Surgical treatment of colorectal liver metastases

Resection is the only curative treatment of colorectal liver metastases proofed by a long-term follow-up. The operation is indicated if the metastases are completely removable with sufficient liver parenchyma remaining after resection and if the patient is fit for surgery. The resection is not indicated in cases with non resectable extrahepatic tumours and lymph node metastases distal the hepatoduodenal ligament. The postoperative mortality amounts to about 5 % and the 5-year-survival-rates range between 20 and 40 % depending on the selection of patients. Aims of new concepts of operative therapy are the improvement of resectability by preoperative portal vein embolization, the resection combined with local destructive methods and preoperative chemotherapy. Additionally, new drugs for adjuvant treatment after resection of metastases are studied. The interdisciplinary discussion of the course before and after therapy is essential for the individual optimal treatment.     

结直肠癌肝转移的规范化治疗

结直肠癌发病率逐年升高,超过50％的患者会发生肝转移.随着治疗理念的不断发展以及治疗水平的提高,结直肠癌肝转移目前被认为是潜在可治愈性疾病,其预后也有了显著改善.但是,如何选择治疗方法的问题也随之产生.对于结直肠癌肝转移的规范化治疗,应该包括影像学检查,治疗方式的选择以及多学科团队(MDT)诊断治疗等多个方面,同时应该针对患者制订个体化治疗方案.笔者就结直肠癌肝转移影像学检查方式的选择,不同治疗方法的疗效比较,肝转移灶的外科治疗以及MDT诊断治疗模式等内容进行讨论.     

Surgical treatment of colorectal liver metastases

Recent advances not only in diagnostic imaging examinations but also in surgical techniques of liver resection have extended the indication of liver resection for colorectal metastases, and accumulated experience has improved surgical outcome. Liver metastases develop in a quarter of patients with colorectal cancer, and of these 30 % are candidates for liver resection under the criteria that liver resection is indicated when all tumors can be removed technically with adequate normal parenchyma left, no extrahepatic metastases are detectable, and the patients is considered fit for surgery. As the 5 year survival rate ranges from 30 % and 40 %, liver resection benefits 9 % to 12 % of patients with liver metastases. Recurrence in the liver remnant after liver resection develops in 40% to 50 %, and repeat liver resection benefits those patients.     

结直肠癌肝转移的外科治疗

外科手术是治疗结直肠癌肝转移的重要手段。手术切除的适应证已扩展至满足肝内肿瘤能全部切除、切缘阴性、肝脏储备功能足够即可;而手术切除联合局部治疗进一步扩大了手术适应证。转移癌及原发癌一期或二期手术的远期生存率比较,差异无统计学意义。腹腔镜手术治疗结直肠癌肝转移安全可行,疗效确切。围手术期辅助化疗疗效并不明确,新辅助化疗可能不会使所有患者都受益。     

Surgical treatment of liver metastases from colorectal carcinoma

In patients with colorectal liver metastases, hepatic resection is the treatment of choice, and the 5-year overall survival rate after surgery is now approaching 60%. The multidisciplinary and multimodality approaches that may include preoperative systemic chemotherapy, and the recent innovative surgical techniques that may include complex ultrasound guided hepatic resection, have enabled a large proportion of patients to undergo potentially curative treatment. The definition of resectability has shifted from a focus on tumor characteristics, such as tumor number and size, to determination whether both intrahepatic and extrahepatic disease can be completely resected, and whether such an approach is appropriate from an oncological standpoint. Hepatobiliary surgeons and medical oncologists should work together to evaluate patients with colorectal liver metastases to individualize the treatment strategy to maximize the chances of long-term survival.     

