Chemotherapy toxicity was assessed at each cycle using the Common Terminology Criteria for Adverse Events (CTCAE, v5.0), which is divided into 5 grades, grade III and above being considered severe. During the chemotherapy, only grade I was noted (leukopenia) and no severe adverse events occurred.
2.4 Follow-up and outcomes
During the postoperative period, no severe postoperative complications, including liver complications, were noted. Following the partial tumor response observed during chemotherapy, he underwent descending hemicolectomy in January 2018.
From May 2017 to October 2018, the duration of follow-up after the left hemicolectomy was 22 months. The patient was alive and well at the final follow-up. Further systemic therapy was administered at the latest follow-up. To date, no recurrence has been documented and the patient was satisfied with the treatment effect.
Surgical resection of CRLM offers patients the best likelihood of cure, with one case study reporting an average 5-year survival rate of 47% after resection, and only 15% to 35% of patients having indications for hepatectomy.
The NCCN clinical practice guidelines in oncology for colon and rectal cancers recommend FOLFOX as the optimal treatment for patients with unresectable recurrent colon cancer and hepatic metastasis. A combination of systemic chemotherapy with FOLFOX and anti-VEGF antibody or anti-EGFR antibody allows the rescue of 12.5% of patients with unresectable CRLM via hepatectomy.[3,11] Neoadjuvant chemotherapy for initially unresectable CRLM can also improve the hepatectomy rate.[12,13] Consistent with previous studies,[6,14,15] our patient showed partial response to chemotherapy (mFOLFOX6+Cet), and radical surgery was performed for the primary tumor and liver metastases.
Liver-first surgery may be particularly applicable to CRC patients with synchronous liver metastases, where preoperative long-course chemoradiotherapy for the colorectal primary prior to surgical resection creates a potential ‘window’ in which liver resection can be undertaken.[13,16] The liver-first strategy may also be oncologically advantageous as it addresses the hepatic metastatic burden before progression in the liver leads to unresectability. Another potentially important benefit of the liver-first approach is that pelvic surgery may be either avoided or be less extensive in patients with rectal tumors, with a complete endoscopic, radiological, and clinical response to chemoradiotherapy.
In this case, after completing 6 cycles of chemotherapy, with reduction in the CRC liver mass, the choice of an appropriate time to resect the liver metastasis tumor remained unclear. An MDT, including specialists in gastrointestinal surgery and hepatobiliary surgery and members from the departments of intervention, imaging diagnosis, radiotherapy, pathology, and oncology, discussed the best treatment option for the CRLM. The liver metastasis was close to the vena cava according to computed tomography, so continued chemotherapy was considered an appropriate strategy.
Our case suggests an equal effectiveness of combined systemic chemotherapy and the reverse strategy following MDT consultation in clinical practice. The present case is unique and had a favorable prognosis, suggesting a more appropriate treatment direction for patients with huge/multiple CRLM.
However, a limitation of the present case report is the absence of long-term follow-up. A 3-year or 5-year follow-up duration could have more adequately confirmed the treatment's curative effect.
Treating CRC patients with huge hepatic metastases is possible, and surgeons should consider various treatment options in the management of these patients.
Conceptualization: Yuan Lin and Yuzhou Qin, Zhaoting Bu.
Data curation: Cheng Lu, Xu Yang.
Formal analysis: Zhaoting Bu, Yuting Jiang.
Investigation: Zhaoting Bu, Yicheng Li.
Methodology: Zhaoting Bu, Yicheng Li, Yuan Lin.
Supervision: Zhaoting Bu, Hao Lai.
Visualization: Minxi Xiao, Chunfeng Cheng, Qi Liu.
Writing – original draft: Zhaoting Bu, Cheng Lu and Xu Yang
Writing – review editing: Zhaoting Bu, Hao Lai and Yuzhou Qin
. Garden OJ, Rees M, Poston GJ, et al. Guidelines for resection of colorectal cancer
liver metastases. Gut 2006;55(suppl 3):iii1–8.
. Ferlay J, Soerjomataram I, Dikshit R, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 2015;136:E359–86.
. Adam R, Delvart V, Pascal G, et al. Rescue surgery for unresectable colorectal liver metastases downstaged by chemotherapy: a model to predict long-term survival. Ann Surg 2004;240:644–57. discussion 657-648.
. Engstrand J, Nilsson H, Stromberg C, et al. Colorectal cancer
liver metastases—a population-based study on incidence, management and survival. BMC Cancer 2018;18:78.
. Adam R, De Gramont A, Figueras J, et al. The oncosurgery approach to managing liver metastases from colorectal cancer
: a multidisciplinary international consensus. Oncologist 2012;17:1225–39.
. Weledji EP. Centralization of liver cancer surgery and impact on multidisciplinary teams working on stage IV colorectal cancer
. Oncol Rev 2017;11:331.
. Yang YF, Wang GY, He JL, et al. Overall survival of patients with KRAS wild-type tumor treated with FOLFOX/FORFIRI+/− cetuximab as the first-line treatment for metastatic colorectal cancer
: a meta-analysis. Medicine 2017;96:e6335.
. Eisenhauer EA, Therasse P, Bogaerts J, et al. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer (Oxford, England: 1990) 2009;45:228–47.
. Hozumi H, Hasegawa H, Miyashita K, et al. Efficacy of corticosteroid and intravenous cyclophosphamide in acute exacerbation of idiopathic pulmonary fibrosis: a propensity score-matched analysis. Respirology (Carlton, Vic) 2019.
. Adam R, de Gramont A, Figueras J, et al. Managing synchronous liver metastases from colorectal cancer
: a multidisciplinary international consensus. Cancer Treat Rev 2015;41:729–41.
. Alberts SR, Horvath WL, Sternfeld WC, et al. Oxaliplatin, fluorouracil, and leucovorin for patients with unresectable liver-only metastases from colorectal cancer
: a North Central Cancer Treatment Group phase II study. J Clin Oncol 2005;23:9243–9.
. Folprecht G, Gruenberger T, Bechstein WO, et al. Tumour response and secondary resectability of colorectal liver metastases following neoadjuvant chemotherapy with cetuximab: the CELIM randomised phase 2 trial. Lancet Oncol 2010;11:38–47.
. Ihnat P, Vavra P, Zonca P. Treatment strategies for colorectal carcinoma with synchronous liver metastases: which way to go? World J Gastroenterol 2015;21:7014–21.
. Garufi C, Torsello A, Tumolo S, et al. Cetuximab plus chronomodulated irinotecan, 5-fluorouracil, leucovorin and oxaliplatin as neoadjuvant chemotherapy in colorectal liver metastases: POCHER trial. Brit J Cancer 2010;103:1542–7.
. Sueur B, Pellerin O, Voron T, et al. Unresectable liver metastases in colorectal cancer
: review of current strategies. Minerva Chir 2016;71:382–97.
. Brouquet A, Mortenson MM, Vauthey JN, et al. Surgical strategies for synchronous colorectal liver metastases in 156 consecutive patients: classic, combined or reverse strategy? J Am Coll Surg 2010;210:934–41.
. Okuno M, Hatano E, Kasai Y, et al. Feasibility of the liver-first approach for patients with initially unresectable and not optimally resectable synchronous colorectal liver metastases. Surg Today 2016;46:721–8.
Keywords:Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
case report; colorectal cancer; hepatic metastasis; partial response