An educational tool to assist in the management of hepatic metastases in patients with colorectal cancer

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Case 3:

Discussant: ALAN VENOOK, MD

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Case Description:

A 60-year-old patient presents with rising CEA levels, three years after resection of a Stage II primary CRC treated without adjuvant therapy. PET/CT scans indicated a 2-cm lesion in the right liver lobe centrally and a 0.5-cm lesion in the medial left liver lobe. Preoperative chemotherapy was discussed, but due to the patient’s concern of disease progression and surgical challenges associated with disappearance of a smaller lesion, immediate surgery was recommended. The patient underwent right lobectomy and ablation of the left medial segment lesion followed by 12 cycles of FOLFOX.

Case Discussion:

This was a 60-year-old patient who presented with an elevated CEA level approximately three years after resection of a Stage II primary tumor treated without adjuvant therapy. A PET/CT scan showed a 2-cm resectable lesion in right liver lobe and a 0.5-cm ablatable lesion in the left liver lobe.

This was a tough case because of the bilobar lesions — one could be resected and one could be ablated. We struggled about whether to perform the operation immediately or if we should administer chemotherapy first. The other issue for this patient was that the lesion in the left lobe was small. So we were concerned that if the lesion disappeared, we would not be able to find it during surgery. We were going to remove the right lobe, so we knew we would remove that disease. A lot of the decision was based on the patient’s preference who wanted the metastases removed right away. We talk about a neoadjuvant strategy as if patients are always going to be amenable to it. This patient said, “What do you mean you’re going to administer chemotherapy? What if the chemotherapy doesn’t work and this becomes the horse that gets out of the barn?”

This patient underwent an immediate resection with a right lobectomy and an ablation of the lesion in the left medial segment, and then we treated with FOLFOX for 12 cycles. The patient is alive and well at this time, approximately 2.5 years after the completion of therapy.

Our philosophy is that RFA is the second choice to resection. In combination with resection, it’s something we’ll often use as an alternative for a patient that has bilobar disease with inadequate resection margins on each side of the liver.

It’s believed that in combination, for a smaller lesion that is less than two centimeters, reliable margins are obtained with open RFA. On the other hand, as the tumor size increases to three, four or five centimeters, RFA is going to fail too often.

For example, with a small lesion in the left medial segment, under direct visualization with ultrasound, you may be confident with such an alternative. One of the things we do not perform is percutaneous ablation. Also, if in the eyes of the surgeon, the patient has resectable disease, it’s important to reiterate that we don’t perform ablation.

Many interventional radiologists have the technical ability and knowledge to perform percutaneous ablation. Percutaneous ablation is performed by ultrasound guidance through the skin. Our belief is that it’s simply unacceptable — the exception is that rare instance in which percutaneous ablation may be appropriate due to the failure rate that would be encountered without performing the procedure, in which much poorer visualization of the liver in the margin would be obtained. It’s a less evidenced-based procedure that is generally performed by the interventional radiologist, and is not normally performed at a larger tertiary center. Some oncologists believe that these willy-nilly ablations are helpful, but we simply view such ablations as totally unacceptable, except in rare instances where we’d consider it.


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