Synchronous Colorectal Liver Metastases

Resection of primary tumor versus resection of liver lesions first

Commentator: RENÉ ADAM, MD

Comment:

Not all surgeons would take the same approach when treating a patient who has synchronous colon cancer with highly distributed bilobar metastases. Whereas some surgeons would resect the primary tumor first then begin chemotherapy — thinking that the primary tumor will have been addressed — like-minded surgeons believe that since the primary tumor is asymptomatic and the hepatic metastases are much more life-threatening, it is best to begin by using systemic treatment. If you resect the primary tumor first and the patient experiences a complicated course, the chance to treat the metastases is lost. For that reason, we use systemic chemotherapy first, rather than beginning with a colon resection.

Incidence of synchronous primary and metastatic disease at presentation

Commentator: STEVEN ALBERTS, MD

Comment:

In the general practice, approximately 15 to 20 percent of patients present with synchronous metastatic disease at the time that their colon or rectal cancer is diagnosed.

Decision to operate simultaneously on colorectal and liver metastasis

Commentator: NICHOLAS PETRELLI, MD

Comment:

If a patient required a larger operation in the liver, I would not perform that at the same time as a lower anterior resection. I would conduct the lower anterior resection first, stage the disease pathologically and then perform the liver resection, because a right hepatic lobectomy is a major operation and a lower anterior resection is a major operation, so I would perform the procedures in two separate stages.

Although my colleagues are a bit more aggressive, I feel it’s often safer to proceed with a staged procedure. For example, if a patient had four lesions in the right lobe and a T3 lesion or was node-positive, he would receive preoperative chemoradiation therapy, and then repeat the CT scan eight weeks later. If the CT scan showed additional lesions in the left lobe, I would not be anxious to operate. That patient would receive chemotherapy again to treat the disease systemically or try to convert him to resectable status.

Right versus left colonic tumor with synchronous hepatic metastases

Commentator: JOHN PRIMROSE, MD

Comment:

In general, if the liver resection is straightforward and a right colonic tumor is present, it is perfectly reasonable to combine the surgeries. It’s technically much simpler to perform a right colonic resection than a left colonic resection, together with the liver resection.

Treating an asymptomatic primary tumor with synchronous metastases

Commentator: JOHN PRIMROSE,MD

Comment:

If the primary tumor is asymptomatic, I generally treat it with chemotherapy first or chemoradiation therapy, if the patient has rectal cancer. If the primary disease is asymptomatic, there’s no urgency to deal with it. Dealing with a systemic disease is, I think, the more important thing.

Administration of aggressive therapy

Commentator: STEVEN CURLEY, MD

Comment:

If patients are in good health, we treat aggressively regardless of age by combining multimodality therapy, which includes major liver resections for metastatic disease. Ten to 15 years ago, because this patient had metastatic nodes in the porta hepatis, many would not have considered her a candidate for a resection and would have used palliative chemotherapy only.

Approach to resection of the primary tumor for those who present with synchronous mets

Commentator: STEVEN CURLEY, MD

Comment:

In general, the approach to resection of the primary tumor in patients who present with synchronous disease depends on the patient’s symptoms. Essentially, if the primary tumor is not obstructing or not bleeding excessively to the point where you must intervene surgically to deal with the primary tumor, our standard practice is to initiate treatment with systemic chemotherapy first. We’ve seen response in metastatic disease and in the primary lesion. This is true even for patients who we feel will not become candidates for surgical treatment of metastatic disease. They may have peritoneal seeding. They may have multiple pulmonary metastases, multiple liver metastases. A subset of patients will ultimately succumb to their metastatic disease, but have enough of a response in their primary lesion that they never require surgical treatment. The choice of using surgical treatment as the first treatment depends on whether or not they have an obstructing lesion in the colon.

Incidence of patients who present with synchronous primary colon cancer and metastases versus metachronous metastases

Commentator: AXEL GROTHEY, MD

Comment:

When you consider the overall metastases rate for colon cancer in general, 60 percent of patients die of their disease. So we can assume that 60 percent of patients in the end of all stages will have metastases. Approximately 35 percent present with synchronous primary tumor and metastases, while the other 25 percent have metachronous metastases.

Controversy over performing simultaneous surgeries for a primary rectal cancer and hepatic metastases

Commentator: DANIEL HALLER, MD

Comment:

Whether one performs simultaneous rectal and hepatic surgeries is controversial and a number of variables need to be considered. One is the experience of the surgeon. Another is the age and comorbidity of the patient.

Also important is how long the patient will be under anesthesia, because performing both surgeries simultaneously can lengthen anesthesia. An example of a worst-case scenario would be a patient with a number of comorbidities who requires an APR with colostomy for rectal cancer — which clearly lengthens surgery — and a liver resection. I believe most surgeons would shy away from performing the hepatic metastasectomy in such a case, particularly if it requires more than simply a wedge resection.

CAPOX versus FOLFOX

Commentator: STEVEN CURLEY, MD

Comment:

We have used CAPOX — particularly as a radiation sensitizer — with great success. Initially, patients were treated with CAPOX as part of the chemoradiation therapy, a protocol for patients with T3 or T4 rectal tumors and either N0 or N1 by ultrasound. We were using the CAPOX initially to see if it improved the complete response rate in the primary tumor that was subsequently resected. We found that in patients who presented with synchronous disease, like this patient, the CAPOX was adequate — it not only was a good radiation sensitizer, but it was adequate as chemotherapy to treat small-volume metastatic disease. We had a number of patients who showed response not only in the primary tumor that was receiving the radiation therapy, but some reduction in the size of their metastatic lesions was observed after being treated with CAPOX. The toxicity profile is obviously a little bit different. We have found that when we use full-dose capecitabine, the hand-foot syndrome and the neuropathy can be impressive. Some patients feel that the capecitabine makes the oxaliplatin-based neurotoxicity worse or that they have more trouble with it. So we are focused on that, and we follow up to make sure that if patients are having neuropathy, we’ll go back to a FOLFOX-based regimen and the intravenous fluoropyrimidines.

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