Dr. Sardi and colleagues lay out, in a clear and concise fashion,
current alternatives for the management of primary and metastatic
liver tumors. Their emphasis on "high-value" treatments
is crucial. In this group of patients, unnecessary treatments
not only are costly in terms of dollars but also reduce the quality
of the short life remaining in patients with unresectable disease.
This review of the state of the art describes no exciting new
therapies because no promising treatment options have emerged
recently. Nevertheless, a review of the management of primary
and metastatic liver tumors is very timely. Even though new management
strategies are absent, the ones currently being employed by meticulous
practitioners produce far superior results than were achieved
in the past. This is the result of many small changes that, as
a composite, are making a definite difference in the benefits
that accompany the treatment of liver tumors.
Large Differences from Small Changes
Sardi et al enumerate several of these important small changes
that have led to big differences. First, radiologic techniques
are far superior now than they were in previous years. Our ability
to detect disease at distant sites has greatly improved. Lung
metastases as small as 3 mm in size are routinely detected by
CT. Other metastatic lesions as small as 5 mm that had previously
escaped detection are now routinely imaged by MRI or spiral CT
with contrast infusion. This means that fewer patients are left
with persistent disease after the surgeon's best efforts to achieve
a complete resection. Radiologic "stage migration" probably
does more to improve the results of surgery than any other single
One caveat in this regard remains: The hepatic lymph nodes are
a difficult area for the radiologist to image. However, being
aware of this "radiologic blind spot," surgeons biopsy
the hepatic lymph nodes intraoperatively as part of the abdominal
exploration so that patients with metastatic disease do not undergo
a liver resection that is not indicated .
Second, resection of liver tumors nowadays is associated with
low mortality (< 5%) and low morbidity (< 10%) . In addition,
the survival rate is greatly improved, even doubled, over that
reported by Hughes and colleagues  in 1986. Stage migration
is important, but improved margins of excision, less intraoperative
disruption of resected specimens, and chemotherapy may all contribute
to better survival. This improvement in survivorship is evident
even though resection of two to four metastases (as opposed to
a single metastasis) is commonplace.
Tumor Markers of Great Value
Tumor markers also are of great value in this population of patients,
especially those with colorectal metastases to the liver. Serial
carcinoembryonic antigen (CEA) assays or CA 19-9 assays after
a colon resection reveal liver metastases in approximately 40%
of patients, and these are isolated in approximately 10%. Now,
smaller isolated lesions that are confined to the liver are seen,
rather than symptomatic lesions that themselves have caused metastases.
Tumor marker follow-up of patients after a potentially curative
resection of colorectal cancer, leading to subsequent curative
liver resection, is an extremely important part of postoperative
management of large bowel cancer .
Tumor marker follow-up not only is necessary after colon resection
but also is of value in monitoring patients after liver resection
for primary and metastatic liver tumors. A second rise in CEA
during serial assessment of this marker may lead to the identification
of an additional liver lesion. The same may be true of alpha-fetoprotein
follow-up after resection of a hepatoma. The surgical value of
second liver resections is the same as, if not better than, that
of resection of an initial liver metastasis [5-7].
Conclusions regarding the selection of patients for liver resection
with colorectal metastases have been greatly clarified. However,
after all the data have been gathered, the selection criteria
remain extremely broad. Patients who have a reasonable morbidity
and mortality and who can be rendered clinically disease free
by liver resection should be given the benefit of this treatment
Proliferation of Nonresection Techniques
Finally, Dr. Sardi and colleagues call our attention to the proliferation
of nonresection techniques for tumor ablation within the liver.
Cryosurgery, chemoembolization, percutaneous ethanol injection,
and hepatic artery infusion chemotherapy are but a few of the
liver-specific treatments. In my opinion, these techniques should
be viewed as complementary rather than competitive. Together,
they can result in a more complete treatment than was possible
in the past, and can make the concept of liver cytoreduction a
reality.8 For example, the major problem with the infusion techniques
has been local recurrence at the site of large tumors. Therapy
such as cryosurgery can ablate nodules and prevent this breakthrough
in response to chemotherapy. Combinations of these treatments
that result in little or no morbidity and no mortality are necessary
in the next decade of research on hepatic tumor
l. Lefor AT, Hughes KS, Shiloni E, et al: Staging of patients
with suspected isolated colorectal liver metastases. Curr Surg
2. Detroz B, Sugarbaker PH, Knol JA, et al: Causes of death in
patients undergoing liver surgery, in Sugarbaker PH (ed): Cancer
Treat Res 69:241-257, 1994.
3. Hughes KS, Simon R, Sugarbaker PH, et al from the Hepatic Metastases
Registry: Resection of the liver for colorectal carcinoma metastases:
A multi-institutional study of patterns of recurrence. Surgery
4. Sugarbaker PH: Follow-up of colorectal cancer. Tumori 81(suppl):126-134,
5. Fernandez-Trigo, Shamsa F, and other members of the Repeat
Hepatic Resection Registry: Repeat liver resections from colorectal
metastases, in Sugarbaker PH (ed): Hepatobiliary Cancer, pp 185-196.
Boston, Kluwer, 1994.
6. Trigo-Fernandez V, Shamsa F, Sugarbaker PH, and other members
of the Repeat Liver Resection Registry: Repeat liver resections
from colorectal metastasis. Surgery 117:296-304, 1995.
7. Sugarbaker PH: Repeat hepatic resection for primary and metastatic
carcinoma of the liver (editorial). Hepat Pancreat Bil Surgery
8. Sugarbaker PH, Steves MA: A cytoreductive approach to treatment
of multiple liver metastases. J Surg Oncol 3:161-165, 1993.