结直肠癌肝转移的手术治疗

目的 探讨手术治疗结直肠癌肝转移的疗效以及影响因素.方法 收集74例手术治疗的结直肠癌肝转移病例,进行回顾性分析.结果 本组患者3年和5年生存率分别为63.8%和49.8%.原发灶淋巴结转移者5年生存率(33.3%)显著低于无转移者(63.7%,P=0.002),脉管侵犯者(39.6%)显著低于无侵犯者(61.6%,P=0.025).转移灶个数≤3个者(53.7%)显著高于＞3个者(34.6%,P=0.021).肝转移灶局限于半肝者,其5年生存率(65.2%)显著高于双侧弥漫者(23.9%,P=0.001).结论 手术切除是唯一可能治愈结直肠癌肝转移的方法.原发灶无淋巴结转移、无脉管侵犯,转移灶个数不超过3个、局限于半肝者预后较好.     

Surgical treatment of liver metastases from colorectal cancer

We analyze our experience over a 10-year period in the surgical treatment of liver metastases from colorectal cancer. Between 01.01.1995 and 08.31.2005 189 liver resections were performed in 171 patients with liver metastases from colorectal cancer (16 re-resections - 2 in the same patient and a "two-stage" liver resection in 2 patients). In our series there were 83 patients with synchronous liver metastases (69 simultaneous resections, 12 delayed resections and 2 "two-stage" liver resection were performed) and 88 metachronous liver metastases. Almost all types of liver resections have been performed. The morbidity and mortality rates were 17.4% and 4.7%, respectively. Median survival was 28.5 months and actuarial survival at 1-, 3- and 5-year was 78.7%, 40.4% and 32.7%, respectively. Between January 2002 and August 2005 hyperthermic ablation of colorectal cancer liver metastases has been performed in 6 patients; in other 5 patients with multiple bilobar liver metastases liver resection was associated with radiofrequency ablation and one patient underwent only radiofrequency ablation for recurrent liver metastasis. In conclusion, although the treatment of colorectal cancer liver metastases is multimodal (resection, ablation, chemotherapy and radiation therapy), liver resection is the only potential curative treatment. The quality and volume of remnant liver parenchyma is the only limitation of liver resection. The morbidity, mortality and survival rates after simultaneous liver and colorectal resection are similar with those achieved by delayed resection. Postoperative outcome of patients with major hepatic resection is correlated with the surgical team experience. The long-term survival was increased using the new multimodal treatment schemes.     

Indicators for treatment strategies of colorectal liver metastases

OBJECTIVE: To analyze the survival predictors of patients undergoing hepatectomy for colorectal liver metastasis to determine useful indicators for therapy selection. SUMMARY BACKGROUND DATA: Although recurrence develops in more than two thirds of patients undergoing hepatectomy for colorectal liver metastasis, preoperative characteristics that might predict such recurrence have yet to be clearly identified. METHODS: Clinicopathologic data of 85 consecutive patients with colorectal cancer who underwent a curative resection of primary lesions and metastatic liver diseases at one institute were analyzed using the multivariate method with respect to both the metastatic state and the primary lesion. RESULTS: Multivariate analysis indicated that the aggressiveness of the primary tumor, early liver metastasis, and a large number of liver metastases were the characteristics that could be detected before hepatectomy and that independently indicated a worse survival. A three-ranked classification based on these coefficients (H-staging) was significantly related to both the recurrence rate within 6 months (7% in H-stage A, 30% in B, and 44% in C) and the 5-year survival rates (55%, 14%, and 0% respectively). An additional scoring system (H'-staging) based on the aggressiveness of the primary tumor and the level of carcinoembryonic antigen 1 to 3 months after hepatectomy was found to be related to the mode of subsequent recurrence and surgical resectability of the recurrent foci. CONCLUSIONS: H-staging can provide useful prognostic information for the treatment of liver metastasis. H-staging could also help in predicting the possible mode of recurrence after hepatectomy and in determining the most suitable mode of additional therapy. Further multiinstitutional studies based on a large collective database will confirm the utility of these two staging systems.     

Multimodal treatment options for bilobar colorectal liver metastases

Purpose  

We evaluated individualized multimodal oncological strategies in patients with bilobular colorectal liver metastases (biCRC-LM) as well as their effect on R0 resection rates, disease-free survival (DFS), and overall survival (OS).     

