ASO Author Reflections: Synchronous Liver and Peritoneal Metastasis From Colorectal Cancer
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Synchronous Liver and Peritoneal Metastasis From Colorectal Cancer Eyal Mor, MD1, Mohammad Adileh, MD1, Arie Ariche, MD2, and Aviram Nissan, MD1 1
Department of General and Oncological Surgery–Surgery C, Sheba Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel; 2Department of Surgery, Hadassah-Hebrew University Medical Center Mount Scopus, Jerusalem, Israel
PAST
PRESENT
Distant metastasis is considered to be a systemic disease, so surgical resection was not a treatment option. Colorectal cancer is among very few disease types for which surgical resection is shown to improve survival. The treatment of oligometastatic disease in the liver has evolved into complex resections of multiple metastasis with a good oncologic outcome. The management of peritoneal metastasis remains controversial. Findings have shown that cytoreductive surgery (CRS) performed in centers of excellence improves survival. The role of adjuvant systemic or intraperitoneal therapy remains to be proven. Simultaneous liver and peritoneal spread of colorectal origin is associated with a poor prognosis, and surgical resection still is contraindicated by most oncologists.1–3 A consensus statement in 2008 maintained that in cases of minimal hepatic involvement (up to 3 lesions), complete cytoreduction may be feasible.4 Several small retrospective studies have shown the feasibility of the procedure, with acceptable postoperative morbidity. In these studies, patient selection was considered essential to the achievement of acceptable outcomes.5 Although this approach currently is accepted by some surgeons and oncologists, most patients currently undergo systemic chemotherapy alone without consideration of surgical intervention.
Surgical treatment of combined liver and peritoneal metastasis is not only a technical dilemma but also a conceptual dilemma. This study6 evaluated both oncologic and safety outcomes for patients who underwent combined CRS/intraperitoneal hyperthermic chemoperfusion (HIPEC) and liver resection. Early and late outcomes were compared with outcomes for patients who underwent CRS/ HIPEC alone and liver resection alone. The major postoperative morbidities did not differ among the three groups (p = 0.83). The majority of the complications in the HIPEC groups were due to anastomotic leaks and intraabdominal fluid collections compared with the liver resection-alone group, in which biliary leaks and liver abscess were the most prevalent. The 5-year overall survival (OS) rate was 48.8% in the combined CRS/HIPEC and liver resection group compared with 55.4% in the CRS/HIPEC-only group and 60.2% in the liver resection-alone group. A comparison of CRS/HIPEC with and without simultaneous liver resection did not show a statistically significant difference in OS (p = 0.311). The 5-year disease-free survival (DFS) differed significantly among the three groups, with DFS of 14.2% in the combined CRS/HIPEC and liver resection group, 23% in the CRS
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