Case study 112.1

A 65-year-old healthy female patient presents with a non-obstructing sigmoid colon adenocarcinoma found on screening colonoscopy. During her preoperative work-up, a 3 cm lesion consistent with metastasis is found near the surface of the right lobe of the liver.

1. What is the best therapeutic option for this patient?

Laparoscopic sigmoid colectomy and laparoscopic wedge resection of the metastasis followed by chemotherapy
Initial 3-month course of neoadjuvant chemotherapy followed by surgical resection of the primary and metastasis
Laparoscopic sigmoid colectomy and radiofrequency ablation of the liver metastasis followed by adjuvant chemotherapy
A 12-month course of chemotherapy followed by restaging of the lesions and consideration for surgery only if the disease is stable or regresses in the liver

This scenario and similar situations with initial presentation as stage IV colon cancer have evolved in recent years with proponents of a liver-first strategy typically prevailing in more extensive involvement of the liver. The current data support a strategy of combined colon and liver surgery when the extent of the liver resection is more modest (especially when a limited wedge resection of a surface metastasis is possible). It is probably optimal to perform intraoperative ultrasound examination of the liver to confirm the absence of other deposits. This approach effectively renders the patient tumor free and avoids any potential risk of chemotherapy-induced liver damage. Conversely, in more advanced single-lobe disease, the approach remains more controversial. There are strong advocates for both of the following options: (i) colon resection followed by chemotherapy and restaging with anticipation of a delayed hepatic resection; or (ii) a combined colon and hepatic resection followed by postoperative chemotherapy. The former is advocated in units with strong outcomes in liver resection and in cases where the primary colon resection is not complex (i.e., a large bulky lesion or cases requiring multivisceral resection). A recent analysis using a large US administrative data set suggested that this approach is associated with a significantly higher morbidity and mortality rate compared to a staged resection approach. There are a number of single center cohort studies, however, which demonstrate excellent outcomes and similar complication rates with either approach. The colon-first approach is also advocated on the basis that a major liver resection (i.e., formal lobectomy or trisegmentectomy) may confer an unreasonable operative risk for the patient. In addition, successful completion of the colectomy followed by a 3-month course of chemotherapy will allow time to assure that the patient does not manifest disease advancement in other locations of the liver, possibly to the extent that resection is futile. Unfortunately, no solid prospective randomized data suggest the superiority of either strategy, and the existing data are fraught with selection biases that are difficult to control for with retrospective data sets. Although the modern chemotherapy regimens have shown improved response rates, irinotecan has been associated with steatohepatitis and oxaliplatin with sinusioidal endothelial injury and presinusiodal scarring. These disorders can limit the amount of liver resected.

The final scenario of unresectable liver disease and a non-obstructing, non-bleeding primary colon lesion has largely been resolved in favor of a liver-first approach. The goal of therapy is to hopefully render the liver disease resectable over time. The perceived risk of advancement of the colon primary leading to emergency colectomy for obstruction, hemorrhage, or perforation has been demonstrated to be a rare event in these patients. In addition, an often unappreciated advantage of this approach by surgeons is the fact that surgical complications of the colectomy may actually delay or deprive this patient group of the ability to begin chemotherapy and the chance for a survival advantage.