Colorectal liver metastases
Criteria for resection:
OLD: < 3 lesions confined to a lobe, 1cm margins, no portal nodes.
NEW: evolving. No limit on number of lesions, smaller margins ok, portal nodes ok, extrahepatic
disease (pulm mets) ok if resectable. Contraindications: patient unfit for surgery, >70% liver
involvement, 6 or more segments involved, invasion of hepatic vein or PV confluens.
Preoperative evaluation:
CBC, coags, chem10, CEA, CT C/A/P with quad-phase liver protocol and volumetric
assessments. Patient should be off Avastin x6 weeks (wound healing, bleeding, impaired hepatic
regeneration). FOLFOX can produce sinusoidal dilation (19%, not clear if imparts worse outcome
with resection) and FOLFIRI steatohepatitis (20%).
Role of PET evolving. Sensitivity/specificity is 80%/92% for hepatic disease, 90 and 98% for
extrahepatic disease. Advocates say PET changes management in 25% of cases. Generally
obtained in potentially surgically curable M1 disease.
Biopsy: risk of FNA small for needle-tract mets (only a handful of cases reported). Typically not
performed if primary tumor has been resected and CT appearance is characteristic.
Neoadjuvant chemo: currently used for patients with borderline resectability. Also used in
patients with >4 mets, or other high risk features. Repeat CT q6weeks and resect generally after
3-4 cycles of chemo.
NCCN 2007 guidelines:
synchronous colon and resectable liver mets, all are acceptable:
1) colectomy + liver resection -> chemo
2) neoadjuvant FOLFIRI or FOLFOX x 3mos -> colectomy -> liver resection -> chemo 6mos
total
3) colectomy -> chemo -> liver resection
unresectable synchronous liver only or lung only metastases:
consider colon resection only if immediate risk of obstruction or significant bleeding
consider colon resection and ablative therapy if liver mets only
otherwise FOLFOX or FOLFIRI. Assess for conversion to resectability.
Metachronous resectable mets
Fully stage as above with PET also. Resect. Repeat chemo.
Operative technique:
IOUS for all cases to stage and plan resection
Resection has better outcome than RFA and is preferred in all cases.
If clinical predictor score (see below) 3 or more, some data for diag laparoscopy to start case
since 42% will have unresectable disease (JarniganW Cancer 2001).
Results:
5-year overall survival has increased from 33% to over 50% in recent series.
Author and year
Number of
patients
5 yr OS,
percent
Median survival,
months
Hughes, KS; 1986
607
33
NR
Scheele, J; 1995
434
33
40
Nordlinger, B;
1996
1568
28
NR
Jamison, RL; 1997
280
27
33
Fong, Y; 1999
1001
37
42
Iwatsuki, S; 1999
305
32
NR
Choti, M; 2002
133
58
NR
Abdalla, E; 2004
190
58
NR
Fernandez, FG;
2004
100
58
NR
Wei, AC; 2006
423
47
NR
Clinical predictors of outcome (Fong AnnSurg 1999)
1. LN postitive tumor
2. relapse-free interval <12 months
3. >1 tumor on preoperative imaging
4. CEA > 200mg/mL
5. largest tumor >5cm by preoperative imaging.
=====================
6. extrahepatic disease.
5 year survival by score:
Survival at:
Clinical risk score*
1 yr
2 yr
5 yr
Median survival, mos
0
93
79
60
74
1
91
76
44
51
2
89
73
40
47
3
86
67
20
33
4
70
45
25
20
5
71
45
14
22
Surveillance:
Warren after resection: Quad phase CT AP q4mos. CEA q4mos. No PET (will light up resection
and RFA sites = false positive)
NCCN 2007: if NED:
CEA q3mos x2y, then q6mos x3-5 years
CT CAP q3mos x 2y, then q6 mos for total 5y
Colonoscopy 1yr. If abnormal, repeat in 1yr otherwise repeat in 3y.