General Comments

Importance of a multidisciplinary team in optimal patient management

Commentator: STEVEN ALBERTS, MD

Comment:

In young patients who have primary tumors and extensive liver involvement, a multidisciplinary approach is needed up front to determine whether surgery could lead to a possible cure or not. This allows you to define a plan of care for the patient and then proceed with the plan, rather than having the unfortunate scenario where someone is started on chemotherapy, is never assessed for a resection of the liver metastases and, despite achieving a good response to chemotherapy, disease becomes progressive. The question then becomes if the patient was ever a candidate for resection.

Importance of interdisciplinary management

Commentator: MICHAEL CHOTI, MD

Comment:

The optimal strategy is to discuss the case in a multidisciplinary setting that includes a colorectal surgeon, a hepatic surgeon and a medical oncologist to develop the best treatment plan. In a patient that presents with Stage IV disease, unless the colon cancer is obstructing or the patient needs emergency surgery, we administer chemotherapy before the colon surgery.

Importance of a multidisciplinary team in optimal patient management

Commentator: MICHAEL CHOTI, MD

Comment:

The optimal management of patients with metastatic colorectal cancer should include a multidisciplinary team approach, which includes all the diagnostic and therapeutic options, including an experienced liver surgeon. The most important factor is the experience of the surgical team.

If the medical oncologist or community physician evaluates a potential candidate for surgical therapy, they should use imaging from a high-quality CT scan and perhaps even a PET scan to determine whether the patient may have potentially resectable disease. In most of those cases, those imaging studies should be reviewed by an experienced hepatic surgeon. I think most patients with liver-only metastases or potential resectable liver metastases and resectable extrahepatic disease should be evaluated by an experienced team. We often use a combination of imaging studies done in the local community and some high-tech imaging done at the tertiary care center.

Anatomy of the liver

Commentator: NICHOLAS PETRELLI, MD

Comment:

The liver is divided into eight segments, including a caudate lobe. As surgeons, we usually talk in terms of these segments. Think of the liver being divided into the right and left lobe. The lobes are divided by a line called Cantlie’s line, which runs from the left side of the vena cava to the middle of the gallbladder fossa at about a 70-degree angle. You cannot see the line in surgery, although I draw it at the time of surgery. The left lobe of the liver is divided into two segments — the median and the lateral segments. The lateral segment has two subsegments known as segments II and III, and the medial segment is called segment IV. The right liver includes anterior and posterior segments that are divided by the right hepatic vein. The posterior segment includes two subsegments — segments VI and VII. The anterior subsegments are segments V and VIII. The segments are based upon the distribution of the portal vein.

The anterior and posterior segments of the right lobe are defined by the anterior and posterior tributary of the right branch of the portal vein. The left branch of the portal vein sends blood to the medial and lateral segments (ie, segments II, III and IV). In this day and age, you can resect individual segments without taking out the entire lobes or major segments. There are three hepatic veins — a left hepatic vein, a middle hepatic vein and a right hepatic vein. The location of the lesion in relation to those outflow tracts — those hepatic veins — will impact the type of resection that one needs to perform.

Multidisciplinary approach to treatment

Commentator: NICHOLAS PETRELLI, MD

Comment:

In this day and age, all patients need the multidisciplinary approach, especially in patients with colorectal cancer and liver metastases. Decisions for these patients must be made using a multidisciplinary approach. The decisions can’t be made by the surgeon alone or the medical oncologist alone or — in rectal cancer cases — the radiation therapist alone.

Number of annual liver resections in a single UK center

Commentator: JOHN PRIMROSE, MD

Comment:

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 will not become suitable after chemotherapy — probably about double the number that we operate on.

Utilizing a multidisciplinary approach in the care of patients with gastrointestinal cancers

Commentator: DANIEL HALLER, MD

Comment:

In gastrointestinal cancer, the patients that require the most multidisciplinary care are patients with gastroesophageal, pancreatic and rectal cancer. Even in a fairly straightforward rectal cancer case, there’s generally not only one plan of action. Rather, treatment revolves around a series of multiple, sequential decisions based on response to therapy and the involvement of the multidisciplinary team, including the rectal surgeon, radiologists, pathologist and medical oncologist.

For optimal care, these cases necessitate a high-volume hospital, a physician who sees a lot of these patients and a team approach. In almost every one of these instances, trimodality care is required and trimodality experience and superiority requires a fairly large center — you can’t do it alone.

I believe more institutions are adopting the multidisciplinary approach. As I participate in tumor boards in medium-sized hospitals across the country, I see that they are on board. The pressure to do so is coming from insurance carriers, who may require surgical second opinions in many instances, and it’s coming from patients. The consumer will drive the medical community to develop such programs. We saw it happen in breast cancer and now even the smallest hospital has a breast clinic. In our newer facilities, the surgeons and radiation oncologists are no longer separate — they all have offices on the same floor.

I doubt that in the United States we will ever see adoption of the European approach, where states would designate what facilities can and cannot do. We’re too diverse a society and not as happy about governmental regulation. However, Americans usually succeed by evaluating what works and being pragmatic. Rectal cancer is common enough that I believe people can see the differences in care from one institution to another, particularly with regard to rectal surgery. Patients are willing to travel for a good surgery.

Within the trimodality approach, I believe superior surgery and, therefore, the surgeon, is the most important driver of outcome in terms of survival and quality of life when caring for patients with liver metastases and rectal cancer. The second most important is the radiation therapist. This field is technical and a lot of decisions need to be made. At the bottom of the chain is the medical oncologist. If a patient tells us that they live too far away to come to our institution for all three modalities — surgery, radiation therapy and chemotherapy — then we recommend they have their surgery here, and we will try to find the best hospital close to them to administer the chemoradiation therapy.

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