A 72-year-old woman presented five years after preoperative chemoradiation therapy and an abdominal perineal resection for a T3N2 adenocarcinoma, complaining of right upper quadrant discomfort. CT showed eight bilobar liver lesions ranging from two to five centimeters in size. The patient completed two cycles of preoperative FOLFOX and had a complete imaging response in the two lesions in the left lateral segment, while the remaining six lesions located in the right posterior lobe all decreased in size. She proceeded to right posterior segmentectomy (segments VI and VII). The left lobe lesions, which had disappeared on imaging, were biopsied for frozen section. Microscopic tumor was confirmed, and a left lateral segmentectomy was performed. The patient then completed six cycles of postoperative FOLFOX.
Case Discussion:
DR PETRELLI: This was a 72-year-old woman who received preoperative chemoradiation therapy and an abdominal perineal resection for a T3N2 adenocarcinoma five years earlier and now presented complaining of right upper quadrant discomfort. A CT scan showed eight bilobar liver lesions ranging from two to five centimeters in size.
She was treated with two cycles of FOLFOX. Two lesions in the lateral segment of the left lobe showed a complete imaging response, while the remaining six lesions — all located in the posterior segment of the right lobe — decreased in size. I felt that with that response, we could now resect these lesions.
I felt that this patient’s disease was not initially resectable because of the amount of liver initially involved, even if I ended up performing portal vein embolization (PVE). Looking at her CT scan, conversion therapy was an option for this patient to downsize lesions and potentially save some normal liver.
Because she had bilobar disease, we did not perform PVE. When you embolize the portal vein, the contralateral lobe of the liver undergoes hypertrophy, so an increase in the residual or remaining liver volume occurs. You increase the volume of normal liver. This is done when you’re concerned that the remaining liver volume will be inadequate, so you want to hypertrophy the remaining lobe.
I emphasized to the patient that we would perform an intraoperative ultrasound and attempt to remove the lesions but that only 15 percent of patients who we attempt to convert ultimately undergo resection because there is a good chance that additional lesions or extrahepatic disease will be found. At that point, he would have been continuously treated with FOLFOX.
For this patient, we were able to rule out extra-hepatic disease, and confirmed the six lesions in segments VI and VII. No lesions were present in segments V and VIII, which is the anterior part of the right lobe of the liver. We performed a posterior segmentectomy on segment VI and VII. We also biopsied residual scar tissue for frozen section examination from the two lesions in the lateral segment of the left lobe — which had disappeared on imaging — and found viable tumor. Therefore, we performed a left lateral segmentectomy leaving behind the medial segment of the left lobe of the liver and the anterior segment of the right lobe of the liver.
We recommended continuing FOLFOX postoperatively, so she received six cycles postoperatively and fared well.
In patients with liver metastases who are treated with chemotherapy with targeted agents, and consequently have a complete imaging response on CT, the data have shown that 80 percent still have disease in the liver even though you can’t see it on imaging.
It is rare to achieve a complete pathologic response with the agents that we have today. We were fortunate in this individual because we could see a residual scar — many times, you can’t even see anything in the liver, but in this patient there was a residual scar. In my mind, even if the imaging shows a complete response, you still have to remove those areas of the liver — otherwise you’re going to leave tumor behind in those patients. A couple of months down the line, the tumor’s going to show up and people are going to say that’s a recurrence, but in actuality, it was residual cancer.
