Chapter 11 - Metastatic colorectal carcinoma (CRC)

Abstract

Hepatic metastases of colorectal carcinoma (CRC) are the most common hepatic tumors. Approximately 30%–50% of patients diagnosed with CRC will have synchronous or metachronous hepatic metastases. An increase of carcinoembryonic antigen (CEA), AST/ALT, bilirubin, or alkaline phosphatase during posttreatment surveillance for CRC is suggestive of local or distant metastatic disease. The surgical strategy in patients with CRC and synchronous hepatic metastases is individualized for each patient. The appropriate sequence and timing of chemotherapy, hepatic resection, and colorectal resection is not clearly defined. Concomitant colorectal and hepatic tumor resection may be performed if minor liver resection and a straightforward colorectal resection is feasible. “Liver first” resection is appropriate in patients with extensive hepatic metastatic disease, or in patients with rectal cancer with planned neoadjuvant chemoradiotherapy. A “colorectal first” resection is indicated for symptomatic CRC; namely, bleeding and/or obstruction. Most frequently, upfront chemotherapy is given. This is useful for tumor response assessment and treatment of micrometastases. Hepatic resection, when feasible, provides optimal oncological outcomes. Parenchymal-sparing resections are preferred; they offer similar recurrence and overall survival rates when compared with major hepatectomy. Resection combined with ablative modalities is possible with multiple metastases. Additional/alternative treatment may include cytotoxic chemotherapy with FOLFOX/FOLFIRI, radioembolization with yttrium-90-microspheres, and targeted therapy with monoclonal antibodies.