Synchronous Metastatic Rectal Cancer Completely Resected After Multidisciplinary Planning and Treatment: A Case Report

View More View Less
  • a From the Division of Surgical Oncology, Department of Surgery, and Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, California.

Colorectal cancer is a common and significant public health concern. The liver is the most common site of metastasis, and colorectal cancer liver metastases (CRLM) may affect up to 60% of patients at some time during the course of their disease. Approximately 25% of patients are found to have synchronous CRLM at the time of diagnosis, and these patients have a worse prognosis than those who develop metastases later in their disease course. In the absence of extrahepatic disease, resection of CRLM with negative margins along with chemotherapy can lead to a 5-year overall survival rate of up to 60%. This report presents the case of a 48-year-old man diagnosed with rectal cancer and synchronous liver metastases that a multidisciplinary tumor board initially deemed to be unresectable because of large size and insufficient future liver remnant. The patient underwent FOLFOX chemotherapy with bevacizumab and experienced conversion to resectable hepatic disease. After neoadjuvant short-course radiation treatment to the rectum, the patient underwent combined low anterior resection of the rectum and a right hepatectomy and was rendered disease-free. The management of the patient’s clinical course with correlation to the NCCN Clinical Practice Guidelines in Oncology for Rectal Cancer is presented in this report, including discussion of the role of chemotherapy in the conversion of CRLM to resectable status, the role of surgical metastasectomy, and postoperative surveillance of patients with colorectal cancer.

NCCN: Continuing Education

Accreditation Statement

This activity has been designated to meet the educational needs of physicians and nurses involved in the management of patients with cancer. There is no fee for this article. No commercial support was received for this article. The National Comprehensive Cancer Network (NCCN) is accredited by the ACCME to provide continuing medical education for physicians.

NCCN designates this journal-based CME activity for a maximum of 1.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

NCCN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

This activity is accredited for 1.25 contact hours. Accreditation as a provider refers to recognition of educational activities only; accredited status does not imply endorsement by NCCN or ANCC of any commercial products discussed/displayed in conjunction with the educational activity. Kristina M. Gregory, RN, MSN, OCN, is our nurse planner for this educational activity.

National Comprehensive Cancer Network is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

NCCN designates this continuing education activity for 1.25 contact hour(s) (0.125 CEUs) of continuing education credit in states that recognize ACPE accredited providers. This is a knowledge-based activity. UAN: 0836-0000-13-113-H01-P.

All clinicians completing this activity will be issued a certificate of participation. To participate in this journal CE activity: 1) review the learning objectives and author disclosures; 2) study the education content; 3) take the posttest with a 66% minimum passing score and complete the evaluation at http://education.nccn.org/node/31015; and 4) view/print certificate.

Release date: October 4, 2013; Expiration date: August 31, 2014

Supported by education grants from Bayer HealthCare Pharmaceuticals Inc.; Genentech, USA; Lilly USA, LLC.; and sanofiaventis U.S. and Regeneron Pharmaceuticals.

Learning Objectives

Upon completion of this activity, participants will be able to:

  • Discuss the NCCN Clinical Practice Guidelines in Oncology for Rectal Cancer recommendations for the management of potentially resectable synchronous metastatic disease
  • Describe the role of chemotherapy with bevacizumab in the conversion of CRLM to resectable status

Case Presentation

A 48-year-old man presented to City of Hope Comprehensive Cancer Center (COHCC) with a diagnosis of rectal adenocarcinoma and synchronous liver metastases. For 1 year, the patient had been experiencing intermittent hematochezia, thinning stool, diarrhea, and a 50-pound weight loss. Colonoscopy was ultimately performed, revealing a friable mass in the proximal rectum, and biopsy revealed adenocarcinoma. The patient underwent staging with a contrast-enhanced abdominopelvic CT scan, demonstrating a 10- to 12-cm segment of thickened rectosigmoid colon extending to the proximal rectum, enlarged mesorectal lymph nodes (Figure 1A), and an 11-cm hypodense mass occupying most of the right lobe of the liver (Figure 1B). The patient presented to COHCC for treatment options.

Figure 1
Figure 1Figure 1

(A) Thickened segment of rectum with adenocarcinoma (arrows) and lymphadenopathy in the mesorectum (arrowhead). (B) Synchronous metastatic rectal cancer occupying most of the right lobe of the liver (arrow) and a satellite lesion adjacent to the inferior vena cava (arrowhead).

