According to the National Cancer Institute, colorectal cancer (CRC) is the second leading cause of cancer death in the United States. However, modern chemotherapy and improved surgical techniques for resectable metastases have increased the average survival for patients with stage IV metastatic CRC from approximately 6 months about 20 years ago to between 2 and 3 years today. To further enhance clinicians’ ability to manage liver metastases from CRC and contraindications to initial liver resection, a group of experts convened and published a consensus statement in The Oncologist.
Aggressive Surgical Approaches for CRC
“With surgery, it’s expected that some patients with metastatic CRC will be cured,” explains Jean-Nicolas Vauthey, MD, lead author of the consensus statement. “That’s unique for a stage IV solid cancer. It’s also why we’re aggressive by performing surgery. The typical approach is to resect the primary CRC, administer chemotherapy, and then resect the liver metastases [Table]. Some patients, however, present with both primary colon cancer and liver metastases in place. In some of these patients, resection of the liver metastases is recommended, followed by resection of the primary CRC in a second surgery.”
Dr. Vauthey notes that both of these surgeries can be performed at the same time if the primary colorectal tumor is easily resectable, and the number of liver metastases is low. “When patients have extensive metastatic disease with multiple metastases involving the right and the left lobe of the liver, two sequential liver resections can be performed. For example, one strategy could be to treat patients with chemotherapy, perform a first liver surgery to remove metastases in the left lobe, and then perform a second major surgery 3 months later to remove the remaining metastases in the right lobe. Since the liver can regenerate, surgical resection gives clinicians the option of attempting curative surgery because it’s intended to completely eradicate the disease.”
Pearls of Colorectal Cancer Treatment
According to Dr. Vauthey, there are five key factors of metastatic CRC management that clinicians should consider:
1. Be optimistic. The 5-year survival rate for CRC patients has approached 60% in those who undergo resection of liver metastases, representing an increase from 25% just 15 years ago. Surgery-related mortality is low.
2. Do not overextend chemotherapy. Short-course chemotherapy (2 to 3 months) should be considered prior to resection. Resection should be undertaken as soon as resection is feasible.
3. Consider advanced approaches. These may include sequencing surgery. Portal vein embolization can be used preoperatively to increase the liver’s size and allows for safer resection of either lobe.
4. Use advanced chemotherapy and imaging to predict survival. Liver metastases from CRC have a radiologic response to chemotherapy. Although they may not shrink, those that become very dark and homogenous on CT are associated with a higher than 50% cell kill. This allows for better patient selection for surgery and survival prognostication.
5. Avoid solely palliative procedures and consider more curative approaches. Radiofrequency ablation or other non-curative approaches should only be considered after resection has been excluded.
Teamwork Matters for Metastatic Colorectal Cancer
According to the consensus statement, multidisciplinary teams should be used whenever possible when caring for patients with metastatic CRC. “The team should include oncologists, pathologists, nurses, nutritionists, cancer coordinators, and interventional radiologists,” says Dr. Vauthey. “Radiology is the cornerstone for quality care. Early discussions of treatment options between surgeons and medical oncologists based on high-quality imaging—usually high resolution CT of the chest, abdomen, and pelvis—are best for optimizing outcomes.”
Barriers to effective multidisciplinary teams exist, including a lack of or conflict regarding leadership and coordination, insufficient administrative support and implementation, limited resources (eg, expertise, time, and associated costs), and a lack of commitment and/or interest from team members. However, research suggests that taking a multidisciplinary approach is beneficial for both patients and team members. “Efforts are needed within the cancer care community to overcome such barriers,” adds Dr. Vauthey.
Visions of Hope for CRC
The recommendations issued by Dr. Vauthey and colleagues are intended to simplify treatment decisions and standardize care. Dr. Vauthey hopes that the document “will raise the standard of care for patients with liver metastases from CRC and ensure that they’re receiving the best treatment possible to extend survival and improve outcomes.”
Readings & Resources (click to view)
Adam R, De Gramont A, Figueras J, et al. The oncosurgery approach to managing liver metastases from colorectal cancer: a multidisciplinary international consensus. Oncologist. 2012;17:1225-1239. Available at http://theoncologist.alphamedpress.org/content/17/10/1225.abstract.
Adams R, Aloia T, Loyer E, et al. Selection for hepatic resection for colorectal liver metastases: expert consensus statement. HPB (Oxford). 2013;15:91-103.
Abdalla E, Bauer T, Chun Y, et al. Locoregional surgical and interventional therapies for advanced colorectal cancer liver metastases: expert consensus statement. HPB (Oxford). 2013;15:119-130.
Schwarz R, Berlin J, Lenz H, et al. Systemic cytotoxic and biologic therapies of colorectal liver metastases: expert consensus statement. HPB (Oxford). 2013;15:106-115.
Chun YS, Vauthey JN, Boonsirikamchai P, et al. Association of computed tomography morphologic criteria with pathologic response and survival in patients treated with bevacizumab for colorectal liver metastases. JAMA. 2009;302:2338-2344.