The latest changes in surgery of liver metastatic colorectal
cancer. Preoperative evaluation of the patient with hepatic
metastases Treatment of liver metastatic colorectal cancer
Surgical, chemotherapy and biological.
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General Information Colorectal cancer (CRC) is the third most
commonly diagnosed cancer in the United States. CRC is the
second-most common cause of cancer death in western countries.
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In approximately 50% of patients with CRC liver metastatic, the
metastatic disease is confined to the liver. The liver is the most
frequent site of metastasis in CRC, both at the time of diagnosis
(2025% of cases) or after an apparently radical surgery on the
primary tumor (40% of cases).
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0 1 2 3 4 5 100 50 0 % surviving Years after diagnosis of
colorectal metastases 3% 19881998 Rougier P et al. Brit J Surg 1995
1928 0% 1943 First hepatectomy for colorectal liver metastasis 1957
Introduction of 5-fluorouracil
The Benefits and Side effects of Surgery Recent reports- 5
years overall survival >28%. Low mortality-1.5% (high volume),
and 9.6% (low volume) but higher morbidity- 15-30% : hemorrhage,
abscess, bile leaks, hepatic failure.
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Hepatic resection for colorectal metastases, limited to the
liver, has become the standard of care. Surgery currently remains
the only potentially curative therapy.
Preoperative Evaluation of the Patient with Hepatic Metastases
Easily resectable disease Initially unresectable disease
Unresectable
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Defining Resectability Criteria for surgery Imaging.
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Old approach criteria for surgery(1989, Steele et al): Less
then four lesions in the same lobe. Maximum lesion dimensions
Current approach for liver surgery New approach criteria for
surgery(2006,Vauthey et al): Complete Radical resection(less then
1cm margin). Preservation of two adjacent liver segments. adequate
vascular inflow and outflow and biliary drainage can be preserved
Future liver remnant(total volume>20%). Aggressive approach More
then one hepatectomy Resecting metastases in other sites as
well(lungs, adrenal etc)
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Contra-indications: Radiographic evidence of involvement of the
common hepatic artery, common hepatic or common bile duct, or main
portal vein Extensive liver involvement (>70 percent, more than
six segments, or involvement of all three hepatic veins) Inadequate
predicted post resection functional hepatic reserve
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Normal Underlying Liver 20% of TLV Kubota, Hepatology 1997
Azoulay, Ann Surg 2000 Abdalla, Arch Surg 2002 Vauthey, Ann Surg
2004 High Dose Chemotherapy 30% of TLV Chronic Liver Disease 40% of
TLV Azoulay, Ann Surg 2000 Adam, Ann Surg 2004 Liver Remnant
Volume
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Liver Volumetry
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Minimized the postoperative mortality- preserving a liver
remnant that is >20% of the total liver volume. pre-operative
portal vein embolization (PVE) to initiate compensatory hypertrophy
of the future remnant liver. Atrophy of embolized lobe. Hypertrophy
of non embolized lobe- Increasing Remnant liver. More potential
surgical candidates Preoperative portal vein embolization
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Imaging CT CT is the staging modality most widely used in CRC
Widespread availability and relatively low cost in comparison with
MRI or PET/CT. In a study with surgically proven liver lesions, a
sensitivity of 69% to 73% and a specificity of 86% to 91% was
shown.* Limitations: steatosis, lesions smaller than 1 cm,
Hemangiomas. *Kamel et el.J comput 2003, Kinkel et el. Radiology
2002, Bhattacharjya et al.Br J Surg. 2004.
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Imaging FDG-PET/CT Evaluation of patients with known or
suspected recurrent colorectal cancer. Most sensitive method for
detecting extra-hepatic disease in patients with CLM. Alters
surgical management in 23% to 29% of patients. Measures the
responsiveness of the tumor to preoperative treatment. For hepatic
lesions compared with CT, it has a Sensitivity - 91100 % and
Specificity- 75-100% (Patel S et el. Ann Surg 2011). Limitations:
Correlation of pathological response and metabolic response,
detecting lesions smaller than 1 cm, expansive.
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Imaging MRI Sensitivity 81.1% and specificity of 97.2%.
mangafodipir trisodium imaging has a sensitivity of 100%, a
specificity of 92%. Better sensitivity with patients that have
steatosis, lesions smaller than 1cm. Best preoperative imaging
technique for CLM detection, but not used routinely. Used to
differentiate metastatic findings from benign findings such as-
cysts, adenomas, and hemangiomas. Limitations: length of the scan
time, patient compliance and higher costs.
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Imaging US Widespread availability. Sensitivity is in the range
of 36 to 61% in small liver lesions. Limitations: lesions> 2cm,
experience of the operator, impaired accuracy with: obese patients,
liver steatosis. Used for surveillance and liver lesion
biopsy.
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Imaging- Intraoperative US Intraoperative US- most sensitive
technique for detecting liver lesions (sensitivity 93 to 94%).
Discovers 25 30 % new lesions. May change planning of the
operation.
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Imaging- Summary CT scan is an essential tool in the optimal
imaging of the majority of CLM. MRI : for patients with liver
damage owing to prolonged treatment or co-morbidities. For lesions
smaller than 1cm, the sensitivity estimates for MRI were higher
than those for CT. (Niekel et al 2010). PET/CT is extremely useful
to exclude extrahepatic disease. Intraoperative evaluation by IOUS,
mandatory in all patients undergoing surgical resection of
CLM.
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Overall survival in advanced colorectal cancer in 2008: The
impact of multi-disciplinary management 0 1 2 3 4 5 100 50 0 %
surviving Years after diagnosis of colorectal metastases 2008
chemotherapy Median survival >24 months 5 year survival 9 %
3%
Radiofrequency ablation (RFA) Needle probe under image guidance
generating heat and thus destroying the interstitial. Temperatures
>60 results in cell necrosis
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Others Cryosurgery Yittrium 90
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Hepatic resection for colorectal metastases that are limited to
the liver is a standard of care. Preoperative Evaluation of the
Patients is vital. Each patient needs a different care. The future
is promising.