Although metastatic colorectal cancer is typically incurable, in a good percentage of patients (20% to 50%) who have oligometastatic disease confined to a single organ—usually the liver—complete metastasectomy can result in cure. However, once the decision to pursue surgery is made, there remain a number of issues that must be addressed in order to ensure the best possible outcome. These include whether to perform synchronous or staged resections of the liver metastasis and the primary colon cancer; whether surgery should be performed before, after, or in the absence of chemotherapy; if chemotherapy is used, which agents will be best; and in patients with locally advanced rectal cancer, whether pelvic radiation should be incorporated into the treatment plan. Unfortunately, there are limited data that can provide guidance in deciding these questions in a particular patient. Here we present the insights we have arrived at through our own considerable experience with this patient population, and we reflect on the relevant studies that are available.
Metastatic colorectal cancer is typically a treatable but incurable disease. Patients with oligometastatic disease confined to a single organ, most often the liver, are a notable exception. Multiple series have now confirmed that in this setting cure is attained in 20% to 50% of patients who undergo complete metastasectomy. Even in the absence of randomized trials comparing operative with nonoperative management, surgery has become standard practice for patients with resectable oligometastatic disease. On the other hand, for those with more extensive disease involving multiple organs and numerous (> 4) lesions, the value of this approach is controversial; surgery may be followed by long-term survival but is rarely curative.[2,3] Consider the hypothetical case of an asymptomatic patient with colorectal cancer and two resectable liver metastases. The issues that would need to be addressed in such a case are typical of this patient population. These include whether surgery should be performed before, after, or in the absence of chemotherapy; and whether operations for the metastases and the primary tumor should be performed at the same time. In the setting of locally advanced rectal cancer, an additional concern is the utility of pelvic radiation. There are few, if any, data to directly inform these decisions. Therefore, all recommendations are subjective and remain open to debate. In this paper we present our views and the rationale behind them.
Synchronous or Staged Surgery?
Combined resection of liver metastasis along with the primary colon cancer is often feasible and is commonly performed. The benefits of synchronous resection include less exposure to general anesthesia (one vs two operations), less morbidity, and the opportunity to eradicate all disease in one procedure. The risk associated with anesthesia varies from patient to patient and depends on comorbidity, age, and disease status. Although the risk is minor in many patients, it is additive and can be substantial in older patients. Perioperative complications are also additive, and there are fewer total complications following synchronous vs staged resections. Complications are especially burdensome in patients who undergo staged resections, and these can significantly delay treatment of remaining gross disease. However, some centers advocate a more selective approach, reserving synchronous resection for patients with colon rather than rectal cancer, and for those who require more minor hepatectomy.[5,6] Our preferred approach is synchronous resection to eradicate all disease, except in the settings of high comorbidity or emergent presentation with perforation or obstruction.
It can be argued that metachronous resection should be reconsidered in the era of laparoscopy. Most colon tumors can now be removed using a minimally invasive approach, with fewer complications and rapid recovery. Although we favor synchronous resection, in the era of laparoscopy, one could argue that laparoscopic colon resection should be performed first, followed at a later date by liver resection. In some very select circumstances, the logical approach is to resect the metastases first.
Preoperative disease workup for synchronous resection includes high-quality CT scans of the chest, abdomen, and pelvis, with triphasic examination of the liver. In patients with hepatic steatosis resulting from chemotherapy or other causes, liver MRI is often used, since it provides better visualization of the parenchyma. Positron emission tomography (PET) scans are not routinely obtained. Liver volumetry (calculation of the future liver remnant volume) is performed for patients being considered for extended hepatic resection; preoperative portal vein embolization can then be performed in patients with inadequate or borderline future liver remnant volumes (Figure).
Role of Nonsurgical Modalities in the Eradication of Liver Metastasis
Other modalities are available to eradicate liver metastasis; however, surgery is favored in fit patients with resectable disease. In general, ablative therapies play a secondary role in patients with hepatic colorectal metastases. Thermal ablation (radiofrequency or microwave) is the technique used most commonly, and while potentially effective in select patients, it has limited application in patients with larger tumors (> 3 cm) or tumors in close proximity to major intrahepatic vascular or biliary structures or adjacent extrahepatic organs (ie, stomach, duodenum, colon). Thermal ablation is most appropriate in patients with limited disease who are poor candidates for resection, or in conjunction with resection in patients with multiple, bilobar tumors. Transcatheter arterial embolization techniques with bland or drug-eluting beads, and radioembolization with yttrium-90 are palliative therapies; these currently are not appropriate for patients who are candidates for complete surgical resection.[9,10]
Dr. Saltz serves as a paid consultant to Bayer, Bristol-Myers Squibb, and Roche-Genentech; and as an unpaid consultant to Sanofi-Aventis. Drs. Jarnagin and Weiser have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.
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