CRLM

1. Management of Colorectal
Liver Metastasis
Dr Aditya Punamiya
DNB Trainee
Department of Surgical Oncology

2. • 3rd most common cancer
• 3rd leading cause of mortality among men and women.
• Approximately 30% to 50% of patients with this disease will develop
liver metastases at the time of presentation or later during the course
of their disease.

3. Treatment Strategies
• Primary first approach
• Simultaneous approach
• Liver first approach
• True liver first approach
Peter Ihnát, Petr Vávra, Pavel Zonča et al, World J Gastroenterol 2015 June 14; 21(22): 7014-7021

4. Primary first approach
• Also called classical/traditional approach
• Surgery for primary colorectal tumor
• Chemotherapy (Rt for rectal tumors)
• Liver resection after 3-6 months (provided CLM are still resectable)

5. • Rationale :
• Likely source of mets (colorectal tumor)
• symptomatic because of primary
• Advantages :
• Avoids potential complications from primary tumor
• Decreases risk of progression of primary tumor during liver surgery or initial
chemotherapy
• Disadvantage:
• Progression of CLM beyond resectability during primary tumor resection
• 30% of pts underwent complete t/t
• Reverse strategy : 80% of pts completed t/t

6. Simultaneous Resection
• 54/M
• h/o PR bleed
• Colonoscopy : growth in the hepatic flexure of colon
• Biopsy : Adenocarcinoma
• CEA : 10ng/ml
• Ct scan Abdomen and Pelvis : circumferential growth in
the hepatic flexure of colon with hypodense lesion in
segment VI of liver
• Rt Radical hemicolectomy with Wide excision of
segment VI lesion of liver done
• HPR : PT3NI
• On adjuvant chemotherapy.

7. Simultaneous Resection :
• Involves simultaneous resection of liver and primary
• Adjuvant CT after surgery (+ Rt for rectal tumor)
• Strategy : avoid delaying Surgical resction and met liver disease
• Best suited for:
• Only if surgical resection is minor
• Rectal resection with minor hepatectomy
• Rt sided colon resection with major hepatectomy

8. Advantages :
• Removal of all macroscopic disease during a single surgery f/b
systemic chemo with minimal delay
Disadvantages :
• Increased post-op morbidity and mortality
• increased risk bacterial liver infection (from contamination from int.
obstruction)
• increased anastomotic complication (due to impaired LFT)
• negative impact of DFS
• Post-op morbidity:
• 5-48% : Minor hepatectomies (<3 segments)
• 33-55% : Major hepatectomies (>= 3 segments)

9. Liver first Approach
• Reverse t/t strategy introduced by Metitha et all 2000
• Initial preop
Chemo liver resection chemo Sx for primary colorectal
(3-6 cycles) tumor
• Modern cytotoxic drugs (oxaloplatin and irinotecan based ) with
biologics (targeted agents against EGFR/VEGFR) resulted in improved
tumor response rates and prolonged survival of pts with colorectal
tumors

10. case
• 56/m
• H/O pain in abdomen and PR bleed
• Colonoscopy : growth in Sigmoid colon , approx. 15 cms from anal
verge
• Biopsy : well diff adenocarcinoma
• Ct scan abdomen and pelvis/PET CT : metabolic active lesion in
segment V of liver (4.3x3.9cms) and Rectosigmoid junction.
• Received FOLFOX 4 cycles
• Repeat PET CT scan : significant reduction in wall thickening of
rectosigmoid jumction and seg V of liver.
• Anterior resection with wide excision of segment of liver done
• HPR : ypT3N1M1 (liver : viable tumor)
• Currently on Adjuvant chemotherapy.

11. • Prognosis of stage IV CRLM is determined mainly by the curability of
CRLM and not any primary tumor or its potential complications.
• Rationale of Chemotherapy first approach is to provide systemic
therapy to pateints with stage IV CRLM

12. Benefits of chemotherapy first approach
• Early systemic t/t
• Lowering the risk of CLM progression
• Possibility of CLM downstaging or converting unresectable CLM to
resectable
• To perform more selective liver resection and achieve an RO resection
• There is fear of progression of primary in terms of complications
(obstruction, perforation and bleeding), however primary tumor
complications in pts with stage IV CA are rare.

13. • Long periods of systemic therapy before resection can lead to two issues:
• chemotherapy-induced liver injury or steatohepatitis
• disappearing colorectal liver metastases.
• With modern chemotherapy, a subset of patients (approximately 15% to
40%) with unresectable disease may convert to resectable disease, and
these patients have a long-term outcome comparable to those with an
original diagnosis of resectable disease (ie, a 5-year survival of 30% to 40%)
• Patients receiving chemotherapy who continue to have unresectable
disease either because of lack of adequate response or because of
progression of disease have a poor prognosis.