结直肠癌肝转移多学科综合治疗的建立和推广

结直肠肝转移是非常常见而又可以有效治疗的晚期肿瘤疾病.对结直肠癌肝转移的治疗会牵涉到多个临床学科.因此目前各国包括我国的临床诊治指南中都要求采用多学科综合诊治（MDT）对结直肠肝转移进行治疗.本文对结直肠癌肝转移的多学科综合诊治的建立,组织,运行的基本要求提出建议.     

The combined treatment of colorectal cancer with liver metastases

The direct and follow-up results of surgical and combined treatment of colorectal cancer with liver metastases are presented. Complication rate after liver resections was 28.4% and lethality was 3.5%. Follow-up results evidence the decrease of survival in patients with adjuvant chemotherapy after surgery. The safety of oxalyplatin in patients after liver resections, including its intraarterial infusion through the hepatic artery is shown. Oxalyplatin-based chemotherapy regimen tended to be more effective in comparison with 5-fluorouracil scheme, especially in patients with synchronous or multiple liver metastases. Considering that the difference is not statistically significant, further studies of oxalyplatin influence on survival of patients with colorectal liver metastases are necessary.     

Imaging strategies before beginning treatment of colorectal liver metastases

The management of colorectal intrahepatic metastases before resection is multidisciplinary and radiologists and nuclear medicine specialists play a major role. In accordance with the French National Guide for appropriate use of diagnostic imaging, the approach should be multimodal: a chest-abdomen and pelvic (CAP) CT scan and hepatic MRI are mandatory while PET-CT provides important additional information, in particular on intra-abdominal extrahepatic metastases. This multimodal approach emphasizes the importance of early and appropriate use of imaging in these patients, as well as the central role of multidisciplinary meetings in oncology.     

结直肠癌肝转移的微创治疗策略

结直肠癌是世界范围内常见的恶性肿瘤,也是肿瘤导致死亡的重要原因。肝脏是结直肠癌最常见的转移部位,约20%的患者伴有同时性肝转移,另20%患者在疾病的发展中也出现肝转移。结直肠癌肝转移（CRLM）是目前结直肠癌治疗的重点与难点,也是影响患者预后的重要因素。手术切除仍然是患者长期生存甚至治愈的最佳治疗选择,其中微创切除更是兼具微创的优势与根治的效果,长期的肿瘤学疗效也与开放手术相当。但受限于肿瘤大小、位置分布等解剖因素、患者的肝脏功能以及一般状态等因素,只有少数患者在初诊时适合手术切除。其他微创治疗策略包括消融治疗、立体定向放射治疗、介入治疗等,这些技术的发展为不可手术切除的患者提供了新的治疗机会,同时也提高了单纯系统治疗的生存率。消融治疗对于选择性的患者兼具有微创与类似手术的根治性效果,对于深部肿瘤也更具优势。立体定向放射治疗是不适合手术切除或消融困难或复发病灶的重要替代选择。Y⁹⁰选择性体内放射治疗更是兼具肿瘤控制与增大余肝的双重作用,在转化治疗时代其地位也不断上升。随着微创理念的深化与技术的进步,CRLM的微创治疗取得一定进展,但仍面临诸多挑战,如在精准、个体化与转化治疗时代微创治疗策略如何合理地联合或序贯使用等。在选择微创治疗策略时,应该根据多学科团队的指导进行个体化评估和综合治疗,尽可能实现R₀切除或无疾病证据状态,从而最大程度地提高患者的长期生存率。本文就近年来CRLM的微创治疗策略进行综述,以期为临床治疗的选择提供参考。     

