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Case History

Image not available. A 70-year-old man has rising levels of carcinoembryonic antigen (CEA) 3 years after a left hemicolectomy for Dukes C carcinoma of the descending colon. An abdominal ultrasound scan is suggestive of liver metastases. The patient is fit and asymptomatic and is offered a work-up for liver resection.

What further assessment should this patient have?

What factors determine tumour resectability?

Assuming the liver can be cleared of tumour, what is the immediate and long-term prognosis?

What are the patient's options if the liver is the only site of disease, but the tumours are not resectable?

Background

What further assessment should this patient have?

Image not available. All patients with suspected or diagnosed liver metastases which might be amenable to resection should be referred to specialist liver surgeons for evaluation.1 Patients who may be undergoing a liver resection require a full medical assessment to ensure fitness for major surgery. If there are doubts about existing comorbidities, the patient should have an anaesthetic review or be referred to the appropriate specialist prior to surgery. Blood tests that should be done before surgery include a full blood count, clotting screen, urea and electrolytes, tumour markers and liver function tests. It is important to check the synthetic function of the liver as people with steatosis, fibrosis or cirrhosis will not tolerate a major liver resection.

Staging computed tomography (CT) of the chest, abdomen and pelvis should be done. Magnetic resonance imaging (MRI) of the liver is done as it has a higher sensitivity in detecting and characterizing smaller lesions (Figure 28.1). Precise anatomical imaging and tumour mapping is essential, to assess the feasibility of a safe oncological liver resection and to determine the presence of extra-hepatic metastases.2 The radiological assessment is completed with intraoperative ultrasound. Intraoperative ultrasound helps in detecting hitherto unknown lesions and in the localization of deep lesions that are difficult to palpate.

Figure 28.1

MR image showing colorectal cancer liver metastases.

What factors determine tumour resectability?

Surgical resection is currently the gold standard, potentially curative treatment for liver metastases. However, less than 30% of patients are suitable due to the extent and distribution of the disease or concurrent medical disability.3

Most patients with liver metastases do not require extended surgery. However, central tumours, tumours near the major vessels or multiple tumours spread over three segments necessitate extended resections to obtain adequate oncological clearance. Previously, extended resections were not usually considered due to associated morbidity and a high risk of perioperative mortality. With advances in surgical and anaesthetic techniques, the mortality from hepatic resection has reduced from as much as 20% to less than 5%.1,4,5 The lower mortality and improved long-term survival has pushed towards more aggressive surgery.

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