Abstract
Few malignancies have their prognosis changed by resection of their metastatic deposits. Why this should be possible with colorectal cancer is being investigated by researchers worldwide. This observation, however, has seen surgical therapy of colorectal liver metastases witness revolutionary changes over the past years. Historically, liver resection was seen as a formidable operation fraught with complications. Perioperative safety has improved and specialist centers performing liver resection for colorectal liver metastases are reporting operative mortality rates of less than 1%. A challenge for the future is to make more patients eligible for curative intent surgery by downstaging the tumours with chemotherapy to make them resectable. Specialist centers are expanding the operations applied to this disease with vein resection, interposition vascular grafting, in-vivo liver isolation even ex vivo resections with re-implantation of the liver. Surgery is becoming safer for the patient and chemotherapy is slowing the progress of metastatic colorectal cancer to allow surgery to add more effectively to increase patient survival. Five year survival rates continue to improve. Chemotherapy does have effects on the liver which at times limit the possibilities for resection; however, newer therapies, combinations of therapies, timing and shorter courses of therapy see similar tumour responses without the deleterious effects. The amount of liver remaining after resection also limits which tumours are technically resectable. The volume of residual liver required has been further defined. Portal vein embolization can preoperatively selectively hypertrophy the future liver which the patient will be dependant upon. Better imaging and volumetric analysis has seen an extension of the criteria of what is thought resectable. Tumour margins of the resected specimen have been shown to be important only if less than 1 mm, therefore expanding the indications for resection. The evolving field of chemotherapeutics will continue to push the limits of tumour response. These improvements will see dynamic changes in the roles of the members of the multidisciplinary cancer care team.
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Notes
- 1.
The tumor status following treatment is described by the residual tumor (R) classification: R0, no residual tumor; R1, microscopic residual tumor; R2, macroscopic residual tumor. Residual tumor may be found in the area of primary tumor and its regional lymph nodes and/or at distant sites. The R classification reflects the effects of treatment and influences further treatment planning. Furthermore, the R classification is a strong predictor of prognosis. An acceptable long-term prognosis can be expected only in R0 patients. Although there exist clear correlations between stage and R classification, the differences in prognosis of R0 versus R1, 2 cannot be explained by differences in stage alone. The prognostic significance of R classification is demonstrated by respective data for non-small cell lung carcinoma, squamous cell carcinoma of oesophagus, gastric carcinoma, ductal adenocarcinoma of the pancreas, colorectal carcinoma, lung and liver metastases [80].
Abbreviations
- CLMs:
-
colorectal liver metastases
- CEA:
-
carcinoembryonic antigen
- CT:
-
computerized tomography
- MRI:
-
magnetic resonance imaging
- FAP:
-
familial adenomatous polyposis
- FLR:
-
future liver remnant
- NAFLD:
-
non-alcoholic fatty liver disease
- PET:
-
positron emission tomographic scan
- MCC:
-
Multidisciplinary Cancer Conference
- IVC:
-
inferior vena cava
- PVE:
-
portal vein embolization
- RFA:
-
radiofrequency ablation
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Adrian M. Fox was supported by an educational grant from Sanofi-Aventis pharmaceuticals.
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Fox, A.M., Gallinger, S., Moulton, CA. (2011). Colorectal Carcinoma Liver Metastasis: Surgical Clinical Perspective. In: Brodt, P. (eds) Liver Metastasis: Biology and Clinical Management. Cancer Metastasis - Biology and Treatment, vol 16. Springer, Dordrecht. https://doi.org/10.1007/978-94-007-0292-9_12
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