Management of colorectal liver metastases after complete response to neoadjuvant chemotherapy. A case of computertomography-guided wire marking of the liver tumor

Abstract

Dear Editor, The liver is a frequent site for metastases of colorectal cancer. Approximately 15% of patients have hepatic metastases at time of diagnosis and another 50% develop metastatic disease to the liver over the course of their disease. Unfortunately, only 10–25% of patients are candidates for liver resection. Owing to new chemotherapeutic agents (irinotecan and oxaliplatin) and new targeted agents such as bevacizumab and cetuximab, response rates, respectability rates, and survival times have improved. Furthermore, some patients who undergo neoadjuvant chemotherapy with these new chemotherapy regimens have complete response of the liver tumors and the tumor is no longer visible by computertomography (CT) scan or intraoperatively. The question is now what to do with those patients? We present a case of a 50-year-old female who underwent a right hemicolectomy for caecal cancer and a left oophorectomy due to metastasis in an outside hospital. At that time, the patient had a synchronous liver metastasis in segment IV b of the liver. After an uneventful postoperative course, eight cycles of xelox plus bevacizumab were administered to the patient. Follow-up CT revealed complete response and no tumor was visible. The patient was then referred to our center for further investigations. CT scan and magnetic resonance imaging showed no visible tumor. Furthermore, F-fluorodeoxyglucose positronemission tomography (F-FDG PET) was performed and revealed enhanced FDG uptake in segment IV b representing a biologic active lesion. After extensive discussion with our oncologist and interventional radiologist, we decided to mark the former metastatic lesion by hook wire as used in breast surgery. With the aid of the CT scan before neoadjuvant chemotherapy, which showed the exact position of the metastatic lesion in the liver, the tumor was measured out and preoperatively a CT-guided hook wire under antibiotic prophylaxis was placed at the position of the presumptive metastatic lesion. Afterwards, the patient was brought in the operating room and an atypical liver segment resection with appropriate safety margin around the pike of the wire was performed. Routinely performed intraoperative ultrasonography of the liver was unremarkable; no tumor lesion could be found. Furthermore, the histological specimen was tumor-free representing also complete pathologic response. The operative and postoperative course was uneventful and the patient was discharged after 1 week length of hospital stay. After close surveillance and a follow-up time of 5 months, the patient is free of tumor. The described case is to our knowledge the first in the literature with a CT-guided wire marking of a non-visible colorectal liver tumor after complete response due to neoadjuvant chemotherapy. The number of patients with colorectal liver metastases receiving surgical resection is increasing. Clinically, the first measurement of efficacy of Int J Colorectal Dis (2009) 24:125–126 DOI 10.1007/s00384-008-0548-3