Colorectal liver metastases

Colorectal liver metastases

Worldwide colorectal cancer (CRC) is the third most common solid organ malignancy and the fourth most common cause of cancer-related deaths. Up to 70% of patients with CRC develop synchronous (15–25%) or metachronous (20–45%) liver metastases. Thirty years ago, metastatic CRC was asso - ciated with a 5-year survival of less than 3%; however, liver resection in selected patients with liver-only metastatic disease demonstrated 5-year survivals of 50%, so the potential benefits were recognised. Despite recent advances in chemotherapeutic agents, resection remains the only potentially curative option, but only 20% of patients will be candidates at presentation. A further 20–30% will become operable following chemotherapy , the 5-year overall survival rate following resection is 50% and tumour recurs in 65% with the recurrent disease limited to the liver in 40%. - Defining resectability for colorectal liver metastases t - Previously , patients with synchronous metastases, a rectal primary , multiple di ff use metastases, metastases larger than 5 /uni00A0 cm, disease-free intervals of less than 1 year from the diag - - nosis of primary disease or a high serum CEA were considered irresectable and suitable only for palliative treatment. Modern surgical techniques and chemotherapy regimes now mean that r esection with curative intent is defined as the ability to successfully remove all residual disease from the liver with clear surgical margins, leaving adequate disease-free viable liver. Technical contraindications to resection are related to the anatomical location of metastases, principally the involvement - of major vascular or biliary structures. An R0 resection with a negative surgical margin of 1 /uni00A0 cm - is considered the gold standard, but with e ff ective modern chemotherapy patients with an R1 resection ( ≥ 1-mm margin have similar survivals to those with R0 resections. An FLR of 25% of preoperative volume is considered su ffi cient to prevent postoperative hepatic failure (see Portal vein embolisation Historically , extrahepatic metastatic disease was considered a contraindication to liver surgery , but long-term survival is now possible in selected patients. Survival after lung resection for colorectal metastases is similar to that seen after liver resection (40–50%) with low morbidity and mortality . Staging and selection of patients for liver surgery A specialist multidisciplinary team should coordinate the staging of patients with colorectal liver metastases and the treatment plan. Routine staging involves triple-phase CT chest/abdomen/pelvis, contrast MRI scan of the liver, whole- body PET-CT to identify metastatic disease with/without laparoscopy and intraoperative ultrasonography . Chemotherapy for colorectal liver metastases Despite new chemotherapeutic agents and locoregional therapies (embolisation, percutaneous ablation, hepatic artery- directed infusion chemotherapy , internal radiation) the role of adjuvant and neoadjuvant chemotherapy remains unclear. The traditional approach was to resect an operable colonic primary followed by routine postoperative chemotherapy or holding chemotherapy ‘in reserve’ in case of metastases. Neoadjuvant chemotherapy is now recommended by some groups for the majority of patients even if the liver disease is resectable. The aim is to reduce lesion size and improve resectability while treating occult disease and revealing the tumour biology where progression despite chemotherapy signifies a poor prognosis. A major development with advanced disease was the recognition that a subgroup of patients may become resectable after systemic chemotherapy . Although resectability rates after c hemotherapy for initially irresectable disease vary , when successful 5-year survivals of 35–50% are similar to disease resectable at presentation. Chemotherapy with 5-fluorouracil and folinic acid produces a response rate of approximately 30% but combination with oxaliplatin increases this to 50–60%. Combination chemotherapy with monoclonal antibodies that recognise vascular endothelial growth factor receptor (VEGFR) or epidermal growth factor receptor (EGFR) provide additional benefit (see also Chapters 12 and 77 ).