Practical questions in liver metastases of colorectal cancer: general principles of treatment

Abstract

Liver metastases of colorectal cancer are currently treated by multidisciplinary teams using strategies that combine chemotherapy, surgery and ablative techniques. Many patients classically considered non-resectable can now be rescued by neoadjuvant chemotherapy followed by liver resection, with similar results to those obtained in initial resections. While many of those patients will recur, repeat resection is a feasible and safe approach if the recurrence is confined to the liver. Several factors that until recently were considered contraindications are now recognized only as adverse prognostic factors and no longer as contraindications for surgery. The current evaluation process to select patients for surgery is no longer focused on what is to be removed but rather on what will remain. The single most important objective is to achieve a complete (R0) resection within the limits of safety in terms of quantity and quality of the remaining liver. An increasing number of patients with synchronous liver metastases are treated by simultaneous resection of the primary and the liver metastatic tumours. Multilobar disease can also be approached by staged procedures that combine neoadjuvant chemotherapy, limited resections in one lobe, embolization or ligation of the contralateral portal vein and a major resection in a second procedure. Extrahepatic disease is no longer a contraindication for surgery provided that an R0 resection can be achieved. A reverse surgical staged approach (liver metastases first, primary second) is another strategy that has appeared recently. Provided that a careful selection is made, elderly patients can also benefit from surgical treatment of liver metastases.

Microscopic and Macroscopic Tumor and Parenchymal Effects of Liver Stereotactic Body Radiotherapy

“…Thus, as long some threshold volume of normal liver is spared from either radiation or surgical resection, no clinically significant detrimental effect on hepatic function will occur. Occasionally, before surgery, portal vein embolization is used to cause compensatory hypertrophy of the uninvolved liver lobe to increase the hepatic reserve (19,20). This might be reasonable to consider when planning radiotherapy for patients with a borderline hepatic reserve, although the addition of portal vein embolization will convert a noninvasive treatment to an invasive one, albeit a minimally invasive one compared with liver resection.…”

Liver Regeneration in Surgical Animal Models – A Historical Perspective and Clinical Implications

“…Furthermore, as part of the emerging multimodal three-stage treatment of colorectal metastases [2], surgeons may now embolize the portal vein before performing large resections in order to stimulate liver hyperplasia in the remnant to be. By this, one may avoid postoperative liver failure, acknowledging that diverting portal flow away from one side to the other results in the ‘parenchymal shift’ described by Rous and Larimore [17] in 1920.…”

“…Despite continuous improvement in the surgical technique and perioperative intensive care, some patients still experience deficient regeneration and functional failure in the so-called SFSS occurring after liver transplantation if the graft is of marginal size (graft weight/body weight ratio <0.8%) [3], or if the liver remnant is too small after extended hepatectomy (<25% functionally normal liver remaining) [2]. Postresectional liver dysfunction is also a problem with the increasing use of neoadjuvant chemotherapy for colorectal metastasis [4].…”

“…Modern liver surgery has seen the development of split-liver grafting [1] and more aggressive, multimodal treatment of primary and secondary liver malignancies, increasing the possibilities for resection [2]. Despite continuous improvement in the surgical technique and perioperative intensive care, some patients still experience deficient regeneration and functional failure in the so-called SFSS occurring after liver transplantation if the graft is of marginal size (graft weight/body weight ratio <0.8%) [3], or if the liver remnant is too small after extended hepatectomy (<25% functionally normal liver remaining) [2].…”

Systematic review of resecting primary tumor in MNETs patients with unresectable liver metastases

“…The impact of primary tumor removal on metastatic disease is controversial in multiple neoplasms including those of the gastrointestinal tract [33, 34]. Some argued that growth rate of liver metastasis would increase due to post-operative immunodeficiency [35, 36], and this adverse effect could also apply to MNETs. Apart from the study of Givi et al .…”