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Hepatic Resection for Colorectal Metastasis

Hepatic Resection for Colorectal Metastasis

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Published by Syed Nusrath

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Published by: Syed Nusrath on Oct 08, 2012
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12/11/2013

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Hepatic Resectionfor Colorectal LiverMetastases
Russell E. Brown,
MD
, Matthew R. Bower,
MD
,Robert C.G. Martin,
MD, PhD
*
Colorectal adenocarcinoma remains the third most common cause of cancer death inthe United States, with an estimated 146,000 new cases and 50,000 deaths annually.Survival is stage dependent, and the presence of liver metastases is a primary deter-minant in patient survival. Approximately 25% of new cases will present with synchro-nous colorectal liver metastases (CLM), and up to one-half will develop CLM duringthe course of their disease.
The importance of safe and effective therapies forCLM cannot be overstated. Safe and appropriately aggressive multimodality therapyfor CLM can provide most patients with liver-dominant colorectal metastases withextended survival and an improved quality of life.
OUTCOMES AFTER SURGICAL RESECTION OF CLM
Hepatic resection for metastatic disease has been practiced for decades. Lortat-Jacob and colleagues
described right hepatectomy for secondary malignancy in1952. Initial anecdotal success has been followed by continued improvements in peri-operative and long-term survival. The progressive success of CLM resection can beattributedtoimprovementsinmultimodalitytherapyincludingsystemicchemotherapyand targeted therapies, as well as efforts to increase the proportion of patients eligiblefor resection. Choti and colleagues
observed an increase in 5-year survival from31% to 58% for patients undergoing CLM resection between 1984 and 1992compared with patients from 1993 to 1999. For solitary CLM, perhaps the most favor-able group, 5-year overall survival of 71% has been reported.
Hepatic resection, when feasible, is the only treatment associated with long-termsurvival.
Based on a review of 10-year survivors who underwent resection before
Division of Surgical Oncology, Department of Surgery, James Graham Brown Cancer, Universityof Louisville School of Medicine, 315 East Broadway, Louisville, KY 40202, USA* Corresponding author.
E-mail address:
KEYWORDS
Liver resection
Metastases
Colorectal cancer
Surg Clin N Am 90 (2010) 839–852doi:10.1016/j.suc.2010.04.012
0039-6109/10/$ – see front matter
ª
2010 Elsevier Inc. All rights reserved.
 
1994 (ie, before the use of modern chemotherapy), current 10-year survival in at least1 of 6 patients can be postulated after resection of CLM.
With improvements in surgical and anesthetic techniques, as well as postoperativecare, hepatic surgery has become a safe procedure in experienced centers. Patientshave benefited from improvements in perioperative outcomes after hepatic resection,withreports of mortalities of less than 4% and all-cause morbidity approaching40%.
PREOPERATIVE EVALUATION
The central tenets in the preoperative evaluation of patients for potential surgicalresection of CLM are: (1) evaluation of the patient’s fitness for operation; (2) anatomicand functionaldetermination of tumor respectability; (3) estimation of an individual’stumor biology.
 All patients with CLMbenefit from evaluation by a multidisciplinary team comprisingphysicians (surgeons, medical oncologists, radiologists, pathologists), nurses, socialworkers,andresearchcoordinators.Inourexperience,thisapproachhasbeeninvalu-able in terms of reaching efficient consensus on patient treatment plans amongspecialties. Multidisciplinary conferences and clinics minimize delays in treatment,improve communication between specialties, and allow for the identification of thoseunresectable patients who may benefit from surgical resection, ablation, or catheter-based therapies.
Evaluation of Fitness for Operation
 Acarefulevaluationofapatient’sphysiologic capabilitytotolerate hepaticresectionisnecessarytoensurefavorableoutcomesafterhepatectomy.Inadditiontoadeliberatecardiopulmonary evaluation and the attention to medical comorbidities required formajor abdominal surgery, a thorough consideration of the patient’s liver function isrequired. History, physical examination, and routine laboratory studies (completeblood count, liver function testing, and coagulation studies) are relied on to screenfor underlying liver dysfunction. Preoperative imaging studies (discussed later) mayalso help to identify those patients with underlying hepatic disease.Preoperative biopsy of CLM is rarely indicated or beneficial for assessment of CLM,and has been associated with tumor dissemination and decreased survival.
Preop-erative biopsy may have usefulness for confirmation of extrahepatic disease whena change in therapy is planned based on the biopsy results.
 Anatomic and Functional Determination of Resectability 
ResectabilityofCLMhasbeenwelldefinedbytheAmericanHepato-Pancreato-Biliary Association (AHPBA)/Society of Surgery of the AlimentaryTract (SSAT)/Society of Surgical Oncology (SSO) in a 2006 consensus statement
5
as an expected margin-negative (R-0) resection resulting in preservation of at least 2 contiguous hepaticsegments with adequate inflow, outflow, and biliary drainage with a functional liverremnant (FLR) volume of more than 20% (for healthy liver).Determination of resectability is primarily based on preoperative imaging. High-quality cross-sectional imaging is critical for gauging the extent of disease, responseto preoperative therapy, and for operative planning. Patients should be routinely reim-aged after any course of systemic therapy; preferably within 4 weeks of plannedresection. Currently, we find triple-phase helical computed tomography (CT) to bethe most useful modality for defining intrahepatic anatomy and resection planes.We reserve ultrasound and magnetic resonance imaging (MRI) as adjuncts for
Brown et al
840
 
