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Treatment Options for Resectable Colorectal Liver Metastases in the Presence of Extrahepatic Disease

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Colorectal Cancer Liver Metastases

Abstract

Traditionally, extrahepatic disease (EHD) was considered a contraindication to resection of colorectal liver metastases (LM) (Scheele et al. Surgery. 110(1):13–29, 1991; Fong et al. J Clin Oncol. 15(3):938–46, 1997). Nevertheless, widespread improvement in surgical morbidity and mortality, as well as improved efficacy of chemotherapeutic agents, has driven increased interest in surgical metastasectomy with the intent of improved survival and potential cure (Elias et al. Ann Surg Oncol. 11(3):274–80, 2004; Elias et al. Br J Surg. 90(5):567–74, 2003). In patients that undergo complete resection of LM and EHD, recurrence is expected 80–95% of the time (Pulitano et al. Ann Surg Oncol. 18:1380–8, 2011; Leung et al. Ann Surg. 265:158–65, 2017; Rajakannu et al. Clin Colorectal Cancer. 17(1):41–9, 2018; Carpizo et al. Ann Surg Oncol. 16:2138–46, 2009). Therefore, recurrence is the norm, and care must be taken to select patients who are most likely to benefit from surgical resection. However, recent evidence has shown that long-term survival is possible in selected patients with resected LM and EHD.

Various factors have been found to be predictive of a poor outcome in this patient population. Having multiple sites of EHD predicts worse survival, and the total number of metastatic lesions (both within the liver and outside) is inversely related to survival (Elias et al. Ann Surg Oncol. 11(3):274–80, 2004; Pulitano et al. Ann Surg Oncol. 18:1380–8, 2011; Hadden et al. HPB. 18:209–20, 2016). Other factors that have been shown to be negative predictors of long-term survival in patients with LM and synchronous EHD are size of LM > 3 cm, more than five LM, and disease progression on neoadjuvant therapy (Leung et al. Ann Surg. 265:158–65, 2017). In the largest meta-analysis to date, patients with more than one site of EHD had a median survival of only 17 months, which is comparable to chemotherapy alone (Hadden et al. HPB. 18:209–20, 2016). Incomplete surgical resection with both microscopic (R1) and grossly (R2) positive margins also precludes long-term survival and should be avoided (Pulitano et al. Ann Surg Oncol. 18:1380–8, 2011; Carpizo et al. Ann Surg Oncol. 16:2138–46, 2009; Hadden et al. HPB. 18:209–20, 2016).

This chapter endeavors to review the clinical evidence behind metastasectomy in the setting of LM and EHD and to provide clinical guidelines on when surgery should be considered.

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  1. Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada

    Kimberly A. Bertens, Jad Abou Khalil & Guillaume Martel

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  2. Banner MD Anderson Cancer Center, Phoenix, AZ, USA

    Michael A. Choti

  3. Virginia Mason Medical Center, Seattle, WA, USA

    Flavio G. Rocha

  4. Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Ageo Shi, Saitama, Japan

    Go Wakabayashi

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Bertens, K.A., Abou Khalil, J., Martel, G. (2020). Treatment Options for Resectable Colorectal Liver Metastases in the Presence of Extrahepatic Disease. In: Correia, M., Choti, M., Rocha, F., Wakabayashi, G. (eds) Colorectal Cancer Liver Metastases. Springer, Cham. https://doi.org/10.1007/978-3-030-25486-5_13

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