2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

Resection and Thermal Ablation of Liver Metastases
We have reported the results of a prospective study of
outcomes after surgical treatment of CRC liver metastases
using hepatic resection only, RFA plus resection for multiple
tumors, or RFA only when patients had tumor in an unresectable
site in the liver. The study group consisted of 348
consecutive patients with CRC liver metastases and no
extrahepatic disease who were treated for cure with hepatic
resection with or without RFA and 70 patients who were
found at laparotomy to have liver-only disease (but were not
candidates for curative treatment based on involvement of
too many liver segments) as outlined in Fig. 1. 8 An example
of a case in which a combined approach of resection and
ablation was used is illustrated in Fig. 2.
The 5-year overall survival rate among the 348 patients
treated with curative intent was 44%. Survival with resection
alone (58% at 5 years) was significantly greater than
that with either resection plus ablation (28%) or RFA
alone (19%, p � 0.001), with no marked difference among
the approaches, including RFA. The overall 4-year survival
rates after resection, RFA plus resection, and RFA
KEY POINTS
● Management of colorectal cancer liver metastases
requires a multidisciplinary team approach.
● Patients should be considered candidates for resection
whenever possible, regardless of the number of
metastatic lesions.
● Modern systemic chemotherapy can produce response
sufficient to convert unresectable liver metastases
to resectable disease in some patients.
● Chemotherapy can be hepatotoxic, so careful selection
of neoadjuvant therapy agents and duration
must be considered.
● Resection provides better long-term survival probability
compared with thermal tumor ablation
techniques.
210
alone were 65%, 36%, and 22%, respectively (p � 0.0001);
however, 4-year survival rates with resection plus RFA
and RFA only were still substantial and significantly improved
over that achieved with chemotherapy alone (5%) in
the 70 patients not treated with resection or RFA (p �
0.0017).
Systemic Chemotherapy
STEVEN A. CURLEY
Fig. 1. Treatment of 418 consecutive
patients with liver-only CRC metastases
at M. D. Anderson Cancer Center. A total
of 348 patients (83.3%) were treated
for cure with hepatic resection only, RFA
plus resection, or RFA only. Seventy patients
were found to have disease too
extensive for curative therapy and underwent
chemotherapy (systemic, intraarterial
chemotherapy via a hepatic
artery infusion pump placed at the index
laparotomy or intra-arterial plus
systemic chemotherapy).
Abbreviations: CRC, colorectal cancer;
RFA, radiofrequency ablation.
Systemic chemotherapy can convert unresectable CRC
liver metastases to resectable disease in some patients, and
response to neoadjuvant chemotherapy in patients with
resectable disease is an important prognostic indicator of
improved probability of long-term survival. 2,9,10 The use of
neoadjuvant chemotherapy in patients with resectable CRC
liver metastases must be carefully considered in multidisciplinary
treatment planning involving medical oncologists
and hepatobiliary surgical oncologists. Neoadjuvant chemotherapy
regimens that are based on oxaliplatin (Eloxatin;
Sanofi Aventis) or irinotecan (Camptosar; Pfizer) can produce
specific types of liver injury. Oxaliplatin-based chemotherapy
was reported to cause sinusoidal obstruction, venoocclusive
lesions in the microvasculature of nontumoral
liver, and perisinusoidal fibrosis in more than half of the
patients receiving neoadjuvant therapy. 11 Both irinotecan
and oxaliplatin treatment have been found to produce nonalcoholic
steatohepatitis (NASH), and the severity of NASH
is greater in patients who are also obese. 12 Hepatic steatosis
or steatohepatitis was identified as an independent variable
that predicted increased perioperative morbidity and mortality
rates in a retrospective study of 135 patients undergoing
resection of CRC liver metastases. 13 Data suggest that
steatosis impairs hepatic regeneration after resection, and
the rates of liver insufficiency and hyperbilirubinemia are
higher for patients with hepatic steatosis than for patients
with normal livers.
A multi-institution review of 406 patients who underwent
resection of CRC liver metastases and had the severity of
NASH and nonalcoholic fatty liver disease scored on a
standardized system was completed recently. 14,15 Preoperative
chemotherapy was administered to 241 patients (61%),
and 158 patients (39%) received no neoadjuvant treatment.