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 (
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