14. Main contraindications of liver resection
• Close to HV/IVC
• Liver hilum, large and numerous livers mets
• Involvement of both portal veins or one portal vein and C/L HV or
involvement of all HV
Relative contraindications of liver resection
• Multiple, diffuse, large liver Mets
• High level of CEA (>200ng/ml)
• Extrahepatic metastasis
Nabil Ismaili , Ismaili World Journal of Surgical Oncology 2011, 9:154
http://www.wjso.com/content/9/1/154

15. Upfront Hepatectomy
(True liver first approach)
• Surgical resection : only t/t modality that offers long term survival to
pts with synchronous resectable CLM
• Main drawbacks of Chemotherapy:
• Liver toxicity (steatosis, steohepatitis and sinusoidal obstruction syndrome)
• Missing lesions
• Risk of tumor progression
• Increased risk of systemic toxicity, postop bleeding and infection (by inducing
neutropenia)
• Chemo induced liver injury: worse postop outcomes of subsequent
liver resection

16. Case
• 24/M
• H/o PR bleed and loss of weight and appetite since 3 months
• Colonoscopy : growth in rectum, 11 cms from anal verge.
• Biopsy : Mod diff Adenocarcinoma
• CEA: 11ng/ml
• Ct scan Abdomen and pelvis : Hypodense lesion in segment IV A of
liver (2.9x1.9cms ) and another in Segment II of liver
(10x8mm).Irregular eccentric mass in the lower rectum with enlarged
perirectal LN.
• Wedge resection of segment IV A and II done.

17. • He then received NACTRT (long course).
• CEA levels: 6.59ng/ml
• Ct scan Abdomen and MRI pelvis : irregular
circumferential wall thickening in mid
rectum with tethering of anterio mesorectal
fascia with enlarged peri rectal LN.
• Low Anterior Resection with Diverting loop
Ileostomy done.
• HPR : ypT1N1, all margins free.
• Now, on adjuvant chemotherapy CAPOX.

18. Resection Methods
Minor
• Atypical liver resection
• Local excision
• Left lateral segmentectomy
Major
• Rt/Lt hepatectomy
• Trisectionectomy
• ALP.PS procedure (Associating
liver partition for staged
hepatectomy)
Felix Aigner Johann Pratschke Moritz Schmelzle , Visc Med 2017;33:23–28, DOI: 10.1159/000454688

19. Two-Stage Hepatectomy
• In patients presenting with unresectable bilobar liver metastases who
respond to systemic chemotherapy, a two-stage hepatectomy
approach has been proposed.
• Minor disease is resected first, followed by contralateral portal vein
embolization to maximize future liver remnant before major
hepatectomy.
• Brouquet et al : After a median follow-up of 50 months, 5-year
survival was 51% in the two stage hepatectomy group compared with
15% in those treated by chemotherapy alone.
Mashaal Dhir, MBBS, and Aaron R. Sasson, MD , Volume 12 / Issue 1 / January 2016

20. • There are several different possibilities for treatment sequencing:
(1) chemotherapy, hepatectomy (first stage), hepatectomy (second
stage), then chemotherapy
(2) chemotherapy, hepatectomy (first stage), portal vein embolization,
hepatectomy (second stage), then chemotherapy
(3) chemotherapy, hepatectomy (first stage), portal vein
embolization,chemotherapy (second stage), hepatectomy, then
chemotherapy

21. Disappearing liver metastases
• The management remains controversial.
• Resection is the usual recommended treatment, if resection of all
original sites of disappearing liver metastases is feasible.
• If the original sites cannot be resected, it is reasonable to resect
macroscopic disease and leave disappearing liver metastases in situ
because more than one half of these tend to recur within a year.
• Surveillance : patients older than 60 years and with multiple factors
predictive of true complete, pathologic response, such as
normalization of CEA, hepatic artery infusion therapy, body mass
index <30 kg/m2, and diagnosis of disappearing liver metastases
made through MRI.
Mashaal Dhir, MBBS, and Aaron R. Sasson, MD , Volume 12 / Issue 1 / January 2016

22. Decision making before surgery involves
evaluation for the following:
• Number, size, and location of lesions and their relationship to inflow and
outflow vessels;
• subtle radiologic signs such as fatty liver disease
• signs of portal hypertension such as splenomegaly (low platelet count and
impaired liver function tests can be an indicator of underlying liver
damage)
• Portal and retroperitoneal lymphadenopathy
• Peritoneal carcinomatosis;
• Other areas of metastases, including lung, mediastinum, bone, etc
• Size and function of the future liver remnant

23. Evaluation of Future Liver Remnant Volume
• Calculated using three-dimensional CT volumetry.
• The size of the FLR has been used as a surrogate to predict
postoperative outcomes.
• Normal LFT : FLR of atleat 30% is recommended.
• For patients with cirrhosis and for those treated with systemic
chemotherapy because of the underlying liver dysfunction, a larger
FLR is recommended (40% for cirrhosis, 30% after systemic
chemotherapy).

24. Margins of Resection
• R0 resection margins : Goal of surgical resection.
• A positive margin increases the risk of local recurrence and
compromises long-term survival
• As more and more complex resections are being undertaken, a 1-cm
margin is not always feasible. The goal of surgery is to achieve an R0
resection margin

25. To Conclude :
• Primary first: symptomatic primary with synchronous CLM
• Simultaneous if primary associated with minor hepatectomy of Rt
sided colonic CA
• Borderline resectable/unresectable (Marginally)
• Chemo first reassessment after 2months Liver resection
• Upfront Hepatectomy: Initially resectable CLM

31. Thank you….