ESMO WCGC 2013 Report – Surgery for Liver Metastases: How far should the surgeon go?

A review of the presentation by Rene Adam MD (pictured).  There has been considerable progress in the overall survival of patients with colorectal cancer taking chemotherapy. Overall survival (OS) has increased from the days of using 5-FU/FA with an OS of 11 months to now using chemotherapy agents plus cetuximab and reaching OS of 23.5 months.

Surgery has also been shown to have considerable benefits and there is a new ‘practical’ definition of resectability provided (Adam R et al Gastrointest Cancer Res 2009):

• All liver metstases that can be completely removed while leaving at least 30% of remnant liver …
• Even in cases with extrahepatic tumours, if these are also resectable…

Liver metastases are resectable in approximately 50% of cases, the other cases having to rely on chemotherapy alone. There are a number of situations where practice and evidence suggests patients should not be operated on and these include:

1. Those for whom Hepatectomy could not resect all lesions
2. Those with unresectable extahepatic metastases
3. Those with progress while on chemotherapy
4. Those with special extrahepatic deposits
5. Those whose survival after resection is not superior to that of chemotherapy.

Dr Adam went on to provide arguments and examples where there are exceptions to the list above. He suggested that patients having surgery with the poorest prognosis have a median survival similar to that of chemotherapy alone. Dr Adam stated that surgery by its local effect may have a debulking effect comparable to that of a complete pathological response observed with chemotherapy. Dr Adam suggested that owing to the low operative risk of liver resection, surgery should be discussed even in marginal indications.

Dr Adam stated that “what is crazy surgery in a patient not responding to chemotherapy could become reasonable in a patient responding to systemic treatment.”