An otherwise healthy 63-year-old Caucasian man with a prior history of lymph node-positive colon adenocarcinoma, treated with left hemicolectomy and completed adjuvant FOLFOX, presents three years postdiagnosis with a serial rise in CEA levels and CT scan evidence of a 4-cm lesion located within segment VI of the right lobe of the liver. The patient underwent immediate complete surgical removal of segment VI and did not receive any pre- or postoperative systemic therapy for this single resected hepatic lesion.
Case Discussion:
DR PETRELLI: This was an otherwise healthy 63-year-old Caucasian man who initially presented three years prior with a lymph node-positive colon adenocarcinoma, underwent a left hemicolectomy and completed adjuvant FOLFOX. He is now routinely monitored, which has revealed a serial rise in CEA levels. CT confirmed a single resectable 4-cm unilobar lesion in segment VI of the liver.
Eight segments in the liver were found including a caudate lobe. As surgeons, we usually speak in terms of these segments. Think of the liver being divided into the right and left lobe. The lobes are divided by a line called Cantlie’s line, which runs from the left side of the vena cava to the middle of the gallbladder fossa at about a 70 degree angle. You cannot see the line in surgery, although I draw it at the time of surgery. The left lobe of the liver is divided into two segments: the median and the lateral segment. The lateral segment has two subsegments known as segments II, and III, and the medial segment is called segment IV. The right liver includes anterior and posterior segments divided by the right hepatic vein. The posterior segment includes two subsegments: segments VI and VII. The anterior subsegments are segments V and VIII. The segments are based upon the distribution of the portal vein. The anterior and posterior segments of the right lobe are defined by the anterior and posterior tributary of the right branch of the portal vein. The left branch of the portal vein sends blood to the medial and lateral segments (ie, segments II, III and IV). In this day and age, you can resect individual segments without taking out the entire lobes or major segments. There are basically three hepatic veins: a left, middle and right hepatic vein. The location of the lesion in relation to those outflow tracts — those hepatic veins — will affect the type of resection that one needs to perform.
This patient’s lesion was right in the middle of segment VI and was located toward the inferior edge of segment VI. Because it was four centimeters in size, some of my colleagues may have chosen to wedge it out, but I felt safer taking out segment VI because I was concerned about getting a positive margin. No evidence of disease was observed outside the liver prior to surgery and so I felt that this was resectable from the beginning.
I tell patients that potential complications are associated with this kind of surgery. The liver is a vascular organ and even though we have techniques today to control bleeding, bleeding is certainly still an issue. The potential for infection in any surgery always exists, but especially in liver surgery. I also explain that bile can leak from the liver and you have bile ducts in the liver aside from vessels. These complications can occur in as many as 15 to 25 percent of patients with a low mortality rate.
If a patient with a lesion in one segment of the liver asked me their probability of survival, I would say that disease-free survival — in general in the literature — ranges from 30 to 40 percent at five years. Most of the literature quotes, if you will, the overall survival being anywhere from 30 to 50 percent, which is a large range because the survival has increased over time — new techniques are used to control hemorrhage and resection techniques have improved. If you take less of the liver out, the complications rate is lower.
The first thing we perform is an exploratory celiotomy, also called a laparotomy, to explore the abdomen to ensure that no extrahepatic disease is present. If the patient has extrahepatic disease, then “the cow’s already out of the barn,” and the resection is abandoned in favor of systemic therapy. After extrahepatic disease is ruled out, you palpate the liver and examine all of the organs. You inspect the liver, mobilize it and perform an intraoperative ultrasound to make sure that no other lesions are present. You examine the lesion’s relationship to the vessels. If everything is as expected, you proceed with the resection.
I told the patient that we find additional liver lesions in about 10 to 15 percent of patients but that is a little less likely in someone with only a single liver lesion. The patient underwent a segmentectomy of segment VI and fared well. He is still alive today with no evidence of disease.
I did not consider the use of preoperative systemic therapy. The EORTC trial data were not available at the time, and I am not a tremendous advocate of perioperative therapy. The patient did not receive adjuvant therapy after resection, although the team I work with now would probably recommend six months of adjuvant therapy. Which regimen is best for a patient like this is controversial as three years prior he received adjuvant treatment with FOLFOX. I would not object to administering either FOLFOX or FOLFIRI because it is in the postoperative setting.
Conversion chemotherapy should be used for patients with borderline resectable disease. I would use perioperative chemotherapy if a tumor was in close proximity to critical vessels — like the outflow tract of the liver — to downsize the lesion and obtain a negative margin. In that situation, I would use the perioperative EORTC protocol. I rarely recommend perioperative therapy unless the metastasis was borderline resectable — otherwise I proceeded with surgery.
In my Journal of Clinical Oncology editorial, I explain why I object to the use of perioperative chemotherapy for patients with risk factors related to their normal liver parenchyma (ie, obesity, severe diabetes, cirrhosis). We know that obese patients can have steatosis or steatohepatitis. In those individuals — especially if that have resectable disease up front — I object to administering perioperative chemotherapy because chemotherapy is toxic to the normal liver, and compounds the rate of postoperative complications in the obese, diabetics and those with cirrhosis.
It is important to clarify the various terms used to define systemic therapy for these patients. Neoadjuvant therapy usually refers to administering chemotherapy preoperatively for patients with resectable disease. In the perioperative setting, you treat with chemotherapy both pre- and postoperatively. Adjuvant therapy is received only in the postoperative setting. I fail to see a role for the use of neoadjuvant therapy for patients with initially resectable disease.