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 11, suppl_4; 10.6004/jnccn.2013.0219

The patient previously had undergone Mohs surgeries for removal of unknown-type skin neoplasms from his nose; however, he had no other medical problems or previous operations. The patient’s father was treated for colon cancer in his 50s, diagnosed with prostate cancer in his 80s, and was currently alive. The patient had no family history of colorectal cancer, polyps, inflammatory bowel disease, or other malignancies, except lung cancer in a maternal grandmother.

Repeat CT scan of the chest/abdomen/pelvis at COHCC showed enlargement of the liver mass to 12 cm, with smaller satellite masses in the right lobe, and no pulmonary metastases. The patient’s case was presented at a multidisciplinary tumor board conference attended by medical, surgical, and radiation oncologists; diagnostic and interventional radiologists; and pathologists. After presentation, the patient’s liver disease was deemed to be initially unresectable because of insufficient future liver remnant. Mutational testing on the tumor biopsy specimen showed the tumor to be KRAS wild-type, and the mismatch repair proteins MLH1, MSH2, MSH6, and PMS2 were all intact via immunohistochemistry.

The patient underwent treatment with combination mFOLFOX6 chemotherapy with an infusion of yttrium-90 SIR-Spheres microspheres (Sirtex Medical Inc., Woburn, MA) during the first cycle. The patient’s carcinoembryonic antigen (CEA) before treatment was 78.5 ng/mL. The patient continued treatment with mFOLFOX6/bevacizumab, and repeat imaging during treatment showed a decrease in the size of the liver lesion to 9 cm without new lesions. The patient underwent imaging every 2 months during chemotherapy with repeat tumor board presentations. Four months after beginning treatment, both the primary rectal cancer and the liver metastases were deemed to be resectable (Figure 2). The patient had undergone 8 cycles of therapy; however, bevacizumab was held and not given with the final round of chemotherapy. The CEA after treatment had decreased from 78.5 to 5.5 ng/mL.

Flexible sigmoidoscopy was performed as part of a preoperative evaluation, showing the tumor in the mid-rectum 12 cm from the anal verge. The patient was seen by the Radiation Oncology Department for possible short-course neoadjuvant pelvic radiation to improve local control, and was deemed to be a candidate. The patient received 5 Gy of external-beam radiation daily for 5 days, and was taken to the operating room for resection 1 week later, approximately 5 weeks after the last dose of chemotherapy, and 7 weeks after the last dose of bevacizumab.

At exploratory laparotomy, no other intraperitoneal disease was found. The patient underwent low anterior resection of the rectum with total mesorectal excision, colorectal anastomosis, and a diverting loop ileostomy; several bulky-appearing lymph nodes along branches of the inferior mesenteric artery were all resected. Intraoperative hepatic ultrasound showed the large right liver mass and no masses in the left lobe of the liver. Right hepatectomy and cholecystectomy were performed. During liver mobilization, dense edematous adhesions between the omentum, the hepatic flexure of the colon, and the liver were encountered, and edema in the ligaments of the liver, thought to be due to the yttrium-90 radioembolization. Postoperatively, the patient had a slow return of bowel function, and then subsequently excessive ileostomy output, which was ultimately normalized with dietary fiber and antimotility agents. Liver function tests normalized over the course of 1 week. The patient was discharged to home on postoperative day 14 in good condition.

Figure 2
Figure 2

Metastatic rectal cancer after chemotherapy and selective internal radiation with yttrium-90 microspheres. The tumor in the right lobe is much smaller and is amenable to resection.

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 11, suppl_4; 10.6004/jnccn.2013.0219

The final pathologic result from the low anterior resection showed a well-differentiated low-grade adenocarcinoma 8.5 cm in length, extending into the subserosa. Proximal, distal, and radial margins were all negative. Metastatic cancer was seen in 5 of 55 lymph nodes. Treatment effect was noted in the primary tumor, without lymphovascular or perineural invasion. An 8.5-cm metastasis with extensive necrosis was found in the liver, with negative resection margins. No tumor was seen in the resected gallbladder or periportal tissue. The final pathologic stage was ypT3,N2a,M1.

