Surgery for Hepatic Colorectal Metastases
Symptoms and Diagnosis
Serum carcinoembryonic antigen (CEA) concentration is pivotal in the detection of colorectal cancer recurrence. After resection of primary colorectal cancer, an increasing CEA concentration usually indicates recurrence. (Link to SSAT website: Guideline for Surgical Treatment of Cancer of the Colon or Rectum). Overall, 78% of patients with hepatic colorectal metastases have an elevated CEA concentration. Appropriate radiologic imaging is the cornerstone for evaluation of patients with suspected hepatic colorectal metastases. These examinations include a chest x-ray and helical computed tomography of the chest and abdomen If there is doubt about the diagnosis of metastases in the liver, magnetic resonance imaging may better characterize hepatic lesions, especially if a benign condition is suspected (e.g., a hemangioma or cyst). Positron emission tomography (PET) can be used in selected patients to detect occult disease. PET is most useful in patients at high risk for recurrence after hepatic resection (for more on high-risk patients, see Expected Outcomes below).
The resection of hepatic colorectal metastases begins with laparoscopy or a laparotomy through a midline or a subcostal incision. The abdomen is examined for evidence of extrahepatic disease. An ultrasound is performed to further evaluate the hepatic metastases. Any suspicious nodule outside the liver is biopsied, and frozen sections are obtained. The goal of the operation is to eliminate all metastases with clear resection margins. In the past, hepatic colorectal metastases were not resected in patients with more than 3 lesions or with lesions within 1 cm of major vessels (vena cava or main hepatic veins). Surgeons with experience in hepatobiliary surgery should evaluate patients with multiple metastases (more than 3) or lesions close to major vessels to ascertain their candidacy for resection.
Treatment must be individualized and may require a combination of techniques.Undefined subroutine &main::patientCareGuidelines called at C:\inetpub\wwwroot\WebsiteHosting\SSAT\website\cgi-bin\guidelines_HepaticColorectalMetastases_EN.cgi line 56. Thermal ablation techniques (cryoablation or radiofrequency ablation) have been used as an adjunct to resection or in patients who are not candidates for resection. Because ablation procedures involve relatively new techniques, the proof of efficacy is awaiting mature data. Recent data suggests that radiofrequency ablation is associated with greater persistence than originally thought.
The majority of patients experience recurrence (recur) following hepatic resection of colorectal metastases. New systemic (intravenous) chemotherapy agents (such as irinotecan or oxaliplatin combined with fluoropyrimidines) have been associated with improved survival in advanced colorectal cancer. Adjuvant systemic chemotherapy should therefore be considered after hepatic resection. Because of the lack of proven efficacy, hepatic artery infusion pump chemotherapy should only be used as part of investigational protocols. Trials including combination chemotherapy (systemic and regional) are currently under way.
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Board Approved May 15, 2004