Quality of life after surgical treatment of colorectal liver metastases

BACKGROUND: The surgical approach to colorectal liver metastases is becoming increasingly aggressive. The aim of this prospective study was to evaluate the impact of surgery on health-related quality of life (HRQoL) of patients with colorectal liver metastases. METHODS: HRQoL data from 97 patients with colorectal liver metastases were analysed. Sixty patients (group 1) had surgical treatment of the liver metastases. Seventeen patients (group 2) were shown to have inoperable disease at laparotomy. Twenty outpatients with inoperable disease were included as a control group (group 3). Two validated HRQoL instruments, the European Organization for Research and Treatment of Cancer Core questionnaire (QLQ C-30) and the EuroQol-5D, were applied. RESULTS: By 2 weeks after operation patients in group 1 showed a clear overall deterioration in HRQoL, but after 3 months most HRQoL scores had returned to baseline levels. At 2 weeks after surgery there was clear deterioration in almost all HRQoL domains in group 2, and several symptoms were still being reported at 3 months. Patients in group 3 showed hardly any deterioration in HRQoL over the 3 months. CONCLUSION: The fast recovery of HRQoL, generally within 3 months, justifies an aggressive surgical approach to colorectal liver metastases. However, careful preoperative evaluation is crucial to avoid needless laparotomy, considering the ongoing deteriorated HRQoL of group 2.     

Resection of colorectal liver metastases

From 1960 to 1992 a total of 1718 patients with liver metastases from colorectal carcinoma were recorded. Of these patients, 469 (27.3%) underwent hepatic resection, which was performed with curative intent in 434 patients (25.3%). Operative mortality in this group was 4.4%, being 1.8% (2 of 114) during the last 3 years. Significant morbidity was observed in 16% of patients with a decrease to 5% (6 of 112) for the last 3 years. A 99.8% follow-up until November 1, 1993 was achieved. Excluding operative mortality, there are 350 patients with potentially curative resection and 65 corresponding patients with minimal macroscopic (n=19) or microscopic (n=46) residual disease. The latter group demonstrated a poor prognosis, with median and maximum survival times of 14.4 and 56.0 months, respectively. Among the 350 patients having potentially curative resection, the actuarial 5-, 10-, and 20-year survivals were 39.3%, 23.6%, and 17.7%, respectively. Tumor-free survival was 33.6% at 5 years. In the univariate analysis, the following factors were associated with decreased crude survival: presence and extent of mesenteric lymph node involvement (p=0.0001); grade III/IV primary tumor (p=0.013); synchronous diagnosis of metastases (p=0.014); satellite metastases (p=0.00001); metastasis diameter of>5 cm (p=0.003); preoperative carcinoembryonic antigen (CEA) elevation (p=0.03); limited resection margins (p=0.009); extrahepatic disease (p=0.009); and nonanatomic procedures (p=0.008). With respect to disease-free survival, extrahepatic disease (p=0.09) failed to achieve statistical significance, whereas patients with primary tumors in the colon did significantly better than those with rectal cancer (p=0.04). The presence of five or more independent metastases adversely affected resectability (p<0.05). However, once a radical excision of all detectable disease was achieved, no significant predictive value of an increasing number of metastases (1–3 versus4) on either overall (p=0.40) or disease-free (p=0.64) survival was found. Using Cox's multivariate regression analysis, the presence of satellite metastases, primary tumor grade, the time of metastasis diagnosis diameter of the largest metastasis, anatomic versus nnanatomic approach, year of resection, and mesenteric lymph node involvement each independently affected both crude and tumor-free survival.

