Liver Metastases From Colorectal Cancer
Liver Metastases From Colorectal Cancer
Colorectal liver metastases (CLM) represent a major challenge for oncologists and surgeons. In fact, in this setting, the optimal treatment of patients can achieve a long-term survival and sometimes a definitive cure of disease. In recent years, improvements in both medical therapies and surgical approaches have led to an increased rate of patients considered amenable for surgery on CLM. New perspectives in the management of CLM underline the need for a comprehensive assessment of patient and tumor characteristics, to integrate technical and prognostic issues into an individualized therapeutic strategy in different patient subgroups. The multidisciplinary evaluation from the onset and during treatment remains the key element to maximizing the benefit of more intensive treatment modalities.
Colorectal cancer (CRC) is the second-most common cause of cancer death in western countries. The liver is the most frequent and often unique site of metastasis in CRC, both at the time of diagnosis (20–25% of cases) or after an apparently radical surgery on the primary tumor (40% of cases). As a consequence, strategies aiming to achieve optimal control and even complete eradication of colorectal liver metastases (CLM) may result in significant benefit in terms of long-term survival, and it is now demonstrated that definitive cure is a reasonable goal, at least in a subset of patients with CLM.
In the last decade, treatment of metastatic CRC (mCRC) has rapidly evolved; the availability of more effective chemotherapy regimens and biological agents directed against VEGF and the EGF receptor (EGFR), together with the increased use of surgery on metastases, have moved median overall survival (OS) up to more than 20 months in recent trials, with a 10-year OS of 20–25% for radically resected patients. Moreover, better patient selection by the use of modern imaging modalities and more aggressive surgical techniques have widened the indication for liver resection in mCRC patients. At the same time, thanks to the increased activity of combination regimens, the percentage of initially unresectable patients who can be reconsidered for surgery after response to medical treatment is increasing. Finally, deeper insights into the disease biology have paved the way to better patient selection for anti-EGFR agents and better prognostic stratification. This article will cover some of the key issues in the management of CLM in different patient categories, discussing the evidences derived from published and presented data and trying to answer to some of the unresolved questions in the field. In particular, we will focus on potential strategies aimed to best integrate the surgical approach with medical treatments in different patient categories, defined by the possibility of achieving a radical resection of metastases either upfront or after tumor shrinkage. In the following chapters, surgical aspects are mainly interpreted in the light of a comprehensive definition of resectability rather than as merely technical issues, while medical therapy is discussed with a particular emphasis on treatment individualization strategies.
Abstract and Introduction
Abstract
Colorectal liver metastases (CLM) represent a major challenge for oncologists and surgeons. In fact, in this setting, the optimal treatment of patients can achieve a long-term survival and sometimes a definitive cure of disease. In recent years, improvements in both medical therapies and surgical approaches have led to an increased rate of patients considered amenable for surgery on CLM. New perspectives in the management of CLM underline the need for a comprehensive assessment of patient and tumor characteristics, to integrate technical and prognostic issues into an individualized therapeutic strategy in different patient subgroups. The multidisciplinary evaluation from the onset and during treatment remains the key element to maximizing the benefit of more intensive treatment modalities.
Introduction
Colorectal cancer (CRC) is the second-most common cause of cancer death in western countries. The liver is the most frequent and often unique site of metastasis in CRC, both at the time of diagnosis (20–25% of cases) or after an apparently radical surgery on the primary tumor (40% of cases). As a consequence, strategies aiming to achieve optimal control and even complete eradication of colorectal liver metastases (CLM) may result in significant benefit in terms of long-term survival, and it is now demonstrated that definitive cure is a reasonable goal, at least in a subset of patients with CLM.
In the last decade, treatment of metastatic CRC (mCRC) has rapidly evolved; the availability of more effective chemotherapy regimens and biological agents directed against VEGF and the EGF receptor (EGFR), together with the increased use of surgery on metastases, have moved median overall survival (OS) up to more than 20 months in recent trials, with a 10-year OS of 20–25% for radically resected patients. Moreover, better patient selection by the use of modern imaging modalities and more aggressive surgical techniques have widened the indication for liver resection in mCRC patients. At the same time, thanks to the increased activity of combination regimens, the percentage of initially unresectable patients who can be reconsidered for surgery after response to medical treatment is increasing. Finally, deeper insights into the disease biology have paved the way to better patient selection for anti-EGFR agents and better prognostic stratification. This article will cover some of the key issues in the management of CLM in different patient categories, discussing the evidences derived from published and presented data and trying to answer to some of the unresolved questions in the field. In particular, we will focus on potential strategies aimed to best integrate the surgical approach with medical treatments in different patient categories, defined by the possibility of achieving a radical resection of metastases either upfront or after tumor shrinkage. In the following chapters, surgical aspects are mainly interpreted in the light of a comprehensive definition of resectability rather than as merely technical issues, while medical therapy is discussed with a particular emphasis on treatment individualization strategies.