The patient is currently without evidence of disease 5 months postoperatively, and is awaiting ileostomy take-down in the future. The patient received an additional 4 cycles of postoperative mFOLFOX6/bevacizumab, completing a total of 6 months of perioperative chemotherapy. The CEA after resection has decreased to 0.5 ng/mL, and remains low. Postoperative CT shows enlargement of the left lobe of the liver, and no evidence of metachronous disease (Figure 3). Surveillance will consist of history and physical examination with CEA determination every 3 months for 2 years, then every 6 months for the next 3 years, with CT chest/abdomen/pelvis imaging every year, and colonoscopy in 1 year. If metachronous metastases are later detected that are isolated and resectable, the patient will be recommended to undergo metastasectomy.

Figure 3
Figure 3

Postoperative surveillance CT shows enlargement of the left lobe of the liver, and no evidence of metachronous disease. Postoperative ascites is also seen adjacent to the liver.

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 11, suppl_4; 10.6004/jnccn.2013.0219

Discussion

Colorectal cancer is a major public health concern, and the third most common malignancy and cause of cancer-related death in men and women, with approximately 143,000 new cases and 51,000 deaths estimated in the United States in 2013.1 Metastatic disease is common, and the liver is the most common site of metastatic colorectal cancer. Approximately 25% of patients have colorectal liver metastases (CRLM) on presentation, and 60% of all patients will develop liver metastases at some time during the course of their disease.2 Without treatment, patients with CRLM have a median overall survival (OS) of 6 to 12 months,3 and with modern chemotherapy regimens, patients may have median OS of 20 to 24 months.4 Surgical resection of CRLM affords patients the possibility of a cure, with 5-year OS ranging from 20% up to 60% in some series.5,6 Unfortunately, only 15% to 25% of patients with CRLM are resectable at the time of presentation.7 For those patients with resectable synchronous CRLM at presentation, the literature suggests that they have a worse prognosis and a shorter disease-free survival versus those with metachronous CRLM.8

For patients with initially unresectable hepatic disease without other sites of metastases, treatment options include palliative chemotherapy versus upfront neoadjuvant combination chemotherapy given in an attempt to convert the metastases to resectable. In one of the largest worldwide experiences with chemotherapy for conversion, Adam et al9 reported their 11-year experience of 1439 patients with CRLM, of whom 1104 (77%) were initially unresectable. Patients underwent FOLFOX (70%), FOLFIRI (7%), or both regimens (4%), and ultimately 138 “good responder” patients (12.5%) were converted to resectability after a mean 10 cycles of chemotherapy. Rates of 5- and 10-year survival for the surgery group were 33% and 23%, respectively.

Multiple trials have shown that the addition of targeted antibody agents to chemotherapy, such as cetuximab (an anti-epidermal growth factor receptor [EGFR] antibody) or bevacizumab (a vascular endothelial growth factor [VEGF] antibody), leads to increased response and conversion rates in patients with unresectable CRLM. In the phase II multi-institution CELIM trial,10 patients with unresectable CRLM were randomized to receive cetuximab with either FOLFOX6 or FOLFIRI chemotherapy. Response rates were 68% in the cetuximab/FOLFOX arm and 57% in the cetuximab/FOLFIRI arm. Ultimately, 20 of 53 FOLFOX patients (38%) and 16 of 53 FOLFIRI patients (30%) underwent an R0 liver resection.10 Bevacizumab has also been shown to increase response rates with chemotherapy. In the First Bevacizumab Expanded Access Trial (First BEAT), bevacizumab was used in combination with the investigators’ choice of fluoropyrimidine-based chemotherapy for patients with unresectable metastatic colorectal cancer. Of 1914 patients, 225 (11.8%) were able to undergo curative-intent surgery.11

Regarding the optimal management of potentially resectable synchronous metastatic disease, the NCCN Clinical Practice Guidelines in Oncology for Rectal Cancer recommend discussion of patient management in a multidisciplinary conference, attended in this patient’s case, by surgical, medical, and radiation oncologists, and diagnostic and interventional radiologists and pathologists (to view the most recent version of these guidelines, visit NCCN.org). The synchronous metastatic disease was deemed to be unresectable, yet the patient was asymptomatic, thus the NCCN Guidelines for Rectal Cancer12 recommend an attempt at conversion to resectability with a chemotherapy regimen known to have high response rates,13 in this case FOLFOX/bevacizumab, followed by serial reassessments of resectability. NCCN believes that the best management of patients with cancer is in the context of clinical trials. Participation in clinical trials is especially encouraged.12

