ORLANDOWhen colorectal cancer metastasizes to the liver, hepatic resection can offer a survival benefit and even a "cure" in a fraction of patients. Five-year overall survival in some recent series approaches 60%. But the role of neoadjuvant chemotherapy in this group of patients has not been well established, and the issue was debated by two specialists at the invitation of the organizers of the 2008 Gastrointestinal Cancer Symposium. John L. Marshall, MD, chief of hematology and oncology, Georgetown University Lombardi Comprehensive Cancer Center, was assigned to the "pro" side of the debate, and Kenneth K. Tanabe, MD, chief of surgical oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, was given the "con" side.
Preoperative chemotherapy, Dr. Marshall said, is an essential element of "curative management" in patients who are clearly resectable from the outset, mainly because it treats occult disease that cannot be attacked by the surgeon's knife.
But Dr. Tanabe pointed out that preoperative chemotherapy can complicate the surgeon's mission, delay a potentially curative operation, and raise the risk of hepatotoxicity. "Don't assume that a response to chemotherapy will always facilitate liver resection," he said.
Both speakers emphasized that this debate is relevant only to patients who are "definitely resectable" and not to those with borderline or potentially resectable tumors (where there is little controversy) or unresectable tumors (where there is no controversy at all).
The definition of resectability, they added, has changed recently, mainly in that the number of metastases is no longer a deciding factor. "Complex operations are performed routinely, and long-term survivors are observed in each group," Dr. Tanabe noted
In the treatment of this population, guidelines from the National Comprehensive Cancer Network (NCCN) for patients with colon cancer and synchronous liver metastases offer several options but no clear answers. Options include:
(1) Colectomy with synchronous or subsequent liver resection.