Colorectal cancer: prevention and management of metastatic disease

Abstract

This paper compared the similarities and differences of the two most common types of colorectal cancer metastases. The treatment of liver metastases by surgery combined with systemic chemotherapy was explained. The different natural history of liver metastases as compared to peritoneal metastases and the possibility for prevention of peritoneal metastases were emphasized. Perioperative cancer chemotherapy or second-look surgery must be considered as individualized treatments of selected patients who have small volume peritoneal metastases or who are known to be at risk for subsequent disease progression on peritoneal surfaces. However, the fact that peritoneal metastases, when diagnosed in the follow-up of colorectal cancer patients, can be cured with a combination of cytoreductive surgery and hyperthermic perioperative chemotherapy cannot be ignored. Careful follow-up and timely intervention in colorectal cancer patients with progressive disease are a necessary part of the management strategies recommended by the multidisciplinary team. After a critical evaluation of the data currently available, these strategies for prevention and management of colorectal metastases are presented as the author's recommendations for a high standard of care. As more information becomes available, modifications may be necessary.

Figure 1

Schematic diagram that presents a theoretical model comparing the progression of one colorectal liver metastasis to one peritoneal metastasis over one year. The liver metastasis will expand within the liver parenchyma with a doubling time of approximately three months. The peritoneal metastasis will progress at approximately the same speed but will also exfoliate cancer cells into the free peritoneal space. Many cancer nodules of many different sizes will occur, widely distributed throughout the abdomen and pelvis within one year (reprinted with permission from Sugarbaker PH. Cytoreductive surgery plus hyperthermic perioperative chemotherapy for selected patients with peritoneal metastases from colorectal cancer: a new standard of care or an experimental approach? Gastroenterol Res Pract Volume 2012; 2012: Article ID 309417, 9 pages).

Figure 2

Anatomic sites of right colon cancer progression by the dissemination of cancer cells or minute nodules. The mechanism for right colon cancer implantation and progression at the cancer resection site along the superior mesenteric vessels or on peritoneal surfaces is similar (reprinted with permission from Sugarbaker PH, Sammartino P, and Tentes AA. Proactive management of peritoneal metastases from colorectal cancer: the next logical step toward optimal locoregional control. Colorect Ca 2012; 1 : 115–123).