The article by Drs. Ravikumar and Gallos provides an excellent and timely overview of recent developments in the treatment of metastatic liver disease.
Value of Resectional Surgery
Surgery has evolved to become the standard of care for a defined subset of patients with hepatic colorectal metastases. Hepatic resections are now well-controlled procedures, with several centers reporting very low perioperative mortality rates. Although the majority of patients who undergo hepatic resection still succumb to metastatic disease, the authors provide strong data in support of hepatic resection as a means of prolonging survival beyond that expected with systemic or regional chemotherapy alone. In addition, three large single-institution series have reported high tumor-free survival rates after 5 years, thus providing the best presumptive evidence of potential cure from resection.[1-3]
Criteria for Resection
A clear distinction should be made between the factors predicting prognosis following hepatic resection for colorectal metastases and the criteria contraindicating resection. The three major factors affecting outcome after resection are (1) a positive surgical resection margin, (2) a synchronous tumor presentation (liver and primary), and (3) a node-positive primary.[1,3-7] The only two contraindications to resection are the presence of extrahepatic disease and the inability to achieve complete resection.
Although the presence of four or more metastases was once thought to preclude long-term survival, the absolute number of metastases no longer contraindicates resection. Similarly, bilobar disease is no longer considered a contraindication to operative intervention. The inability to achieve a negative margin is considered an absolute contraindication to resection, but the 5-year survival of patients with margins < 1 cm is greater than 20% and justifies hepatic resection as long as a negative margin is obtained.[8,9]
The term extrahepatic disease should be clarified. We agree with the authors’ statement that lymph node metastases contraindicate resection because these metastases are either hepatic (hilar and celiac lymphadenopathy) or advanced from primary colorectal cancer (periaortic and iliac lymphadenopathy). However, extrahepatic disease encompasses a broad spectrum of clinical presentations that per se do not contraindicate combined hepatic and extrahepatic resection, because extended survival has been reported after complete resection for