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Synchronous Hepatic Colorectal Metastases: Old Dilemma, New Problems. Shaun McKenzie, MD Assistant Professor of Surgery University of Kentucky. Objectives. Review the literature driving the controversies behind available approaches

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synchronous hepatic colorectal metastases old dilemma new problems

Synchronous Hepatic Colorectal Metastases:Old Dilemma, New Problems

Shaun McKenzie, MD

Assistant Professor of Surgery

University of Kentucky

objectives
Objectives

Review the literature driving the controversies behind available approaches

Emphasize the complexity involved in the multidisciplinary management of these patients

Propose a baseline algorithm to scaffold an ever evolving treatment strategy

synchronous hepatic crc
Definition: the presence of hepatic metastases identified at the time of diagnosis of the primary tumor or within 6 months of diagnosis

Approximately 2400 US patients present with Synchronous CRC Hepatic Metastases annually

These patients compromise 15-25% of new cases of CRC per year

They compromise 25-50% of most large hepatic resection series for CRC

They are believed to represent a patient population with aggressive biology and poor prognosis

Synchronous Hepatic CRC
is synchronous disease worse
Is Synchronous Disease Worse
  • Many retrospective studies and clinical risk scores have incorporated disease free interval as a poor prognostic factor
  • Several recent series have questioned whether synchronous resectable disease is worse than metachronous resectable disease
    • Bockhorn et al compared 63 pts with synchronous disease to 63 pts with metachronous disease: no difference in DFS or OS
    • Minagawa et all show no difference in survival comparing 3,5,10 year survival of 187 vs. 184 pts respectively
    • Capisotti et al noted 5 year survival of 30% for patients with resected synchronous disease

Reddy et al. Ann Surg Oncol 2009; 16:2395-2410

unresectable hepatic metastases
Unresectable Hepatic Metastases

Muratore et al. Ann Surg Oncol 2007; 14:766-70

leave the primary
Leave the Primary

Poultsides et al

resectable hepatic metastases
Resectable Hepatic Metastases

Aloia, Fahy. Clin Colorectal CA 2008; 7:197-201

need for chemotherapy
EORTC Intergroup Trial 40983

RCT 182 patients per arm

6 cycles FOLFOX 4 pre and post resection vs. hepatectomy alone

Need for Chemotherapy

Nordlinger et al. Lancet 2008; 371:1007-17

simultaneous vs staged resections
Simultaneous Vs Staged Resections

Reddy et al. Ann Surg Oncol 2007; 14:3481-3491

liver first
Liver First

Mentha et al. Br J Surg 2006; 93:872-78

case by case decision making
Case by Case Decision Making

Broquet et al. JACS 2010, 210:934-941.

slide21
Preoperative chemotherapy induces a liver injury that may increase perioperative morbidity and postoperative hepatic dysfunction

Portal Vein Embolization allows hypertrophy of the Future Liver Remnant (FLR) in patients requiring extended resections or after prolonged courses of prehepatectomy chemotherapy

Requires a 4-6 week waiting period prior to resection

Concerns exist regarding its effectiveness during chemotherapy and its oncologic effect

PVE
the evolving algorithm
The Evolving Algorithm

Synchronous Hepatic CRC

Unresectable hepatic disease

Resectable disease

Minor Hepatectomy

Needed

Major hepatectomy

Needed

chemotherapy

Simultaneous resection

Followed by chemotherapy

Inadequate

response

Resectable

Colon

Primary

Rectal

Primary

Bilobar disease

Colon

Resection

Hepatectomy

Chemotherapy

Continue chemotherapy

Or enter a trial

R/S

Neoadjuvant

CRT + rectal

resection

P

N1

N2

Primary +FLR dz

First, +/-PVE,

hepatectomy

Hepatectomy

then chemo

Chemo then

hepatectomy

Chemo