A 65-year-old woman presents four years post-right hemicolectomy with adjuvant FOLFOX for a Stage III ascending colon adenocarcinoma. Routine follow-up CT reveals a 3-cm lesion in segment V of the right liver with no visible extrahepatic disease. She underwent exploratory celiotomy and liver ultrasound confirmed only the solitary liver lesion. However, palpation of the porta hepatis suggested several hard lymph nodes. A 0.5 node was sent for frozen section and returned positive for adenocarcinoma. The patient was surgically closed without removal of liver lesion or nodes. After two cycles of systemic therapy for Stage IV disease, follow-up CT confirmed two new lesions in the liver.
Case Discussion:
DR PETRELLI: This was a 65-year-old woman who underwent a right hemicolectomy for a Stage III ascending colon adenocarcinoma and received adjuvant FOLFOX. She presented four years later because a routine follow-up CT scan revealed a 3-cm lesion in segment V of the liver with no extrahepatic metastases.
She underwent exploratory celiotomy, and liver ultrasound showed only the single lesion. The ultimate imaging method is intraoperative ultrasound. I’m concerned about surgeons who are performing liver resections without using an intraoperative ultrasound to explore for additional lesions or extrahepatic disease. Not performing an intraoperative ultrasound on resectable disease is malpractice. The preoperative imaging includes contrast-enhanced CT scanning, and in scenarios in which we’re a little concerned about whether a lesion is present, we will move to MRI. We also use PET/CT for all patients. PET/CT is important when you’re evaluating a patient for hepatic resection, and especially to document whether they have any extrahepatic disease or not.
On palpation of the porta hepatis, several hard lymph nodes were discovered. A node sent for frozen section examination revealed adenocarcinoma, consistent with her primary tumor from four years ago. Surgery was abandoned, and she started systemic treatment with chemotherapy. After receiving two or three cycles of chemotherapy, her CT scan showed an additional two lesions in her liver, so she was switched to FOLFIRI for a prolonged period of time. She then developed pulmonary metastases, and was entered into a Phase I clinical trial. In my mind, patients who have extrahepatic disease — unless they are participating in a clinical trial — are not candidates for resection of the liver. Instead, they should receive systemic chemotherapy. Several of my colleagues don’t feel that way, but nothing definitive in the literature shows that these patients benefit from resection with chemotherapy as opposed to systemic chemotherapy alone, in which the survival can be as long as 22 months.
My decision to resect liver metastases in patients with extrahepatic disease depends on a number of factors. It depends on the number of lesions in the liver, but I wouldn’t object to taking a patient with extrahepatic disease and administering several cycles of chemotherapy. If disease progresses during those cycles of chemotherapy, I saved them from an unnecessary operation. If they respond either in the liver or in the lung, then I’m more enthusiastic about resection because I know that I can treat with the same chemotherapy postoperatively, as it has shown to be effective preoperatively. In patients with liver and pulmonary disease, I would lean a little bit more towards the perioperative chemotherapy approach.
Patients with resectable disease who respond to the preoperative chemotherapy fare better than those whose disease may progress during chemotherapy, but are still resectable. Patient’s survival is better if they respond and their disease is resected, than if their disease progresses and is resected.
