Challenges in the multidisciplinary management of stage IV colon and rectal cancer

Abstract

Colorectal metastases still represent a challenge to all oncologists despite progresses achieved by improved resectability, systemic chemotherapy and targeted therapies. In particular in patients with oligo-metastases, the role of surgical resections has been redefined. Resection is the most effective treatment method for liver metastases performed with curative intent; however, primary rate of resectability is low. Several methods to increase resectability have been developed: conversion chemotherapy, portal vein embolization, two-stage resections, vascular reconstruction of the liver veins, combination of resection and intraoperative ablation. Liver resections can be performed at present with low mortality. Patients with isolated peritoneal metastases, no extra-abdominal disease, low volume tumor and complete surgical cytoreduction do benefit from surgery and hyperthermic intraperitoneal chemotherapy. Several national guidelines recommend multimodality treatment for highly selected patients. The management of stage IV colorectal cancer includes several disciplines with focus on resection. A multidisciplinary evaluation of all patients is of crucial importance to define the treatment sequence and individual strategies for each patient.

Keywords:

• ALPPS
• HIPEC
• liver metastases
• peritoneal carcinomatosis

Financial & competing interests disclosure

P Piso has received honoraria from Roche and Merck Serono. D Arnold has received research grants from Roche and Sanofi and honoraria from Roche, Sanofi, Merck Serono, Amgen and Bayer. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Resection is the most effective method to treat liver metastases; however, primary resectability is still rather low.

• Several methods to increase resectability are available: conversion chemotherapy, portal vein embolization, two-stage resections, vascular reconstruction of the liver veins, combination of resection and intraoperative ablation.

• During conversion chemotherapy, patients have to undergo resection within the first 3 months of treatment. After that, further response is minimal but perioperative morbidity high.

• Liver resections can be performed at present with low mortality and in specialized centers by minimal invasive routes.

• The continuous (re)interdisciplinary evaluation of all patients with liver metastases is of crucial importance.

• Selected patients with peritoneal metastases may benefit from cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

• Selection criteria are isolated peritoneal metastases with no extra-abdominal disease, low-volume tumor and complete surgical cytoreduction.