As part of his care, the patient underwent liver-directed radioembolization therapy with yttrium-90 SIR-Spheres microspheres. Radioembolization was previously shown to provide survival benefit in the control of unresectable CRLM in small trials of highly selected patients. In a study reported by Mulcahy et al,14 72 patients with liver-dominant CRLM were treated with yttrium-90 microspheres at a median dose of 118 Gy. Tumor response was seen in 40.3% of patients; median OS from the date of diagnosis of metastases was 34.6 months and from the time of yttrium-90 treatment was 14.5 months. In a prospective multicenter phase III trial reported by Hendlisz et al,15 46 patients with chemotherapy-refractory CRLM were randomized to protracted infusional 5-FU or infusional 5-FU with yttrium-90 radioembolization given on the first day of each 3-week cycle, with the end point of time to metastatic progression in the liver. At median follow-up of 24.8 months, time to liver progression was significantly better in the radioembolization group (5.5 vs 2.1 months), as was median OS (10.0 vs 7.3 months). Radioembolization in combination with systemic chemotherapy for attempted conversion is still the subject of clinical trials.

Chemotherapy is associated with hepatotoxicity, including steatosis and steatohepatitis with irinotecan and sinusoidal congestion/dilation with oxaliplatin,16,17 and close monitoring of patients for resectability every 2 months is warranted. During chemotherapy, this patient underwent imaging and tumor board presentation with the close involvement of the surgical team every 2 months.18 When the disease was felt to be resectable, the patient was offered resection after waiting 1 month from the last dose of chemotherapy and, as recommended by the NCCN Guidelines for Colon Cancer, at least 6 weeks after the last dose of bevacizumab (to view the most recent version of these guidelines, visit NCCN. org).19 Complete surgical resection of the CRLM based on anatomic grounds with negative margins was performed, leaving adequate hepatic function.

Short-course radiation therapy for rectal cancer with 25 Gy over 5 days, as opposed to traditional long-course chemoradiation of 45 to 50 Gy in 25 to 28 fractions with infusional or bolus 5-FU or oral capecitabine, is an option discussed in the NCCN Guidelines for Rectal Cancer.12 In a Polish trial randomizing patients to preoperative short-course radiation or long-course chemoradiation, no differences in overall, disease-free survival, or local recurrence rates at a median 48-month follow-up were seen.20 Although discussed in the NCCN Guidelines for Rectal Cancer,12 short-course radiation is currently not part of the NCCN treatment algorithm for the primary treatment of rectal cancer (to view the most recent version of these guidelines, visit NCCN.org). Short-course radiation may be an appropriate choice in certain situations, especially in the case of this patient, in whom chemotherapy had been completed and the patient was to undergo resection 4 weeks later without time for long-course chemoradiation.

Conclusions

This report presents a complex case of synchronous metastatic rectal cancer successfully managed in a multidisciplinary fashion. Input and coordination from multiple specialties were essential in the care of this patient. Adherence to published national guidelines helps provide patients, such as this one, with the best chance of optimal outcomes.

The authors have disclosed that they have no financial interests, arrangements, affiliations, or commercial interests with the manufacturers of any products discussed in this article or their competitors.

EDITOR

Kerrin M. Green, MA, Assistant Managing Editor, JNCCN—Journal of the National Comprehensive Cancer Network

Ms. Green has disclosed that she has no relevant financial relationships.

CE AUTHORS

Deborah J. Moonan, RN, BSN, Manager, CE Supporter Outreach

Ms. Moonan has disclosed the following relationship with commercial interests: AstraZeneca: Stockholder/Former Employee.

Nicole B. Harrold, BS, Manager, Continuing Education and Grants

Ms. Harrold has disclosed that she has no relevant financial relationships.

Kristina M. Gregory, RN, MSN, OCN, Vice President, Clinical Information Operations

Ms. Gregory has disclosed that she has no relevant financial relationships.

References

  • 1.

    Cancer Facts & Figures 2013. American Cancer Society Web site. Available at: http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-036845.pdf. Accessed September 19, 2013.

    • Search Google Scholar
    • Export Citation
  • 2.

    Donadon M, Ribero D, Morris-Stiff G. New paradigm in the management of liver-only metastases from colorectal cancer. Gastrointest Cancer Res 2007;1:2027.

    • Search Google Scholar
    • Export Citation
  • 3.

