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

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Case 7:


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Case Description:

An obese, insulin-dependent diabetic 55-year-old man presents two years status post resection of Stage II sigmoid cancer. During a routine follow-up, CT reveals four lesions scattered throughout the right lobe of the liver, ranging in size from two to four centimeters. He was not offered preoperative chemotherapy, given his risk factors for liver insufficiency. An intraoperative frozen section of a normal appearing liver biopsy revealed evidence of mild steatosis. A right hepatic lobectomy was performed, removing segments IV, V, VI and VII. The patient declined postoperative chemotherapy.

Case Discussion:

DR PETRELLI: This was an obese 55-year old Caucasian man with insulin-dependent diabetes who presented 2 years (4 years?) after a sigmoid resection for Stage II colon cancer. During a routine follow-up, a CT scan revealed four bilobar lesions ranging in size from two to four centimeters.

Although several of my colleagues would have recommended conversion therapy with perioperative chemotherapy, I recommended an immediate resection because his obesity and diabetes put him at risk for steatosis or steatohepatitis, which also can be caused by agents like oxaliplatin. Because he was obese and had insulin-dependent diabetes, I conducted a frozen section examination on what appeared to be normal liver to confirm the degree of steatosis or steatohepatitis. Pathology described it is as mild steatosis. I proceeded to conduct a right hepatic lobectomy and removed segments IV, VI and VII.

This was a mild form of steatosis, so I felt that the patient could tolerate the right hepatic lobectomy. Drawing on my experiences over the years, I felt that this patient would be at a relatively low-risk for complicationsafter a right hepatic lobectomy. The reason I chose the right hepatic lobectomy was that the lesions were located over those four segments of the liver — they weren’t strategically located in one or two segments. They were scattered throughout those four segments. So again, it was safer to go ahead and perform the right formal hepatic lobectomy. If the patient had severe steatosis, I would have considered the use of RFA.

Although the patient had mild steatosis, we felt comfortable administering adjuvant chemotherapy because it was in the postoperative setting. The patient declined chemotherapy.


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