Modern management of colorectal liver metastases
CME Symposium 17.30 Monday 1st July Foyer Level 3
Stephen Fenwick, Aintree Hospital, Liverpool
In recent years there has been a paradigm shift in the approach to management of patients with stage IV colorectal cancer. Liver resection has become a standard therapy, with reported 5 year survival rates approaching 50 per cent. The assessment of resectability is central to optimal treatment planning. With the application of modern surgical techniques, more and more patients are eligible for resection at presentation. Such techniques include extended resections combined with vascular resection and reconstruction, 2 stage resections utilizing portal vein embolization to “grow” the future remnant liver, and combination of resection and ablative therapies. For patients who are unresectable at presentation, there is the chance of conversion to resectable disease through aggressive combination chemotherapy, possibly with the addition of a biological agent.
As imaging continues to improve, more patients are presenting in stage IV. Accurate staging of disease at the outset is paramount so that an appropriate treatment strategy can be proposed. The priority of treatment will vary according to the disease burden in each site, but the aim must be for the best possible long term outcome.
For patients with liver disease not considered suitable for resection, loco-regional techniques may be employed. Percutaneous ablation is one option, most commonly utilizing radiofrequency or microwave energy. Irreversible electroporation is a novel technique which major centres are developing for tumour ablation, particularly where lesions are adjacent to major vascular structures. Embolic therapies can also be used to control metastases within the liver. The agents commonly employed include chemotherapy drug-eluting beads, and Selective Internal Radiotherapy Treatment (SIRT).
Perhaps the most important progress in treating this disease has been the realisation that for optimal management these patients must be managed within an MDT structure, where the focus is advanced colorectal cancer. All specialists involved with treating this disease must be represented in order that a fully informed decision can be made at the initiation of treatment. Regional agreement within cancer networks is essential for this to work, but it is through such collaboration that we can attempt to improve the outcome for these patients.