Colorectal cancer metastasis treatment

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Saarah T. Alkhairy, M.D.; Elliot B. Tapper, M.D.

Overview

When colorectal cancer metastasizes, there will be a different approach than with a localized tumor. The most common site of metastasis is the liver, and the second most common is the lung.

Colorectal Cancer Metastasis

Treatment of Hepatic Metastasis

  • According to the American Cancer Society statistics in 2006, greater than 20% of patients present with metastatic (stage IV) colorectal cancer at the time of diagnosis, and up to 25% of this group will have isolated hepatic metastasis that is potentially resectable
  • Current chemotherapy regimens including oxaliplatin and irinotecan in addition to 5-fluorouracil (5-FU), and leucovorin (LV) have achieved improved response rates in colorectal liver metastases[1]
  • Lesions confined to the right lobe are amenable to en bloc removal with a right hepatectomy surgery
  • Smaller lesions of the central or left liver lobe may sometimes be resected in anatomic "segments", while large lesions of left hepatic lobe are resected by hepatic trisegmentectomy
  • Treatment of the lesions by smaller, non-anatomic "wedge" resections, are associated with higher recurrence rates
  • Some lesions which are not initially amenable to surgical resection may become candidates if they have significant responses to preoperative chemotherapy regimens
  • Lesions which are not amenable to surgical resection for cure can be treated with modalities including radiofrequency ablation (RFA), cryoablation, and chemoembolization
  • These patients may be treated in either a single surgery or in staged surgeries (with the colon tumor traditionally removed first) depending upon the fitness of the patient for prolonged surgery and the difficulty expected with the procedure with either the colon or liver resection

Treatment of Pulmonary Metastasis

  • The surgical approach of pulmonary metastases is dictated by the number, size, location, and lobe involved
  • The bilateral thoracosternotomy (“clamshell” incision) involves bilateral submammary thoracotomies with transverse division of the sternum - this incision provides excellent exposure to the hilum and all lobes of the lung[2]
  • VATS procedures are rapidly gaining popularity - they utilize laparoscopic-style instruments introduced via trocars resulting in smaller incisions and reduced postoperative morbidity[2]

The table below depicts the patterns of pulmonary metastatic spread and the suggested operative approach:[2]

Nodule Characteristics Thoracotomy VATS
Number >3 3-Jan
Size (cm) >4 <1.5
Location Central Peripheral
Lobe Lower Upper, middle

References

  1. Misiakos, Evangelos P (2011). "Current treatment for colorectal liver metastases". World Journal of Gastroenterology. 17 (36): 4067. doi:10.3748/wjg.v17.i36.4067. ISSN 1007-9327.
  2. 2.0 2.1 2.2 Villeneuve, P.; Sundaresan, R. (2009). "Surgical Management of Colorectal Lung Metastasis". Clinics in Colon and Rectal Surgery. 22 (04): 233–241. doi:10.1055/s-0029-1242463. ISSN 1531-0043.

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