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

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Case 45:

Discussant: ALAN VENOOK, MD

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Case Description:

A 60-year-old man previously treated with 5-FU and leucovorin presents three years after initial diagnosis. While receiving cholesterol lowering medications, his transaminase levels are elevated as assessed by a routine liver function test. A CT scan showed a solitary, 4-cm liver metastasis in the right lobe and an enlarged porta hepatis node. The patient desired aggressive treatment and received four cycles of FOLFOX with bevacizumab, resulting in shrinkage of both the porta hepatis node and the liver metastasis. He then underwent right hepatectomy, and multinodal biopsies were negative. He received postoperative FOLFOX, but within six months experienced lymphatic recurrence in the iliac, the upper abdomen and had a supraclavicular node.

Case Discussion:

This was a 60-year-old man previously treated with 5-FU and leucovorin for primary CRC. He presented three years after his initial diagnosis with elevated transaminase levels on a routine liver function test during treatment with cholesterol-lowering medications. A PET/CT scan showed a solitary, marginally resectable liver metastasis and a borderline-enlarged porta hepatis node.

The patient wanted to be treated aggressively, so we administered four cycles of FOLFOX/bevacizumab and the porta hepatitis node shrank. The solitary liver metastasis shrank as well. The metastasis was marginally resectable initially but clearly resectable after chemotherapy.

The patient underwent resection of the right liver lobe. Several lymph nodes were biopsied and were returned as negative. The node had been enlarged in the trunk. Postoperatively, the patient received FOLFOX. Within six months of completing FOLFOX, he developed nodal recurrences in the iliac, in the upper abdomen, and had a supraclavicular node.

The patient is still alive a number of years later, but is starting to fail.

Oncologists have different opinions, but I believe that with the involvement of porta hepatis nodes, the horse is out of the barn. That’s based largely on a breadth of literature that precedes the era of FOLFOX/FOLFIRI and the newer agents, so the temptation is to expand on the criteria and be a little more aggressive. I’m not certain that is the right idea.

I think different folks have different opinions. This is another example in which the patients have great interest. A patient may say, “Well, remove the lymph nodes.” Especially when the nodes are negative on resection, we think, “Well, maybe we got away with one.” However, some of us believe it’s a virtual contraindication, and some of us are not sure. I believe if the lymph node is marginal and didn’t change much in size, resecting the patient’s disease is reasonable because you don’t know if the lymph node is malignant or not.

A real dilemma is the lack of absolutes. When discussing the durability of the disease, if the situation is black and white — 100 percent and zero percent — the decisions are made for you. When it’s 95 percent and five percent or in those instances with an unpredicted or unprecedented exception, the decisions are not so clear cut — it’s tough. When making societal decisions, you can be dogmatic, but even if you have the patient in front of you, you don’t know if that patient will be the exception.

In this case, the patient had gone three years from their primary treatment, and it was reasonable to say, “Well, maybe this patient has favorable biology.” It turns out he does. He is alive four years later, but he has metastatic disease and will succumb to metastatic disease.

Time to recurrence is definitely a prognostic factor. As far as being aggressive in resection, I view six months as tenuous — that’s unfavorable. For patients with disease recurrence between one year and 18 months, I think the prognosis is more favorable. To me, recurrence after more than two years is a favorable view and that’s a patient I pull out all the stops for. I am generally less aggressive with patients who recur soon — that’s my approach, but it doesn’t mean the patients will agree with my recommendations.


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