they are amenable to resection.
Colonoscopy is mandatory, this because recurrent pericolic tumors are the most frequent, and sometimes not diagnosed. Liver tests, tumor markers and tests that show the liver’s functional capacity (indocyanine green clearance) are obligatory as well.
Current approach
A patient with a single metastases in a single liver segment should undergo a surgical resection. The difficulty comes with those patients who have more than one lesion, and more than one segment involved.
The new startegies are specifically adapted to four groups of patients:
1. Patients with a large single lesion, to which resection would leave an insufficient amount of liver parenchyma
2. Patients with bilobar metastases
3. Patients with recurrent metastases after resection
4. Patients with a primary colorectal tumor and synchronous liver metastases
Large single Colorectal Liver Metastases
This patients are initially not amenable to undergo surgical resection, but two therapeutic alternatives can be proposed.
Tumor downsizing with systemic or locoregional chemotherapy
Adam et al, at the Paul Brousse Hospital, have one of the largest series of patients treated with this approach. They concluded that patients benefit from tumor downsizing either with systemic chemotherapy or using transarterial chemotherapy and can undergo surgical resection with similar 5 year survival rates.
Compensatory Hypertrophy of the Non-Tumoral Liver
Portal embolization either operative or percutaneous (reviewed in later blogs) can help in augmenting the liver parenchyma through hypertrophy of the non-tumoral liver to make a resection possible without the risk of having a postoperative liver insufficiency.Bilobar Metastases
Two Stage Hepatectomy with Portal Embolization
This surgical strategy has been developed in the last decade for patients with bilobar metastases that would make a resection impossible because of putting the patient at risk of hepatocellular insufficiency.
Because of the fact that growth of liver metastases has been reported in the liver not embolized, a startegy consisting of resection or ablation of the lesions in the future remaining liver, and a portal embolization of the most affected hemiliver to obtain a hypertrophied remaining organ. On a second stage, a resection of the embolized liver can be performed, being sure that an appropiate amount of parenchyma will rest in place.
Two Stage Hepatectomy
This technique described by Rene Adam et al, at the Paul Brousse Hospital, consists of resecting a large number of lesions in the first stage, and after a few weeks, after liver regeneration has taken place, resecting the rest of the metastases in a second procedure. Patients receive chemotherapy in between the two surgical interventions. The reported survival at 3 years is 35%.
Hepatectomy plus Local Destruction of Colorectal Liver Metastases
This strategy consists of resecting the largest lesions of one lobe and ablate the smallest lesions in the remaining liver, either with radiofrequency or cryotherapy. The sole conditions is that the largest lesions must be localized to one lobe, for the fact that 30% of liver parenchyma must be left in place to prevent hepatocellular insufficiency.Two Stage Hepatectomy after Chemotherapy
The goal is to obtain tumor downsizing with chemotherapy and then perform a one or two stage hepatectomy. The current results establish a 5 year survival similar to those patients with initially resectable lesions.
Recurrence after Resection
The most important concept to grasp is that surgical resection remains the only cure for these patients. Resection of either hepatic or extrahepatic recurrences, provide survivals equal to patients without recurrence.
The indications can be widened with the use of local ablative procedures such as RFA or cryotherapy in association to surgical resection.
Resection in patients with Colorectal Tumor and Synchronous Metastases
The results at the Paul Brousse Hospital demonstrated that patients with a simultaneous resection of the colorectal tumor and synchronous liver metastases have the same morbidity and mortality as those with a differed procedure. The 1, 3 and 5 year survival is also similar in both groups.
Ann Surg 1997 ; 225 : 39-50; Ann Surg 1997 ; 225 : 51-62; Ann Surg 2000 ; 232: 777-785; Ann Surg 2000 ; 231 : 480-486; Ann Surg 1996 ; 224 : 509-522; Br J Surg 1999 ; 86 : 784-788; Am J Surg 1995 ; 169 : 254-260; Eur J Surg Oncol 2000 ; 26 : 763-769; Br J Surg 1997 ; 84 : 977-980; J Thorac Cardiovasc Surg1999;118: 1090-1096; Eur J Surg Oncol 1999 ; 25 : 410-417
Ann Oncol 2000 ; 11 : 1477-1483; Ann Surg 2003; 238 :871-884; Ann Surg 2004, 240: 644-658; Ann Surg 2004, 240: 1052-1064; Arch Surg 2006, 141: 460-467
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