In 20-25% of patients with rectum cancer the synchronous liver metastases are diagnosed and in 20% of cases these are resectable at the time of diagnosis. However, there isn't a unique scientific opinion for the best treatment.
There are no clinical trials and probably they'll never exist to respond this question. The laparoscopic approach resolves the problem of the incision, but as always in new tecnologies incorporated to the medical practice, a lot of description of simultaneously rectal cancer and liver metastasis ressections appears in medical literature. In my opinion this question has to be carefully discussed case by case. The laparoscopic rectal cancer ressection is not a small procedure when the mesorectun is adequally removed and a good linfadenectomy is performed. Major laparoscopic liver ressection (more than 3 segments) also should be performed as a single procedure. In my service we prefer not to combine these operations, only in cases that the patient have a single peripheric metastasis and in the anterior segments of the liver.
Just to comment, I'm digestive surgeon, laparoscopist and my main role is currently in hepatic surgery.
This a challenging problem, in my pratice I begin with sistemic CT ( folfoxiri plus biological) and then a short course (i.e. 5 days of RT ) in attempt to local control (previous staging with eco endoscopy) and attempt to resect liver and rectum in an unique operation
There is no best strategy for all patients. Some patients are suitable for simultaneous resection, others – for sequential, sometimes liver-first approach is required. Timing of chemo/radiochemotherapy is also important. There are multiple options in different scenarios and several important factors should be kept in mind – both primary tumor/liver mets related and pts general condition related. This is highly complex question that requires long and detailed answer with stratification of the patients in several groups.
I agree with the opinion of dr A Julianovic. I think also that a minimally invasive approach , in case , of colorectal cancer associated with minor liver resection ( wedge, anterior segmentectomy) can be a valid opition . I think that in this case the robotic assisted procedure can facilitate the procedure and this exceeds the limits of laparoscopy.
Good question, I confess That in daily practice, we tend to offer the surgical approach at the expense of the other procedures you mentioned. In everyday , we tend to offer and reserve the frequency ablation and cryotherapy in patients with high risk of comorbidity or in combination with surgical procedure. In view of the excellent results reported in the literature, regarding the use of frequency ablation, for the treatment of liver and lung MTS, I think that this technique should be proposed as a valid alternative. Take me unprepared with regard to SABR and HDR. I would be grateful if you give me valid references to consult.
Dear Dr. Lombardi,
thank you for opening this interesting discussion focusing on a challenging issue in gastrointestinal oncology.
Please find attached the guidelines published in 2012 by our society (AIRO, associazione italiana di radioterapia oncologica) regarding the use of radiotherapy in GI cancer.
You will find (pages 133-134) our suggested algorhitms for the treatment of patients with sinchronous and metachronous metastases.
Moreover, pages 169-91 are dedicated to the use of radiotherapy in liver malignancies, which is a relatively new field of interest for radiation oncologists with promising results. Suggested indications for the use of SABR in liver metasates can be found on page 180. A table reviewing studies using SABR in liver diseases is also provided (page 182).
I anticipate that an update of these guidelines is currently under preparation.
Sincerely,
Francesco Dionisi
thank you for your answers, after the evaluation of literature and the AIRO guidelines 2012,we can say that the patient must have an compressive information about all types of procedures ; the non-invasive o semi-invasive procedures are a valid alternative in the patient with a lot of contraindications for surgery and with the long history of surgery for liver mts or for a combined treatment (surgery and radio frequency) . But the experience of surgeon should lead to better therapeutic choice; in the case of pt operable with synchrone liver mts, I still believe that the surgical therapy ( combined or sequential), associated with chemotherapy can still be the first choice of the treatment .
@ Harun Badakhshi
thank you for your interesting comments and literature review.
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