characterizing small or equivocal lesions by 3-phase CT. Fusion positron emissiontomography (PET)-CT imaging has shown high sensitivity (95% on a per patient basis,76% on a per lesion basis
 ) and we have found it to be beneficial in assessing extra-hepatic disease burden.Meticulous preoperative attention to the relationships of CLM to arterioportalinflow, biliary drainage, and hepatic venous outflow is necessary and allows for aninformed and efficient hepatectomy. At present, this level of anatomic detail is onlyevident using 3-phase CT or dynamic MRI. PET-CT has insufficient resolution tomake these preoperative determinations. Vascular and biliary anomalies are commonand should be anticipated before resection. If necessary, CT arterial reconstructionand magnetic resonance cholangiopancreatography may be useful in clarifyinganatomic variants.Giventhemorbidityandpotentiallydevastatingconsequencesofpostoperativeliverinsufficiency, much attention has been given to the future liver remnant (FLR), whichremains after extended ( 
R
5 segment) hepatectomy. CT volumetry has been used toquantify the FLR by standardized methods.
Safety of extended hepatectomyhas been shown for FLR volumes approaching 20% for patients with normal liverparenchyma. Those patients with underlying liver disease require more conservativelimits of FLR (ie, 30% for moderate fibrosis; 40% for cirrhosis
 ).Besides delineating intrahepatic anatomy, preoperative cross-sectional imagingmay also help to identify the presence of concomitant parenchymal disease (eg,fibrosis/cirrhosis, portal hypertension, steatohepatitis) or extrahepatic disease. Identi-fication of concomitant hepatic pathology or extrahepatic metastases requires a care-ful search for the presence of hepatic atrophy, beaking of the liver edge, livernodularity, splenomegaly, ascites, varices, omental caking, peritoneal nodules, andporta hepatis or aortocaval lymphadenopathy.
Diagnostic laparoscopy has a role in staging those patients in whom preoperativeimaging or high-risk scores (see laterdiscussion) suggest a high likelihood for findingintra-abdominal extrahepatic disease
or for patients with indeterminate intrahepaticlesions that may be best characterized by intraoperative ultrasound (IOUS). We haveoccasionally found laparoscopy useful in assessing the status of the remnant liver. Inthose patients whose history, laboratory studies, or imaging predicts marginal liverfunction, diagnostic laparoscopy can be used to visually examine the liver as wellas to perform biopsies before proceeding with hepatectomy.
 Analysis of Tumor Biology 
Oncetumorresectability andfitness foroperationhavebeenconfirmed,considerationshould be given to an individual patient’s tumor biology; that is, whether a patient’sdisease favors a more indolent or a more aggressive behavior. Consideration of thisquestion is far from an exact science, but valuable information can be gleaned fromfactors such as the stage of primary disease, number and distribution of CLM, tumorhistology, response to chemotherapy (currently best judged byresponse evaluationcriteria in solid tumors [RECIST] criteria based on CT imaging
 ), rate of growth of CLM on serial imaging, or rate of increase in serum carcinoembryonic antigen(CEA). Fong and colleagues,
proposed a clinical risk score based on a multivariateretrospective analysis that correlated node-positive primary, disease-free interval of less than 12 months, number of metastases in excess of 1, CEA more than 200 ng/mL,and primary tumor larger than 5 cm with decreased survival ( 
 ). In an externalcohort validation study of multiple prognostic indices,
the Fong and Iwatsuki
scores were found to be predictive of survival.
Hepatic Resection for Colorectal Liver Metastases
841

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