Advanced Approaches to the Management of Colorectal Cancer with Liver Metastases

Colorectal surgeons and surgical oncologists at Penn Medicine are now performing staged or combined laparoscopic resections of colorectal cancers with liver metastases (CLM).

Many patients with colorectal cancer develop metastases, often confined to the liver. Of these metastases, about half are present at the time of initial diagnosis.

The remainder manifest as metachronous disease. At presentation, patients with more limited disease may be resectable; however, many individuals have more advanced disease at presentation and require systemic chemotherapy. A subset of these patients will become candidates for resection through downstaging.

Technical advances and improvements in perioperative care have enhanced the safety of liver surgery, and major hepatectomy in particular. Surgery has been shown to improve long-term survival in carefully selected patients with CLM. [1] Criteria for hepatic metastasectomy include the ability to completely resect metastatic disease with preservation of a sufficient remnant liver.

At Penn Medicine, specialists in colorectal surgery, endocrine and oncologic surgery and interventional radiology have developed a collaboration that, despite its practical and intuitive character, remains uncommon in the region. Together, the Penn team has developed a variety of laparoscopic and open approaches to CLM that allow resection of all disease and rapid recovery with an eye to completion of multimodality therapy.

Patients with limited CLM disease may be candidates for single stage combined laparoscopic resection of the colorectal primary tumor and metastases. Those with bilobar synchronous CLM may benefit from laparoscopic resection of colorectal primary and left sided liver metastases. Second stage right hepatectomy can then be performed at a later date. If the left liver remnant is not sufficient to support right hepatectomy based on volume measurements, right portal vein embolization (PVE) may be performed to allow for left liver hypertrophy prior to the second stage operation (see Figure).

Case Study 1

Mrs. E, age 68, was referred to Penn Medicine with a two-month history of anemia. With the exception of mild arthritis, she was otherwise healthy. A colonoscopy at Penn revealed a large (>3 cm) cecal cancer. A biopsy confirmed a diagnosis of adenocarcinoma; subsequently, a CT scan identified a single 3 cm lesion in the left lobe of the liver (Figure 1).

After two months of systemic therapy with radiographic response in the liver, a combined laparoscopic resection of the isolated metastases was performed, aided by intraoperative ultrasound and laparoscopic right colectomy. Mrs. E was discharged from the hospital on postoperative day six and started adjuvant chemotherapy seven weeks after surgery. She completed an additional four months of chemotherapy and is now on surveillance. She remains disease free 11 months after surgery.

Case Study 2

Mr. H, a 73-year-old with a diagnosis of synchronous rectosigmoid cancer and bilobar CLM (two peripheral lesions in the left liver and three lesions in the right liver) came to Penn Medicine for management.

A first stage laparoscopic colectomy and partial left hepatectomy was performed. He then received two months of systemic therapy with radiographic response in the residual right-sided liver lesions. Restaging CT scan revealed a small left future liver remnant (21% of calculated total liver volume). Mr. H then underwent PVE; hypertrophy of the liver remnant was confirmed on repeat CT scan.

Subsequently, Mr. H had a right hepatectomy through an open abdominal incision. He was discharged on the sixth postoperative day and is currently receiving adjuvant chemotherapy as planned preoperatively.

Access

Perelman Center for Advanced Medicine
West Pavilion, 4th Floor
3400 Civic Center Boulevard
Philadelphia, PA 19104

Published on: October 4, 2017

References

1. Mahmoud N, Bullard Dunn K. Metastasectomy for stage IV colorectal cancer. Dis Colon Rectum. 2010;53:1080-1092.

About the the Divisions of Endocrine and Oncologic Surgery, Colon and Rectal Surgery, and Interventional Radiology

Colorectal liver metastases are managed at Penn Medicine by a collaborative team drawn from the Divisions of Endocrine and Oncologic Surgery, Colon and Rectal Surgery and Interventional Radiology. The Division of Endocrine and Oncologic Surgery offers comprehensive management of malignant diseases of the breast, gastrointestinal tract, liver, and endocrine organs such as the thyroid and adrenal gland. The Division of Colon and Rectal Surgery offers diagnosis and treatment of diseases arising in the anus, rectum, and large bowel, including colon, rectal, and anal cancer and inflammatory bowel disease. Penn Interventional Radiology is devoted to the minimally invasive, image-guided procedures for the treatment of vascular and lymphatic disorders, regional and local cancers and women’s health conditions.

Penn Faculty Team