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

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Case 24:

Discussant: RENE ADAM, MD

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Case Description:

A 50-year-old man with rectal cancer and synchronous hepatic metastases underwent a low anterior resection of the primary cancer and received postoperative FU/leucovorin resulting in disappearance of his liver lesions. One year later, he presented with bilobar liver only recurrence (one large lesion in segment VII and multiple small metastases in the left lobe). Deeming his disease unresectable in a single procedure, he was treated with eight cycles of FOLFOX and experienced stabilization of disease. The decision was to proceed with a two-stage hepatectomy, including left lateral lobectomy with right PVE, followed by intercurrent chemotherapy and subsequent right liver resection (with adequate hypertrophy of residual segments I and IV). He received additional postoperative chemotherapy.

Case Discussion:

This was a 50-year-old man with a primary rectal tumor and synchronous bilateral hepatic metastases. After a low anterior resection of the primary rectal tumor, he received 5-FU/leucovorin. One year later, five liver metastases reappeared in the liver. Because this patient’s tumor was initially considered nonresectable, he received eight courses of FOLFOX. The patient required a right hepatectomy in addition to a left lobectomy, so the remnant parenchyma would have been the central part of the liver, representing less than 30 percent of the total liver parenchyma. After treatment with FOLFOX, his disease stabilized. At that time, we decided the only possible surgical option would be a two-stage hepatectomy.

He needed a right hepatectomy because one of the tumors was located between the two branches of the right portal branch, and he needed the left lobectomy because three lesions were present in the left lobe of the liver. The first stage included a left lobectomy, and a right portal ligature with embolization. After the procedure, there was no more left lobe. Due to the embolization of the right portal branch, segment IV and segment I became hypertrophied. The right liver became relatively atrophic. Three metastases were found, and chemotherapy was continued. During the second stage of the procedure, the right hepatectomy was performed, and we found four additional metastases. The patient then received six additional courses of FOLFOX.

When a lesion is touching an important vessel of a hemiliver, it is usually a reason to sacrifice the hemiliver. If the remnant liver — the comparative liver — is relatively safe, it’s a good indication to perform a portal embolization.

Ideally, embolization is used when you have no lesions in the remnant liver. Unfortunately, in the majority of cases, a lesion often comes in contact with an important vessel of both lobes. When you occlude the portal system of the hemiliver, the other lobe will undergo hypertrophy because of growth factor, but growth factors may also act on the metastasis, possibly to a greater extent compared to the normal parenchyma. Therefore, you may perform hemihepatectomy without portal embolization if your remnant liver is sufficient.

Because the majority of patients have bilateral lesions, we first remove the lesion in the left liver, which is always less affected by the disease. At that time, we performed right portal embolization.

Ten months after the hepatectomy, the patient developed a left lung metastasis. He was retreated with three courses of FOLFOX, and underwent a pulmonary wedge resection in October 2003. In February 2004, a liver metastasis was found on segment IV, so a third hepatectomy was performed. In January 2006, he developed a new endobiliary metastasis that was deemed unresectable, six years after the diagnosis (3.5 years after the first hepatectomy, two years after the third hepatectomy). The patient is probably deceased at this time.

Keep in mind that 60 to 70 percent of patients present with a recurrence. Of these, I would estimate that from one-third to one-half of patients will undergo repeat hepatectomy. At this time, one of two patients in the operating program of our institution is undergoing a repeat hepatectomy.


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