1. Should chemotherapy given for all
colorectal liver metastases before
resection?
Chandramohan K
Additional Professor
Surgical Oncology
Regional Cancer Centre
Trivandrum

3. Liver metastasis
Synchronous 15% All stages
Metachronous 13% All stages
30% Stage III
Survival 5yr 10yr
36% to 58% 23%
to 36%
perioperative
mortality rates
< 5%

4. Response of Chemotherapy
0
10
20
30
40
50
60
70
5-fluorouracil 5FU+Irinotecan 5FU+Oxaliplatin with
Monoclonal AB
Drugs
Series 1

5. Upfront Chemotherapy for all CRC LM
Resectable
Borderline
Unresectable

6. Is Neoadjuvant Chemotherapy Justified for Resectable Lesions?
• Issues with NAC
• No increase in OS & No Adjuvant arm
Nordlinger B, Sorbye H, Glimelius B, et al. Perioperative chemotherapy with FOLFOX4 and surgery versus surgery alone
for resectable liver metastases from colorectal cancer (EORTC Intergroup trial 40983): a randomised controlled
trial. Lancet. 2008;371(9617):1007–1016.
Adam R, Bhangui P, Poston G, et al. Is perioperative chemotherapy useful for solitary, metachronous, colorectal
liver metastases? Ann Surg. 2010;252(5):774–787
Adjuvant Chemotherapy
Improved survival, whereas NAC had no impact on DFS and OS.
Postoperative complications increased from 24%to 37% in NAC Group

7. Blue Liver

8. Liver Toxicity
• Oxaliplatin  sinusoidal obstruction
syndrome (SOS) (5-50%)
• Irinotetan chemotherapy-associated
steatohepatitis (CASH)
Eur J Surg Oncol. 2008 Jun;34(6):609-14. Epub 2007 Aug 30.
Hepatic complications following preoperative chemotherapy with oxaliplatin or
irinotecan for hepatic colorectal metastases.
Morris-Stiff G1, Tan YM, Vauthey JN.
J Hepatobiliary Pancreat Surg. 2009;16(2):137-44. doi: 10.1007/s00534-008-0016-z.
Epub 2008 Dec 18.
Patterns of chemotherapy-induced hepatic injury and their implications for
patients undergoing liver resection for colorectal liver metastases.
Khan AZ1, Morris-Stiff G, Makuuchi M.

9. • In the EORTC trial, 6 cycles of FOLFOX before
surgery increased
• the overall complication rate from 16% to
25%, and the rate
• of hepatic complications from 9% to 15%.
• But mortality same.

11. Annals of Surgery Volume 255, Number 2, February 2012 Chemotherapy Before Liver Resection

12. Annals of Surgery Volume 255, Number 2, February 2012 Chemotherapy Before Liver Resection

13. Esmo Guideline

14. NCCN

15. Upfront Chemotherapy for all CRC LM
Resectable
Borderline
Unresectable