I have been watching with great interest the large number of postings related to this topic, I was amazed with the diversity of replies ranging from doing nothing, to the gentle kiss of liver failure, passing through Hartmann's, stent, intaarterial chemotherapy, chemoembolization. Also there was one or two replies addressing resection of the primary & chemo-immunotherapy.
Colorectal cancer is a common malignancy and the incidence of this disease is increasing. Approximately 50% of patients with colorectal cancer die from recurrent disease following an apparently curative resection of the primary tumor and the liver is the most frequent site of relapse. Although only a small proportion of patients will benefit from resection of liver metastases, this form of treatment offers the only possibility of cure.
Surgery is currently the first-line treatment option for primary colorectal cancer (CRC) and resectable metastatic disease. Cytotoxic chemotherapy is used for adjuvant treatment as well as for the treatment of advanced disease; the combination of 5-fluorouracil (5-FU) plus leucovorin is currently the standard chemotherapeutic regimen used in most centers. In many countries patients with CRC do not receive chemotherapy because some clinicians perceive that the benefits of such treatment do not compensate for the potential negative effects on patient quality of life in terms of toxicity and inconvenient dosage schedules. However, recent evidence suggests that the use of cytotoxic chemotherapy can lead to an improvement in quality of life and effective palliation in CRC. A number of new treatment options are becoming available for the treatment of this malignancy.
The following active areas of research and/or treatment approaches are currently investigated in many clinical trials: (1) approaches for enhancing 5-FU/leucovorin activity; (2) novel delivery of 5-FU or 5-FU precursor agents; (3) new thymidylate synthase inhibitors; (4) new platinum analogues; (5) topoisomerase I inhibitors; (6) targeting specific proteins or pathways important for the growth, survival, or metastasis of CRC cells; (7) biologic response modifiers, including monoclonal antibodies; and (8) gene therapy. As the cellular mechanisms involved in CRC are further defined and chemotherapy or biologic agents more precisely targeted, response rates and ultimately survival will hopefully improve in this patient population.
Hepatic resection remains the only potentially curative treatment for metastatic colorectal cancer, Resection of liver secondary tumors improves 5-year survival from 0% to approximately 30% and offers the only possibility for cure
Data support the concept that patients with unilobar metastatic disease who undergo surgical resection with tumor-free surgical margins can be afforded a significant opportunity at long-term survival with acceptable morbidity, mortality, and hospital stay. Also, certain patients with bilobar or extrahepatic disease (or both) who undergo complete resection can enjoy a long-term survival. In these subgroups of patients resection should be considered on an individual basis.
Overall, hepatic resection appears to be an important means of curing patients with metastatic colorectal cancer isolated to the liver. The only absolute contraindication to surgery was the impossibility of a radical removal of tumor: if residual disease will remain after the hepatic resection, this operation is not indicated. A possible second contraindication to surgery is the presence of tumor in the hepatic or celiac lymph nodes
Rehapectomy may be performed safely and may provide the only chance of long-term remission in patients presenting with technically resectable liver recurrence in the absence of widespread extrahepatic disease. In conclusion, repeat hepatectomy for recurrent liver metastases is a viable option for the well selected patient. It is a low risk surgical procedure and may augment survival in the patient with well documented metastases limited to the liver.
There are current studies suggesting that hepatic and pulmonary resection can result in long term survival in select patients with hepatic and pulmonary metastases from colorectal carcinoma because surgery remains the only potentially curative treatment.
Colorectal cancer is an aggressive disease, and it should be managed with an aggressive surgical approach and there are lots of evidence that it works. To my mind your patient will need initial surgical excision of the primary, with assessment of extrahepatic involvement, a combination of 5-fluorouracil (5-FU) plus leucovorin should be given, then wait for a period of 3-4 months. At the end of this interval a thorough assessment is made for recurrent local, regional or extrahepatic metastatic disease before making a decision to do a liver resection if technically feasible.