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Resection of Liver Metastases: State of the Art

Resection of Liver Metastases: State of the Art

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

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