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

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Extrahepatic Disease Resection

Resection in patients with extrahepatic disease



In my mind, patients who have extrahepatic disease are not candidates for resection of the liver, unless they are participating in a clinical trial. 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 in combination with chemotherapy as opposed to systemic chemotherapy alone, where the survival can be as long as 22 months.

In the rare instance when I do consider liver resection in a patient with extrahepatic disease, my decision 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 the 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 administer 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 toward the perioperative chemotherapy approach.


Timing of resection for hepatic and extrahepatic metastases

Commentator: STEVEN CURLEY, MD


In this patient, the liver resection was done ahead of the pulmonary metastasis resection because I was more concerned about the liver metastases. The larger of the two liver lesions encroached on both the right and the middle hepatic vein, necessitating an extended right hepatectomy. It would not have required much growth for the left hepatic vein to have been involved as well. We did not want to risk the possibility that this patient’s disease could progress during systemic chemotherapy, causing a missed window of opportunity for resection. So, we did the resection of the liver lesions first, allowed him to recover, then did chemotherapy. The lung lesion was small and asymptomatic — only about 2 to 2.5 centimeters in size at presentation. It was the large liver metastases that were our gravest concern initially. At times, we resect the lung and the liver at the same time. In this patient’s situation, based on the volume of resection, we felt that a combined approach was not feasible.


Curability of patients with colorectal cancer and hepatic and/or pulmonary metastases

Commentator: DANIEL HALLER, MD


Certainly, colon cancer is notable for having a reasonably large number of patients who are curable with metastatic disease. Although this clinical scenario may be less common among other tumor types, we we are extending our indications for curability by asking, “Why should we not attempt to do something?"

We know that patients with limited liver metastases can be cured with surgery alone. The second most likely location for colorectal metastases is the lung, and now we even have a cure rate for patients who have a solitary pulmonary nodule, or even a few nodules. The real question is whether we can cure patients who have both pulmonary and hepatic metastases. Are they biologically an incurable situation, or do they appear to be incurable simply because we don’t treat them surgically and, therefore, the inevitable happens and their disease progresses, typically on single-agent chemotherapy? I believe we are rewriting history.


Rationale for up-front surgery in patients with resectable pulmonary lung metastasis

Commentator: DANIEL HALLER, MD


In the past, I might have administered preoperative chemotherapy to a patient with a resectable lung metastasis. Then, if the patient experienced a complete response, I would ask the thoracic surgeon, “Aren’t you proud of me? Can you remove it?” However, the surgeon’s response would have been, “Remove what?”

While a complete response in the liver is desirable, the lung is a different organ. First of all, the liver is a fixed organ with segments, so if the lesion was in segment seven, even if it disappears, the surgeon can remove segment seven. Secondly, the liver regenerates.

With lung metastases, if the patient has a single nodule, the surgeon can probably perform a wedge resection, but if he can’t find it while in the operating room, he can’t simply conduct a video-assisted thoracoscopy to explore. Nor will he perform a whole lobectomy, because the lung doesn’t regenerate.



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