Expressing the Surgery First Position on Treatment of Synchronous Colorectal Metastases in the Asymptomatic Patient

The patient is asymptomatic with synchronous hepatic metastases from a colorectal primary tumor. The options for treatment would be to resect the colorectal primary tumor and treat the liver metastases or to give chemotherapy first and then see if resection is feasible. The ultimate goal of every cancer surgeon is to cure the patient. For the vast majority of patients with metastatic disease, this is impossible. In those situations, surgery must be used as a palliative tool; thus, extirpative surgery is generally not needed in the asymptomatic patient, especially with the advent of new chemotherapy agents that have such good response rates in patients with colorectal cancer. However, in the patient with synchronous liver metastases only, there remains a chance for cure, and that chance should always be pursued. New data about hepatic artery infusions in the face of unresectable liver metastases show extremely high response rates in the liver and make the chance of converting patients disease into resectable lesions a possible reality. Thus, in a patient who is capable of undergoing surgery and who has a primary colorectal cancer and liver metastases only, the best treatment would be a resection of the primary cancer and placement of a hepatic artery infusion pump for unresectable disease or resection of the liver metastases and placement of a hepatic artery infusion pump. Treatment with systemic chemotherapy before surgery would not help the situation and may allow potentially curable disease to become too large for resection. Synchronous hepatic metastases from colorectal primary tumors occur in approximately 20% of patients with colorectal cancer. The question of operability of the hepatic lesions does not hinge on whether or not the metastases are synchronous. Because patients with synchronous disease can also have 5-year survivals of >25%, they should not be excluded from hepatic resection. The important factors for assessing whether colorectal metastases are resectable have been assessed by two groups with large retrospective studies. Both of these groups were addressing patients with metastases confined to the liver, and thus patients with portal lymph nodes involved with tumor, with carcinomatosis, or with lung or other organ metastases were not considered good candidates for hepatic resection. One of the systems was developed by Dr. Yuman Fong at Memorial Sloan-Kettering Cancer Center and included five clinical criteria. They were (1) the nodal status of the primary tumor, (2) the disease-free interval from the time of the primary operation to discovery of liver metastases (£12 or >12 months), (3) more than one tumor, (4) a preoperative carcinoembryonic antigen level >200 ng/mL, and (5) largest tumor >5 cm. Each negative criterion was assigned one point, and the 5-year survivals were calculated. For patients with a score of 0, the 5-year survival was 60%, compared with 14% for those with Received July 27, 2005; accepted October 24, 2005; published online January 16, 2006. Address correspondence and reprint requests to: M. Margaret Kemeny, MD, FACS; E-mail: kemenym@nychhc.org