| International Session (Symposium) 7 (JSGS・JSGE・JSH) |
| Sat. November 3rd 14:00 - 17:00 Room 4: Portopia Hotel South Wing Portopia Hall |
| Surgical indications for multiple colorectal liver metastases | |||
| Taku Aoki1, Keiichi Kubota1 | |||
| 1Second Department of Surgery, Dokkyo Medical University | |||
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| Surgical resection is the only treatment that can expect the chance of cure even in cases with multiple colorectal liver metastases. However, previous studies have documented that only about 30 % of the patients were judged as “cured” using surgical resection(s) alone 1); in other words, multidisciplinary approach including chemotherapy was applied for 70% of the patients in the course of the disease. In this concern, the high risk group for recurrence after surgical resections is considered to be the candidates for neoadjuvant and adjuvant chemotherapy. The “limit” of surgical resection for multiple colorectal liver metastases is prescribed in terms of (1) technical safety of the procedure, and (2) oncological benefit. First, technically “resectable” colorectal liver metastasis is defined as long as complete macroscopic resection is feasible, while maintaining 30-40 % of functioning liver parenchyma. In cases of insufficient volume of the future liver remnant, portal vein embolization (PVE) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) are the useful options to obtain the hypertrophy of the future liver remnant. ALPPS has been shown to be associated with rapid volumetric hypertrophy, but it has not been clarified whether the rapid volumetric hypertrophy is accompanied with rapid functional gain of the future liver remnant, contributing to the reported high morbidity and mortality rate associated with ALPPS. Some of “technically resectable” colorectal liver metastases should be considered “marginal” or “borderline” indications if the survival benefit of the surgery is limited. Although the consensus of “borderline” liver metastases has not been reached, many previous reports have identified prognostic factors after liver resections, and tumor number, the timing of the presentation of liver metastasis (synchronous or metachronous) and the presence of extrahepatic disease spread have been common strong prognostic factors. In cases with unfavorable prognostic factors, perioperative chemotherapy should be considered., and FOLFOX and CAPOX have been the alternative for the neoadjuvant setting. In the recent guidelines, presence of unresectable concomitant extrahepatic disease, tumor number ≥5, and tumor progression have been the contraindications for upfront surgery 2). On the other hand, cases with initially unresectable liver metastases should be considered to be candidates for “conversion surgery” whenever sufficient tumor shrinkage is obtained after responding to chemotherapy. However, the best treatment strategy aiming at conversion has not been established. After conversion surgery, the recurrence rate remains high, requiring the effective adjuvant chemotherapy. References 1) Takahashi M, et al. Am J Surg 2015; 210: 904-910. 2) Van Cutsem E, et al. Ann Oncol 2016; 27: 1386-1422. |
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Index Term 1: colorectal liver metastasis Index Term 2: multidisciplinary approach |
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