Cytoreduction for colorectal metastases: liver, lung, peritoneum, lymph nodes, bone, brain. When does it palliate, prolong survival, and potentially cure?

Abstract

Colorectal cancer commonly metastasizes. The liver is the most frequent site of metastases and dominates the length of survival for this disease. As surgical and systemic therapies have become accepted and now are proven to be potentially curative, other sites of metastases have become more clinically relevant in terms of clinical symptoms and influence on survival. Treatment of extrahepatic metastases by surgical and ablative procedures is increasingly accepted and is proving to be effective at palliating symptoms, as well as life prolonging. In this review, we will first summarize key issues with metastatic colorectal cancer to the liver and available treatments. We will then discuss surgical and ablative treatments of other sites of disease including lung, lymph nodes, peritoneum, bone, and brain. Best available evidence for treatment strategies will be presented as well as potential new directions.

Figure 1.

Sites of metastases at death. Data from 476 patients with colorectal cancer followed until death.

Figure 2.

Dominant sites of disease/ causes of death for 476 patients with stage IV colorectal cancer followed until death.

Figure 3.

Sites of cancer progression and likelihood of site of disease causing death.

Figure 4.

Median time of presentation of each metastatic site (gray bars) and median survival after presentation (white bars) for each metastatic site of disease.

Figure 5.

Survival of patients subjected to liver resection for hepatic colorectal metastases in the pre-adjuvant chemotherapy era. Data represents actual 25-year survival. Adapted from Fortner and Fong, 2009 (4).

Figure 6.

Algorithm of treatment for patients with synchronous hepatic colorectal metastases.

Figure 7.

Incision dominant case of liver metastases. Located in segment 7 of the liver, this small lesion (circled) requires a large incision for open surgery. It is also difficult to reach this with routine laparoscopy. This is a lesion ideal for out-patient robotic hepatectomy.

Figure 8.

Long-term results of microwave ablation for cancer. For tumors less than 1 cm in size, recurrence was 1%. For those > 3cm in size, recurrence rate was 9%. Adapted from Leung et al., 2015 (97).

Figure 9.

Patients with ill-placed lesion involving both portal veins, and all three hepatic veins (A). Combined treatment with microwave and IRE resulted in FDG-PET-negative scan 2 years later (B).

Figure 10.

Survival of patients after peri-aortic lymph node dissection. Kaplan Meyer curves are shown for node dissection (D+) and control (D-) patients. Reproduced with permission from Choi et al., 2010 (261).