    Bengtsson G, Carlsson G, Hafstrom L, Jonsson PE. Natural history of patients with untreated liver metastases from colorectal cancer. Am J Surg 1981;141:586589.

    • Search Google Scholar
    • Export Citation
  • 4.

    Gallagher DJ, Kemeny N. Metastatic colorectal cancer: from improved survival to potential cure. Oncology 2010;78:237248.

  • 5.

    Charnsangavej C, Clary B, Fong Y. Selection of patients for resection of hepatic colorectal metastases: expert consensus statement. Ann Surg Oncol 2006;13:12611268.

    • Search Google Scholar
    • Export Citation
  • 6.

    Pawlik TM, Scoggins CR, Zorzi D. Effect of surgical margin status on survival and site of recurrence after hepatic resection for colorectal metastases. Ann Surg 2005;241:715722.

    • Search Google Scholar
    • Export Citation
  • 7.

    Adam R, Miller R, Pitombo M. Two-stage hepatectomy approach for initially unresectable colorectal hepatic metastases. Surg Oncol Clin N Am 2007;16:525-536, viii.

    • Search Google Scholar
    • Export Citation
  • 8.

    Tsai MS, Su YH, Ho MC. Clinicopathological features and prognosis in resectable synchronous and metachronous colorectal liver metastasis. Ann Surg Oncol 2007;14:786794.

    • Search Google Scholar
    • Export Citation
  • 9.

    Adam R, Delvart V, Pascal G. Rescue surgery for unresectable colorectal liver metastases downstaged by chemotherapy: a model to predict long-term survival. Ann Surg 2004;240:644657.

    • Search Google Scholar
    • Export Citation
  • 10.

    Folprecht G, Gruenberger T, Bechstein WO. Tumour response and secondary resectability of colorectal liver metastases following neoadjuvant chemotherapy with cetuximab: the CELIM randomised phase 2 trial. Lancet Oncol 2010;11:3847.

    • Search Google Scholar
    • Export Citation
  • 11.

    Okines A, Puerto OD, Cunningham D. Surgery with curative-intent in patients treated with first-line chemotherapy plus bevacizumab for metastatic colorectal cancer First BEAT and the randomised phase-III NO16966 trial. Br J Cancer 2009;101:10331038.

    • Search Google Scholar
    • Export Citation
  • 12.

    Benson AB III, Bekaii-Saab T, Chan E. NCCN Clinical Practice Guidelines in Oncology: Rectal Cancer. Version 4, 2013. Available at: NCCN.org. Accessed May 25, 2013.

    • Search Google Scholar
    • Export Citation
  • 13.

    Bartlett DL, Berlin J, Lauwers GY. Chemotherapy and regional therapy of hepatic colorectal metastases: expert consensus statement. Ann Surg Oncol 2006;13:12841292.

    • Search Google Scholar
    • Export Citation
  • 14.

    Mulcahy MF, Lewandowski RJ, Ibrahim SM. Radioembolization of colorectal hepatic metastases using yttrium-90 microspheres. Cancer 2009;115:18491858.

    • Search Google Scholar
    • Export Citation
  • 15.

    Hendlisz A, Van den Eynde M, Peeters M. Phase III trial comparing protracted intravenous fluorouracil infusion alone or with yttrium-90 resin microspheres radioembolization for liver-limited metastatic colorectal cancer refractory to standard chemotherapy. J Clin Oncol 2010;28:36873694.

    • Search Google Scholar
    • Export Citation
  • 16.

    Pawlik TM, Olino K, Gleisner AL. Preoperative chemotherapy for colorectal liver metastases: impact on hepatic histology and postoperative outcome. J Gastrointest Surg 2007;11:860868.

    • Search Google Scholar
    • Export Citation
  • 17.

    Vauthey JN, Pawlik TM, Ribero D. Chemotherapy regimen predicts steatohepatitis and an increase in 90-day mortality after surgery for hepatic colorectal metastases. J Clin Oncol 2006;24:20652072.

    • Search Google Scholar
    • Export Citation
  • 18.

    Abdalla EK, Adam R, Bilchik AJ. Improving resectability of hepatic colorectal metastases: expert consensus statement. Ann Surg Oncol 2006;13:12711280.

    • Search Google Scholar
    • Export Citation
  • 19.

    Benson AB III, Bekaii-Saab T, Chan E. Metastatic colon cancer, version 3.2013: featured updates to the NCCN Guidelines. J Natl Compr Canc Netw 2013;11:141152; quiz 152.