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Resumen En el período 1960 a 1992 registramos un total de 1.718 pacientes con metástasis hepáticas de carcinomas colorectales; 469 (27.3%) fueron sometidos a resección, la cual fue realizada con propósito curativo en 434 pacientes (25.3%). La mortalidad en este grupo fue 4.4%, siendo 1.8% (2 de 114) en los últimos 3 años. Se observó morbilidad significativa en 16% de los casos con una disminución a 5% (6 de 112) en los últimos 3 anños. Hasta noviembre 1 de 1993, se logró un 99.8% de seguimiento. Excluyendo la mortalidad operatoria, hay 350 pacientes con resección potencialmente curativa y 65 pacientes con enfermedad residual macroscópica mínima (n=19) o microscópica (n=46). Este último grupo demuestra el pronóstico tan pobre con una sobrevida media y máxima de 14.4 y 56 meses, respectivamente. Entre los 350 pacientes que tuvieron una resección potencialmente curativa la tasa actuarial de sobrevida a 5, 10 y 20 años fue 39.3%, 23.6% y 17.7%, respectivamente. La tasa de sobrevida libre de tumor fue de 33.6% a 5 años. En el análisis univariable, los siguientes factores aparecieron asociados con disminución de la tasa cruda de sobrevida: presencia o extensión de la invasión ganglionar mesentérica (p=0.0001), tumor primario grado III/IV (p=0.013), diagnóstico sincrónico de metástasis (p=0.014), metástasis satélites (p=0.00001), diámetro de las metástasis>5 cm (p=0.003), elevación preoperatoria del CEA (p=0.03), márgenes limitados de resección (p=0.009), enfermedad extrahepática (p=0.009) y procedimiento no anatómico (p=0.008). Con respecto a la sobrevida libre de enfermedad, las lesiones extrahepáticas (p=0.09) demostraron no tener significancia estadística; los pacientes con tumores primarios del colon evolucionaron significativamente mejor que los pacientes con cáncer rectal (p=0.04). La presencia de 5 o más metástasis independientes afecta la resecabilidad (p<0.05). Sin embargo, una vez lograda la resección radical de todas las metástasis, no se encontró un valor significativo de predicción según un númeo creciente de metástasis (1–3 vs 4) sobre la tasa global de sobrevida (p=0.40) o sobre la tasa de sobrevida libre de enfermedad (p=0.64). En el análisis multivariable de regresión de Cox se encontró que los siguientes factores afectan en forma independiente la tasa cruda de sobrevida y la tasa de sobrevida libre de tumor: presencia de metástasis satélites, grado del tumor primario, momento del diagnóstico de las metástasis, diámetro de la mayor de las metástasis, abordaje anatómico vs no anatómico, año en que se efectuó la resección e invasión de los ganglios linfáticos mesentéricos.

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Résumé Entre 1960 et 1992, un total de 1718 patients ayant des métastases d'un cancer d'origine colorectale ont été enregistrés. Quatre cent soixante-neuf patients (27.3%) ont eu une résection hépatique qui a été effectuée avec une intention curatrice chez 434 (25.3%_. La mortalité opératoire a été de 4.4%, mais seulement de 1.8% pendant ces trois dernières années (2/114). La morbidité globale a été de 16%, et de 5% pendant ces trois dernières années (5/112). A la date du 1 Novembre 1993, on avait des nouvelles de 99.8% des patients. Après exclusion des patients décédés pendant l'intervention, 350 patients ont eu une résection «potentiellement» curatrice. Parmi ceux-là, 65 étaient le siège de tumeur résiduelle soit macroscopique (n=19) soit microscopique (n=46). Parmi ces derniers, le pronostic était moins bon car la médiane et le maximum de survie a été respectivement de 14.4 et 56 mois. Parmi les 350 patients ayant une cure «potentiellement» curatrice, la survie actuarielle à 5, 10 et à 20 ans a été respectivement de 39.3%, de 23.6% et de 17.7%. La survie sans tumeur a été de 33.6% à 5 ans. En analyse univariable, les facteurs suivants ont été associés avec une diminution de survie globale: présence de métastase lymphatique mésentérique étendue (p=0.0001), tumeur primitive stade III/IV (p=0.013), métastase synchrone (p=0.014), métastases satellites (p=0.00001), diamètre de métastase>5 cm (p=0.003), taux d'ACE élevé (p=0.03), marges de résection limitée (p=0.009), cancer extrahépatique (p=0.0009), et intervention non-anatomique (p=0.008). En ce qui concerne la survie sans tumeur, la présence de cancer extra-hépatique n'a pas atteint de signification statistique, alors que les patients avec un cancer primitif du côlon avaient un pronostic meilleur que ceux qui avaient un cancer du rectum (p=0.04). La présence de cinq métastases indépendantes ou plus influençait la résequabilité en sens inverse (p<0.05). Une fois qu'une résection radicale de toute maladie détectable a été faite, le nombre de métastases (1–3 vs. 4 ou+) n'avait plus de valeur prédictive sur ni la survie globale (p=0.40) ni la maladie sans métastases (p=0.64). En utilisant le modèle de Cox, la présence de métastases satellites, le stade de la tumeur primitive, le moment du diagnostic de métastases, le plus grand diamètre, de métastase, l'approche anatomique ou pas, l'année de la résection et la présence d'envahissement lymphatique mésentérique ont tous été des facteurs indépendants influençant la survie globale et la survie sans tumeur.

