A 76-year-old woman presented with an obstructing tumor in the splenic flexure and large synchronous metastases in the right peripheral hemiliver, with some extension to segment IV. A stent was placed to alleviate the emergent obstruction. She then received three months of FOLFOX. Despite showing some evidence of progression of her liver disease while on chemotherapy, she underwent a staged right hepatectomy with left nonanatomical excision, followed by a left hemicolectomy six weeks later. Upon recovery, she will commence postoperative irinotecan-based systemic therapy.
Case Discussion:
DR PRIMROSE: A 76-year-old woman presented with a splenic flexure carcinoma and liver metastasis. A carcinoma of the splenic flexure occurs at the junction of the transverse and the left colon, and it extends to the spleen. It’s a reasonably common site for obstructing carcinomas, for reasons which are not entirely clear. Increasingly, our colorectal surgeons have managed patients who have malignant obstruction with stents, rather than emergency operations. The rationale is that the use of an interventional procedure allows us to perform the surgery electively, rather than when the patient is unwell and obstructed. I think this is probably a sensible approach. It’s particularly appropriate in a patient whose CT has shown that they have both a primary tumor that’s obstructing and liver metastasis, because most of these patients will not be suitable for resection anyway.
This patient was treated with a stent for her obstruction and then received three months of treatment with FOLFOX. Despite progressing on chemotherapy, she underwent a staged right hepatectomy with left nonanatomical excision followed by a left hemicolectomy six weeks later because the patient was well and the disease was significant but operable. Progression on chemotherapy is known from a number of studies to be a bad prognostic feature. Some liver surgeons feel that if a patient experiences progression on chemotherapy, they may not be eligible for surgery.
My unit performs about 100 liver resections a year. The majority of these (about 60) would be for colorectal liver metastases. We certainly examine a considerably larger number of patients with colorectal liver metastases who are not suitable for resection, and do not become suitable after chemotherapy, probably about double the number that we operate on.
The reason we chose the liver first is that her stent was working well — she was having no symptoms from her colon cancer. Furthermore, if it was not possible to remove all her liver disease, the colorectal surgeons would have declined to treat her primary tumor.
After a complete resection of her liver metastases, she made an uncomplicated recovery and subsequently the colorectal surgeons removed her splenic flexure tumor.
We considered performing the procedures simultaneously but decided that the risks outweighed the benefits in view of her age, her general health and the previous chemotherapy. So we decided to stage the procedures. I think that has turned out to be a reasonable strategy, because she has recovered well from both of them and had no complications.
I believe that plenty of evidence now exists that both unilateral and bilateral disease are resectable. Clearly, bilobar disease is sometimes more difficult to resect completely, because an insufficient number of remaining segments for adequate liver function may be present, but we have techniques to deal with this. The two that we commonly use are portal vein embolization (PVE) of the right portal vein — to encourage hypertrophy on the left — and staged resection. For instance, in the first surgery, you might remove the disease from the left liver, allow a few weeks for recovery, and then perform a right hepatectomy. That’s a safe strategy for managing these patients, and it’s worked well for us in many situations.
Postoperatively, she will most likely be treated with an irinotecan-based regimen.
Based on the results of the EPOC trial, our service has moved toward using chemotherapy as an initial treatment approach. In a sense, it makes the treatment scheduling and treatment decision-making a lot simpler. If the patient has colorectal liver metastasis, they receive chemotherapy. If they have advanced liver metastases that are not operable, they receive chemotherapy. If they are potentially or borderline operable, they receive chemotherapy. Basically, everyone will receive chemotherapy and we see what can be accomplished after three months. If they are inoperable, they will be treated to best response and then reassessed by our multidisciplinary team to see if they’re resectable.
Occasionally, we avoid the use of chemotherapy for certain patients, such as the older patient with good-prognosis disease (eg, a solitary metastasis that’s a couple of years out from the primary resection). Frequently, we discuss it with the patients, but most elect to have the liver tumor removed and not receive prior chemotherapy, because often for elderly patients, they tolerate surgery a lot better than they tolerate chemotherapy. You should base your decision on the individual, but the general strategy now is to initiate chemotherapy for all patients.
Rene Adam’s group published data concerning disease progression during preoperative treatment for resectable metastases. Their view is that patients whose disease progresses during chemotherapy have a bad prognosis. I have a patient who is in this exact situation. He received three months of chemotherapy and, on the follow-up scan, had hundreds of metastases in the liver. That patient cannot possibly be curable by an operation. The disease was already there, and he responded poorly to chemotherapy, so I don’t think you’re denying too many patients the possibility of a curative resection by administering chemotherapy first. I believe that it is important to perform a three-month scan, because the possibility exists of offering surgery to patients whose disease is progressing but remains operable. But in general, I think these patients have a bad outlook.
