Mohamed Fathy Abdel Ghaffar

Professor of Hepatobiliary Surgery

Ain-Shams University

Transplant surgeon in Wady El-Neel /Ain-Shams University Hospital

Colorectal Liver Metastases:Multidisciplinary Approach

Colorectal Liver Metastases:Multidisciplinary Approach

• Colorectal cancer is the third most commonly diagnosed cancer with one million new cases annually worldwide, representing the commonest gastrointestinal malignancy and the second commonest cause of cancer death.¹

• Over half of patients with colorectal cancer will develop metastatic disease, with a quarter having distant metastatic lesions at diagnosis. 2

1-CA Cancer J Clin 2005;55(2):74–108

2-J Natl Cancer Inst 2004; 96: 1420–25.

What are the options for patients with colorectal liver metastasis?• Do nothing

– median survival of 6 to 9 months.

• Chemotherapy – 14.5-month median survival,

• RFA – 40% 3-year survival rate,

• Resection– 5-year survival rate of 45% to 60%

Conclusion:

RFA can not be recommendedas an alternative to HR. However RFA may contribute to local control of small CLM in patients who are not candid for liver resection

• Radiofrequency ablation (RFA) has been used for unresectable metastasis, sometimes in conjunction with the surgical removal of resectable metastases, and may have a role in the treatment of other selected patients

Cancer Care Ontario (CCO) Report Date: June 15, 2012

• The use of chemotherapy as an adjunct to liver resection has resulted in a 5-year survival in the range of 37 to 58%. ¹

• Ten-year survival is reported to be between 16 to 30%.²

1. Clin Colon Rectal Surg 2009;22:225–232.

2. Ann Surg Oncol 2008;15(9): 2458–2464

Gayowski et al. (1994) - Pittsburg Medical Center

0 33 32%

Jamison et al. (1997) - Mayo Clinic

4 33 27%

Fong et al. (1999) - Memorial Sloan Katering

3 42 36%

Choti et al. (2002) - Johns Hopkins

1 46 40%

Fernandez et al. (2004) - Washington University

1 – 59%

Pawlik et al. (2005) - M.D. Anderson

1 74 58%

Hospital A.C. Camargo (2005)

0 – 51%

Hospital A.C. Camargo (2010)

0.9 (30 days) 1.8 (90 days) – 66.2%

Author (year) Mortality % Mean

survival (months)

Five-year survival

Prior to being considered for surgical resection it must be shown that:

• The patient has no extrahepatic disease

• The intrahepatic disease is safely resectable and the patient must also be in good medical condition.

Contraindications to liver resection

• Non-treatable primary tumor.• Widespread pulmonary disease.• Peritoneal disease. • Extensive nodal disease, such as

retroperitoneal or mediastinal nodes. • Bone or CNS metastases.

Guidelines for resection of colorectal cancer liver metastases. Gut 2006; 55 (Suppl 3):iii1–iii8

Clinical Risk Score

• Nodal status of the primary disease• Free interval from the discovery of the primary to

the discovery of the liver metastases of <12 months• Number of tumors >1• Preoperative CEA level of >200 ng/mL• Size of the largest tumors >5 cm

• Each positive criterion is assigned one point. 5-year survival is 60% with score of 0 points, and falls to 14% in patients with 5 points.

• Fong , et al.,Ann Surg 1999;230:309–318; discussion 318–321

• In 1986, Ekberg et al defined resectability as less than four metastases (even if bilobar), absence of extrahepatic disease, and a resection margin of at least 1 cm.

• Today, resections are based on the remnant liver. A sufficient future remnant liver volume (>20% of the total estimated liver volume) is a prerequisite.

• If R0 with negative surgical margins (≥1mm) is possible and sufficient liver parenchyma remains to maintain liver function, resection should be considered

The Role of Liver Resection in Colorectal Cancer Metastases A Quality Initiative of the Program in Evidence-Based Care (PEBC), Cancer Care Ontario (CCO) Report Date: June 15, 2012

What is a Resectable Tumor?

Two main problems

• Tumor burden: make a small number of patients who are candid for curative resection.

• Synchronous tumor: what is the best approach?

How to increase RESECTABILITY

• Portal Vein Occlusion• Two-Stage Hepatectomy• Tailored hepatectomy• Downstaging chemotherapy• Local Ablation Techniques

Large right lobe lesion

CT Volumetery

1 months after embolization

6 months after resection

Two-Stage Hepatectomy

Tailored hepatectomy

Downstaging chemotherapy

Local Ablation Techniques

Synchronous tumors

What are the possible options?• Colon first: Staged approach

• Colon and liver: Simultaneous approach

• “Reverse Strategy”

Factors determine the decision:

1. The presence of symptoms.

2. Location of primary tumor and liver metastases.

3. Extent of tumor (both primary and metastatic).

4. Patient performance status, and underlying comorbidities.

Surgical incisions according to primary tumor and liver metastases

Advantages of simultaneous resection

• The performance of only a single surgical procedure.

• Reduced length of hospital stay• The removal of all neoplastic foci and

interruption of the “metastatic cascade”.• The avoidance of immunodepression

after isolated primary tumor resection• No delay in initiating systemic treatment

Disadvantages of simultaneous resections

• The combination of a “clean” and a “contaminated” surgical procedure and thus the higher risk of septic complications, which could cause or worsen a liver dysfunction

• The increased risk of anastomotic leak due to splanchnic congestion if prolonged pedicle clamping is needed.

• The inadequate surgical exposure through a single incision.

Disadvantages of simultaneous resections, cont.,

• The need for a double surgical team for liver and colorectal surgery/inadequate treatment if a single team performs the entire procedure.

• Small occult metastases may not be evident during the evaluation and therefore not addressed during the operation.

“Test of time”

• Scheele et al suggested a “test of time” approach of waiting up to 6 months to observe the tumor biology and evolution of metastases as a means of natural selection for operable disease.

• World J Surg 1995;19:59-71.

Tumor doubling time

• Mean tumor doubling time has been assessed using serial computed tomography to be 155 ± 34 days for overt metastases and 86 ± 12days for occult lesions not evident at laparotomy.

• Br J Surg 1988;75:641-4.

Criteria for synchronous approach

• Age<70 years • good surgical fitness.• an adequate tumor-free margin, • lesions that are not advanced(T4), • less than 4 colorectal lymph node metastases• histology that is not poorly differentiated or

mucinous adenocarcinoma.• 3 or fewer liver metastases.• a minor liver resection (less than 3 segments)

is planned Ann Acad Med Singapore 2010;39:719-33

“Reverse Strategy”

• Brouquet et al. and the group from M.D. Anderson Cancer Center

• preoperative chemotherapy is followed by resection of the hepatic metastases and then by resection of the colorectal primary at a second operation.

• J Am Coll Surg 2010;210:934-41.

The rationale for this approach

• complications related to the primary colorectal tumor are rare and treatment of metastatic disease is not delayed by local therapy for the primary tumor or complications associated with treatment of the primary tumor

• It can be considered as an alternative option in patients with advanced hepatic metastases and an asymptomatic primary.

It is a multidisciplinary approach

• Team work

– Patients should be treated at a designated HPB Centre that has appropriate physical resources (diagnostic equipment, operating rooms, ICU, staffing (surgeons with advanced training in HPB and colorectal surgery, nurses, radiologists, medical and radiation oncologists), and a high volume of HPB surgeries (a minimum of 50 index HPB cases per year).

A Quality Initiative of the Program in Evidence-Based Care (PEBC), Cancer Care Ontario (CCO) Report Date: June 15, 2012

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