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This paper is dedicated to Gerd Hegemann, Emeritus Professor of Surgery, outstanding teacher of surgical thinking and practice.     

Resection of colorectal liver metastases

Introduction: Surgical resection is presently the only approach that offers patients with liver metastases from colorectal carcinoma substantial chance of cure. This article summarizes the current literature as well as the author’s personal experience. Background and discussion: Since 1980, 5-year survival figures have ranged from 21% in collected series to 48% in single-institution series. The 30-day mortality of elective liver resection in non-cirrhotic patients ranges now between 0% and 5%. The overwhelming indicator of prognosis is the completeness of tumor removal according to the R-classification. The specific impact of all other factors should therefore be analyzed by excluding non-radical procedures and operative mortality. Among patient characteristics, age and gender do not significantly affect outcome, while the Karnofski stage is important. Regarding the primary tumor, the effect of staging and location is predominantly apparent in patients with synchronous metastases. Timing of metastasis detection is of some importance, as most authors found a slightly better outcome for metachronously detected metastases. With respect to the liver involvement, multiplicity of metastases and bilateral disease both seem to be of minor importance after R0-resection, while satellite lesions are significant in many series. The actual number of metastases is of minor effect, with a slight superiority in 5-year survival for patients with one to three nodules relative to patients with four nodules or more in most series, but identical results in the author’s own experience. The maximum diameter as an indicator of tumor burden represents a significant prognosticator in half of the reports analyzed. Extrahepatic disease reduces 5-year survival, but direct tumor invasion to adjacent structures, local recurrent disease, or one or few pulmonary metastases are no contraindication to liver resection as long as a R0-situation can be achieved. In contrast, lymph-node metastases at the liver hilum predict a poor outcome. They are likely to prove as a clear contraindication. With respect to the operative approach, a clear margin of 1 cm or more should be aimed at but, if the size or location of metastases do not allow a 1-cm margin, resection should still be performed, making every surgical effort to ensure a complete rim of unaffected tissue. Anatomic resections reduce the incidence of non-radical procedures and may improve survival. Whether there is an independent effect of operative blood loss, need for blood transfusion, and intraoperative hypotension on prognosis is still unclear. Adjuvant chemotherapy or radiotherapy after R0-resection is unlikely to improve results. There are also no convincing data available demonstrating a prognostic benefit when a non-curative resection is supplemented by any medical treatment. In patients with recurrent disease, a re-resection is possible in roughly 20%. Survival from the time of re-intervention ranges from 21% to 57% after 5 years and, thus, justifies a close follow-up policy after R0-resection of the initial liver metastases. Conclusion: The previous ”clear” contraindications to liver resection have become less important. Future efforts may be directed to more accurate patient selection and new approaches of neoadjuvant and adjuvant therapeutic strategies. Received: 22 June 1999 Accepted: 28 June 1999     

