Referring Physicians >> Newsletters >> September 2012 Liver Newsletter >> Clinical Scenario: Colorectal Liver Metastases
A 41-year-old male presented with obstructed sigmoid colon cancer. CT scan performed preoperatively showed bilateral liver metastases with the largest lesion 6 cm in size. Following urgent resection of his primary tumor, he was found to have a T3 N1 M1 tumor. Because of the bilateral nature of his tumors (Nov CT), he was started on preoperative neoadjuvant therapy after consultation with HPB Surgery and Medical Oncology. He was enrolled in protocol CALGB 80405 with FOLFOX and bevacizumab.
The patient responded well to therapy, with a decrease in size of the liver metastases (April CT scan). The lesion in segment 2 & 3 markedly decreased, such that it was not visible on preoperative imaging. Because of the extent of his tumors, it was clear he would need an extended right hepatectomy and left sided wedge resection for complete tumor clearance. He underwent liver volumetric studies. Based on the study, his liver segments 1, 2, & 3, his remnant liver, was only 22% of his total liver volume.
We increased the size of his future liver remnant through the use of portal vein embolization after clearing his remnant liver (segments 1/2/3) of all sites of tumor. He underwent staging laparoscopy with a laparoscopic wedge resection of the small lesion in segments 2/3, followed immediately by portal vein embolization the next day. Four weeks after this, he had repeat evaluation of his liver volume, which showed his remnant liver grew to 32% of his functional liver volume. He was taken to the operating room and underwent extended right hepatectomy removing the remainder of his liver (segment 4-8).
The pathology on the laparoscopic wedge resection showed necrosis without residual carcinoma, and on resection of his right liver, he had near complete residual reduction of tumor with < 0.5% residual carcinoma in the tumors. He did well post operatively and continues to show no evidence of recurrent disease.
Evolving technology for colorectal liver metastases has allowed us to extend resection to patients who previously would not be candidates. The partnership of medical oncology, interventional radiology, and surgical oncology has been immensely important for expanding operative interventions for these patients. The use of portal vein embolization to treat patients with borderline hepatic function following major hepatectomy has allowed us to extend surgery to patients with diffuse bilateral metastases.
Whenever possible, we attempt to utilize laparoscopic resection in order to decrease the morbidity of these procedures. In addition to portal vein embolization, we can also utilize local tumor ablation techniques, primarily microwave ablation, which allows us to combine resection and ablation to treat bilateral disease. Since it is unlikely that chemotherapy will completely sterilize metastases from colorectal cancer, it is preferred to resect all tumors which were present on the initial CT scan, prior to initiation of neoadjuvant chemotherapy.
The length of treatment with neoadjuvant therapy has to been carefully weighed with the multidisciplinary team – balancing the risk of liver dysfunction from chemotherapy with the advantage of downstaging tumor. In general, we prefer a short course of neoadjuvant therapy (3 months) for patients with multiple bilateral liver metastases, in order to assure there is no evidence of new metastatic disease, and to assess the response to therapy.
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