MANAGEMENT OF METASTATIC COLORECTAL CANCER TO LIVER
Akmal Isaq Temasawes;
Abstract
In patients with colorectal cancer, synchronous liver metastases may be detected during preoperative testing or identified intraoperatively during colectomy. Metachronous liver metastases may be suspected at some point after colectomy. Further evaluation of patients with colorectal cancer liver metastases is based on anticipated treatment. If the considered options are observation or systemic chemotherapy, confirmation of the presence of metastatic disease by ultrasound or CT scan is sufficient. (Mazzoni G et al., 2008)
No existing treatment other than surgery can result in long-term survival, but only 10– 20% of patients with liver metastasis fulfill standard selection criteria and are amenable to surgery. As a consequence, the trend is to be more aggressive and to increase the indications for surgical resection. (Penna et al., 2002)
The liver is the most common site for hematogenous metastasis from colorectal cancers. A quarter of patients with primary colorectal carcinoma are found to have synchronous hepatic metastasis. Nearly half of patients who undergo resection of the colorectal primary eventually develop metachronous liver metastasis. In patients with isolated hepatic metastasis, the extent of liver disease is the prime determinant of survival, and when left untreated, the survival is measured in months. (Taylor et al., 2007)
The goal of surgery for liver metastases is to remove all the metastatic sites, if possible with a free clearance margin of 1 cm. The extent of liver resection is not by itself a prognostic factor. The type of liver resection depends on the size, the number, and the location of the metastases, as well as their relation to the main vascular and biliary pedicles and the volume of the liver parenchyma that can be left in place after surgery. (Penna et al., 2002)
The “liver-first” approach is the latest and one that is most suited for patients with advanced rectal cancer. Approximately, 30% of patients with locally advanced rectal cancer have synchronous liver metastases. The locally advanced rectal disease is usually treated with a long course of chemo radiation of about five weeks and with at least six weeks going by before the patient can be operated upon. The result is that, and provided that there are no chemo radiation complications, three months will have passed before the liver disease is actually addressed. This is made harder by the high frequency of complications, which push any therapy for the liver disease even further down the road, as well as the fact that the liver metastatic disease is the one ultimately affecting the prognosis. (C. J. A. Punt., 2004)
Traditional prognostic factors have many limitations. First, they just depict the disease at diagnosis and provide scarce information about tumor biology. Second, categorization of variables differs among studies: different cutoff values have been adopted for tumor size and number, for CEA and for the definition of synchronous lesions. Thus, the possibility of directly comparing different studies is generally limited. Similarly, caution must be adopted in equating results from different multivariate analyses since different variables have been included in each model. Finally, in recent series, preoperative chemotherapy might have significantly impacted on traditional prognostic factors, modifying their values (e.g., tumor size) and making their interpretation more difficult. (Spelt L et al., 2012)
No existing treatment other than surgery can result in long-term survival, but only 10– 20% of patients with liver metastasis fulfill standard selection criteria and are amenable to surgery. As a consequence, the trend is to be more aggressive and to increase the indications for surgical resection. (Penna et al., 2002)
The liver is the most common site for hematogenous metastasis from colorectal cancers. A quarter of patients with primary colorectal carcinoma are found to have synchronous hepatic metastasis. Nearly half of patients who undergo resection of the colorectal primary eventually develop metachronous liver metastasis. In patients with isolated hepatic metastasis, the extent of liver disease is the prime determinant of survival, and when left untreated, the survival is measured in months. (Taylor et al., 2007)
The goal of surgery for liver metastases is to remove all the metastatic sites, if possible with a free clearance margin of 1 cm. The extent of liver resection is not by itself a prognostic factor. The type of liver resection depends on the size, the number, and the location of the metastases, as well as their relation to the main vascular and biliary pedicles and the volume of the liver parenchyma that can be left in place after surgery. (Penna et al., 2002)
The “liver-first” approach is the latest and one that is most suited for patients with advanced rectal cancer. Approximately, 30% of patients with locally advanced rectal cancer have synchronous liver metastases. The locally advanced rectal disease is usually treated with a long course of chemo radiation of about five weeks and with at least six weeks going by before the patient can be operated upon. The result is that, and provided that there are no chemo radiation complications, three months will have passed before the liver disease is actually addressed. This is made harder by the high frequency of complications, which push any therapy for the liver disease even further down the road, as well as the fact that the liver metastatic disease is the one ultimately affecting the prognosis. (C. J. A. Punt., 2004)
Traditional prognostic factors have many limitations. First, they just depict the disease at diagnosis and provide scarce information about tumor biology. Second, categorization of variables differs among studies: different cutoff values have been adopted for tumor size and number, for CEA and for the definition of synchronous lesions. Thus, the possibility of directly comparing different studies is generally limited. Similarly, caution must be adopted in equating results from different multivariate analyses since different variables have been included in each model. Finally, in recent series, preoperative chemotherapy might have significantly impacted on traditional prognostic factors, modifying their values (e.g., tumor size) and making their interpretation more difficult. (Spelt L et al., 2012)
Other data
| Title | MANAGEMENT OF METASTATIC COLORECTAL CANCER TO LIVER | Other Titles | كيفية علاج أورام الكبد الثانوية نتيجة سرطان القولون والمستقيم | Authors | Akmal Isaq Temasawes | Issue Date | 2015 |
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