Treatment of colorectal liver metastases

BACKGROUND: Surgical resection is the only potentially curative treatment for colorectal liver metastases, with 5-year survival rates approaching 40 per cent. However, at present only 20-25 per cent of such lesions are deemed resectable. This review examines developments in neoadjuvant and adjuvant treatments of colorectal liver metastases that aim to improve the results of surgical management of this disease. METHODS: A literature review was undertaken based on a Medline search from 1970 to May 1998. RESULTS: Further evolution in surgical technique is unlikely to lead to a dramatic increase in the resectability rate of colorectal liver metastases. Recent developments in neoadjuvant and adjuvant chemotherapy schedules, together with a range of interventional radiological procedures and interstitial lytic techniques, show promise in terms of extending the limits of resectability and decreasing recurrence rates associated with these lesions. Using multimodality regimens 5-year survival rates of 40 per cent are now being reported for lesions that were initially considered irresectable. CONCLUSION: Patients with colorectal liver metastases should be assessed in units that can offer all the specialist techniques necessary to deliver optimum care. Incorporation of newer neoadjuvant and adjuvant treatments into management strategies should occur in the setting of randomized trials.     

结肠直肠癌肝转移的诊断和外科治疗体会

目的 探讨结肠直肠癌肝转移的诊疗方法及影响其预后的因素.方法 回顾性分析我院1991年1月～2006年1月收治的113例结肠直肠癌肝转移病人的临床资料.结果 全组总的1、3、5年生存率分别为91.6%、34.3%和23.1%.同时性肝转移病人的生存率明显高于异时性肝转移病人(P＜0.01).同时性肝转移病人Ⅰ期手术和Ⅱ期手术的生存率无显著性差异(P＞0.05).肝转移瘤最大直径＞5cm者的5年生存率较最大直径≤5cm者低,两者有显著性差异(P＜0.05).结论 外科手术是结肠直肠癌肝转移的首选治疗方法,新辅助化疗已成为术前准备的一部分.     

Management of colorectal liver metastases

Hepatic metastases occur in 60% of patients following resection for colorectal cancer. Liver resection is the only curative option, with one third of resected patients alive at five years. In those developing recurrence in the liver following resection, further liver surgery may be curative, with similar 5 years survival rates of about 30%. Until recently surgery was feasible in only 15–25% of patients with colorectal liver metastases. New strategies, such as downstaging chemotherapy, portal vein embolization and two‐stage hepatectomy, may increase the resectability rate by 15%. Earlier detection of liver metastases would increase resectability, although good follow‐up trials are lacking. Once suspected, colorectal liver metastases are staged by spiral CT, CT portography and MRI, which have similar overall accuracies. Mortality following liver resection is less than 5% in major centres, with a morbidity rate of 20% to 50%. Prognostic scoring systems can be used to predict the likely cure rate with resection. Pulmonary metastases occur in 10–25% of patients with resected colorectal cancer, but are limited to the lung in only 2% of cases. In these selected cases surgery provides long‐term survival in 20–40%, and repeat lung resection has shown similar rates. For patients with unresectable disease, chemotherapy and ablation techniques have been demonstrated to prolong survival, although chemotherapy alone has been shown to improve quality of life.     

Chemoembolization of colorectal liver metastases

In the Center of Surgery of the Justus-Liebig-University Giessen and in the General Hospital in Nuremberg from 1983 to 1987 21 patients with metastases of a colorectal carcinoma were treated with chemoembolization (CHE). The on average survival period of patients treated with chemoembolization after non-successful application of regional chemotherapy amounted to 6 months. The total survival period of these patients amounted to 17.4 months. Since March 1987 chemoembolization has been applied as initial therapy. The on average survival period of the patients, initially treated with cheomoembolization at present amounts to 14 months. 4 of these patients additionally got chemotherapy by the portal vein after CHE. The survival period of 2 patients, having been resected several times after CHE, at present comes to 27 months. These results are the base for a clinical study, in which CHE is combined with the portal venous infusion of a cytostatic agent (Folin acid 5-FU).