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Invited Lecture (JSGS)
Sat. October 14th   14:00 - 14:40   Room 1: Fukuoka Kokusai Center Arena
Invited Lecture-8
Multidisciplinary treatment of liver metastases from colorectal cancer (CRLM)
R. Adam
Paul Brousse Hospital, Paris South University
 Hepatic metastases affect around 50% of patients with colorectal cancer.
Surgical resection is the gold standard treatment as the only one providing long-term survival. Optimal results are obtained in selected patients with three or fewer metastases, confined to one lobe, resected with clear surgical margins (>1cm), in the absence of extra-hepatic disease. However, none of these factors is an absolute contraindication to surgery, provided that the overall strategy could resect all the tumors. Surgery remains in these cases, the only possibility of long-term remission. In recent years results of surgery have improved both for the diminution of the perioperative mortality (0-2% in specialized units) and for the rate of 5-year survival (42% overall for the > 25,000 patients registered in LiverMetSurvey).
However, resection is an initial option for only 10-20% patients, and most patients with CRLM present with unresectable disease. Systemic chemotherapy is the common treatment in these circumstances with recently, a dramatic improvement of both rates of response and survival. This improvement related to the use of oxaliplatin and irinotecan, is presently amplified by targeted therapies such as cetuximab, panitumumab and bevacizumab. However, the increase in median survival with chemotherapy alone, still little impacts long-term survival. Therefore, strategies for treating initially unresectable disease have included induction chemotherapy aimed at downsizing the metastases and making them suitable for resection. At least 20% of unresectable patients respond in such extent to chemotherapy that they could benefit from rescue surgery with a 5-year survival of 30-35%. To further increase the resectability rate, specific techniques such as portal embolisation, radiofrequency ablation combined with resection, and two-stage hepatectomies are presently available. Overall, the onco-surgical concept to combine chemotherapy and surgery is increasingly accepted as the best mean to improve the prognosis of advanced metastatic colorectal cancer and even transplantation could sometimes be performed for very selective cases.
To prevent tumor recurrence following liver resection, adjuvant systemic or intraarterial hepatic chemotherapy are used but still need to demonstrate their efficacy.
Finally, in patients who relapse, repeat resections give the same survival benefit as that of the first liver resection.
In summary, while merely palliative in the past, the treatment of CRLM is currently switching to an increased rate of long-term remission by an onco-surge approach. Strategies are becoming more «agressive» and multidisciplinary, resulting in a significant gain in survival of many patients promised in the past, to a very poor outcome.
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