Management of colorectal cancer liver metastases Aliakbarian M. M.D. Assistant professor of surgery Organ Transplant & Hepatopancreatobiliary Surgeon
SUBJECTS The importance of surgical resection in colorectal liver metastases. Which patients are candidates for resection? What should we do with synchronous liver metastases?
SUBJECTS The importance of surgical resection in colorectal liver metastases. Which patients are candidates for resection? What should we do with synchronous liver metastases?
SURGICAL RESECTION among all treatments, only surgery is associated with a survival plateau. in surgical case series, 5-year survival rates after resection range from 24 to 58 %, averaging 40 % five-year survival rates with the most active systemic chemotherapy regimens are only 10 to 11 %, only about one-fifth of whom have a sustained disease remission.
The importance of surgery in Colorectal Liver Metastases Strangl R et al. Lancet 1994
5-y Survival Resected patients: 25-40% Liver resection= Possibility to cure Adam R.
Resectability in pts with CRC liver metastases where are we now? Metastatic CRC New staging system Improved patient workup Syst. chemotherapy first? 85% unresectable 15% resectable New endpoint Timing? Addition of targeted agents CT Patient selection?% potentially resectable (after neoadjuvant) > 30% resection 7 Improved patient monitoring Mts epatiche - Roma 2007 Cure?
Colorectal cancer liver metastases Liver metastases 25% synchronous with the primary tumor 20% metachronous Mets synchronous : More often bilobar and greater in number/size Poorer survival Tan EK et al, Ann Acad Med 2010
HEPATIC RESECTION PROGNOSTIC FACTORS 1) positive margin 2) extrahepatic disease 3) node-positive primary 4) disease-free interval < 12 months 5) number of hepatic tumors > 1 6) 7) largest hepatic tumor > 5 cm cea level > 200 ng/ml FONG ET AL, ANN SURG 230:309, 1999
SUBJECTS the importance of surgical resection in colorectal liver metastases. which patients are candidates for resection? what should we do with synchronous liver metastases?
WHAT DOES IT MEAN RESECTABLE DISEASE? Traditional controindications: 4 metastases size extrahepatic disease hilar disease resection margin< 1 cm incomplete resection
ABSOLUTE CONTRAINDICATIONS non-treatable extrahepatic dis. >6 segments or >70% involvement not suitable for surgery
SUBJECTS the importance of surgical resection in colorectal liver metastases. which patients are candidates for resection? what should we do with synchronous liver metastases?
SYNCHRONOUS HEPATIC CRC definition: the presence of hepatic metastases identified at the time of diagnosis of the primary tumor or within 6 months of diagnosis
Resectable Hepatic Metastases Aloia, Fahy. Clin Colorectal CA 2008; 7:197-201
SURGERY IN SYNCHRONOUS COLORECTAL LIVER METASTASES the optimal timing of synchronous metastases resction is not well defined surgical strategy are defined as combined (combined resection of primary and liver), classic (primary before liver) and reverse (liver before primary) these surgical strategies are associated with similar outcomes
for low-risk (medically fit, four or fewer lesions), potentially resectable patients, initial surgery rather than neoadjuvant chemotherapy should be chosen, followed by postoperative chemotherapy. for patients who have higher risk, borderline resectable or unresectable disease, neoadjuvant chemotherapy is the preferred approach
Synchronous Colorectal Liver Metastases 1. right sided tumors could be better resected at the same time of liver metastases in selected patients; 2. left sided tumor (especially rectal cancer) present more thecnically difficulties and post-operative risks 3. a delayed (3-6 months) liver resection and chemotherapy administration permits a test of time : selection of patients who really benefits of liver resection with curative intention
Synchronous Hepatic CRC nresectable hepatic disease Resectable disease chemotherapy Major hepatectomy Needed Minor Hepatectomy Needed Inadequate response Resectable Colon Primary Rectal Primary Simultaneous resection Followed by chemotherapy ontinue chemotherapy Or enter a trial N1 Hepatectomy then chemo Colon Resection N2 Chemo then hepatectomy Hepatectomy Neoadjuvant CRT + rectal resection Bilobar disease Chemotherapy R/S Primary +FLR dz First, +/-PVE, hepatectomy P Chemo
Multimodality management of CRC liver metastases NEOADJUVANT CHEMOTHERAPY RESECTABLE LIVER METASTASES: FACILITATE SURGERY OBTAIN PREDICTIVE AND PROGNOSTIC INFORMATION EARLY SYSTEMIC THERAPY FOR POOR-PROGNOSIS PTS CONVERSION CHEMOTHERAPY UNRESECTABLE LIVER METASTASES: ALLOW R0 RESECTION VIA DOWNSIZING POSTOPERATIVE (ADJUVANT) CHEMOTHERAPY HEPATIC ARTERIAL INFUSION (HAI) SYSTEMIC TREATMENT
REVERSE APPROACH recently this kind of surgical approach is considered for rectal cancer with synchronous liver metastases the treatment sequence proposed is the following: - systemic chemotherapy followed by liver resection - chemoradiation followed by rectal resection Van der Pool et al, ASCO 2010 abs e14027
Bittoni, Giampieri et al, CROH 2012