A 70-year-old man who is a smoker with a history of Stage II cecal adenocarcinoma treated four years prior via hemicolectomy (no adjuvant therapy) now presents. Surveillance CT identifies two lesions in the liver — a 3-cm mass in segment III of the left lobe and a 4-cm mass in segment VII of the posterior right lobe — but no extrahepatic disease. He was considered to be a candidate for surgical resection of his bilobar disease. Intraoperative ultrasound uncovered one additional 1-cm lesion in segment II, but no periportal nodes. A left lateral left segmentectomy was performed in addition to removal of segment VII. He completed six cycles of postoperative FOLFOX and currently has no evidence of disease.
Case Discussion:
DR PETRELLI: This was a 70-year-old Caucasian man who presented four years after a right hemicolectomy for a Stage II cecal adenocarcinoma with no adjuvant therapy. He now had two lesions in the liver: a 3-cm lesion in Bismuth segment III and a 4-cm lesion in segment VII on CT scan.
As people age, their organs age — their hearts, kidneys and brains have been there longer. So you perform workups for these individuals, especially a smoker, to make sure that they’re going to have the lung reserve to undergo major surgery. You ensure that they have good kidney function, have stopped smoking and are in reasonable shape because you want to minimize the complications. A smoker — especially a smoker with a 20 pack-year history — would have a higher risk for postoperative pneumonia, so you have to be more aggressive with individuals like this, telling them how important it is to work on their lungs postoperatively, use spirometers to expand their lungs, early ambulation even more so — getting them up and walking around. These are important aspects of any type of surgery, but especially important in liver surgery.
I take age into consideration, not merely age alone. I also consider the past medial history of the patient and obviously the condition of the other major organs in the body like the lung, the brain and the kidneys. In today’s day and age, major operations are done in the octogenarian. Patients are out there who are candidates for liver resection, but they don’t see the surgeons. They end up seeing oncologists who feel that 70-year-old patients with two lesions in the liver are not candidates for surgery. It’s a failure on our part to educate.
This patient had two lesions in the liver that were not strategically located on CT. Because the CT was not of the best quality, we repeated it. We must ensure that there are no reasons — such as significant comorbid conditions, unfavorable findings from lung function tests or extrahepatic disease — not to proceed with the surgery. Even though the preoperative imaging showed only two lesions, he had a 12 to 15 percent chance of having additional lesions in the liver when we conducted the intraoperative ultrasound. The patient understood the possibilities and so we prepared him for surgery.
In general, you can remove about 80 percent of the liver. The liver is the only organ in the body that will grow back to approximately its normal size. However, the 20 percent that we leave behind must be normal liver. If a patient has cirrhosis or has had previous chemotherapy, that 20 percent will not be enough. This patient was not an alcohol user or abuser and he didn’t receive any adjuvant therapy beforehand, so we could remove up to 80 percent of his liver, if we had to. You can conduct volumetric measurements based upon the amount of liver that you’re removing to calculate the amount of functional liver that will remain. In this particular individual, we did not do that because we only had two lesions, and we knew we would have enough liver left behind. The threshold for which you use volumetric studies varies depending on the disease characteristics and whether or not they associated disease in the liver.
During surgery, we ruled out extrahepatic disease and made sure that no positive lymph nodes were present in the porta hepatis area or anywhere else, mobilized the liver, palpated and inspected the liver and performed an intraoperative ultrasound. We indeed found the 3-cm lesion in segment III, the 4-cm lesion in segment VII and we also found a 1-cm lesion in segment II — an additional lesion that wasn’t seen on the preoperative CT. So we ended up with three lesions. We performed a left lateral segmentectomy and then removed segment VII. He was discharged from the hospital in about a week, and had no evidence of disease as of six months ago. He received six cycles of FOLFOX postoperatively for six months. He experienced some neuropathy, and we adjusted his chemotherapy and he fared well.
The gold standard for treating hepatic metastasis on colorectal cancer is hepatic resection. The silver or the bronze standard is radiofrequency ablation (RFA). I would never use RFA for a patient who has a resectable lesion and is a candidate for surgery. Hepatic surgeons who don’t have the experience to perform hepatic surgery fall back on RFA and that’s a disservice to the patient.
I think RFA is an option at times. For example, if you have numerous lesions, you may have to resect some and use RFA for others because you must leave functional liver behind. So you have to be careful. RFA is an option, but not with potentially resectable disease as long as you can leave functional liver behind, and maybe that’s the qualification. Because in general, you’ll end up taking out more functional liver with a resection than you will with an RFA. With RFA, there is a higher potential to leave more viable disease behind.