    • Search Google Scholar
    • Export Citation
  • 20.

    Bujko K, Nowacki MP, Nasierowska-Guttmejer A. Long-term results of a randomized trial comparing preoperative short-course radiotherapy with preoperative conventionally fractionated chemoradiation for rectal cancer. Br J Surg 2006;93:12151223.

    • Search Google Scholar
    • Export Citation

If the inline PDF is not rendering correctly, you can download the PDF file here.

Correspondence: Lucille Leong, MD, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA 91010. E-mail: lleong@coh.org
  • View in gallery View in gallery

    (A) Thickened segment of rectum with adenocarcinoma (arrows) and lymphadenopathy in the mesorectum (arrowhead). (B) Synchronous metastatic rectal cancer occupying most of the right lobe of the liver (arrow) and a satellite lesion adjacent to the inferior vena cava (arrowhead).

  • View in gallery

    Metastatic rectal cancer after chemotherapy and selective internal radiation with yttrium-90 microspheres. The tumor in the right lobe is much smaller and is amenable to resection.

  • View in gallery

    Postoperative surveillance CT shows enlargement of the left lobe of the liver, and no evidence of metachronous disease. Postoperative ascites is also seen adjacent to the liver.

  • 1.

    Cancer Facts & Figures 2013. American Cancer Society Web site. Available at: http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-036845.pdf. Accessed September 19, 2013.

    • Search Google Scholar
    • Export Citation
  • 2.

    Donadon M, Ribero D, Morris-Stiff G. New paradigm in the management of liver-only metastases from colorectal cancer. Gastrointest Cancer Res 2007;1:2027.

    • Search Google Scholar
    • Export Citation
  • 3.

    Bengtsson G, Carlsson G, Hafstrom L, Jonsson PE. Natural history of patients with untreated liver metastases from colorectal cancer. Am J Surg 1981;141:586589.

    • Search Google Scholar
    • Export Citation
  • 4.

    Gallagher DJ, Kemeny N. Metastatic colorectal cancer: from improved survival to potential cure. Oncology 2010;78:237248.

  • 5.

    Charnsangavej C, Clary B, Fong Y. Selection of patients for resection of hepatic colorectal metastases: expert consensus statement. Ann Surg Oncol 2006;13:12611268.

    • Search Google Scholar
    • Export Citation
  • 6.

    Pawlik TM, Scoggins CR, Zorzi D. Effect of surgical margin status on survival and site of recurrence after hepatic resection for colorectal metastases. Ann Surg 2005;241:715722.

    • Search Google Scholar
    • Export Citation
  • 7.

    Adam R, Miller R, Pitombo M. Two-stage hepatectomy approach for initially unresectable colorectal hepatic metastases. Surg Oncol Clin N Am 2007;16:525-536, viii.

    • Search Google Scholar
    • Export Citation
  • 8.

    Tsai MS, Su YH, Ho MC. Clinicopathological features and prognosis in resectable synchronous and metachronous colorectal liver metastasis. Ann Surg Oncol 2007;14:786794.

    • Search Google Scholar
    • Export Citation
  • 9.

    Adam R, Delvart V, Pascal G. Rescue surgery for unresectable colorectal liver metastases downstaged by chemotherapy: a model to predict long-term survival. Ann Surg 2004;240:644657.

    • Search Google Scholar
    • Export Citation
  • 10.

    Folprecht G, Gruenberger T, Bechstein WO. Tumour response and secondary resectability of colorectal liver metastases following neoadjuvant chemotherapy with cetuximab: the CELIM randomised phase 2 trial. Lancet Oncol 2010;11:3847.

    • Search Google Scholar
    • Export Citation
  • 11.

    Okines A, Puerto OD, Cunningham D. Surgery with curative-intent in patients treated with first-line chemotherapy plus bevacizumab for metastatic colorectal cancer First BEAT and the randomised phase-III NO16966 trial. Br J Cancer 2009;101:10331038.

    • Search Google Scholar
    • Export Citation
  • 12.

    Benson AB III, Bekaii-Saab T, Chan E. NCCN Clinical Practice Guidelines in Oncology: Rectal Cancer. Version 4, 2013. Available at: NCCN.org. Accessed May 25, 2013.

    • Search Google Scholar
    • Export Citation
  • 13.

    Bartlett DL, Berlin J, Lauwers GY. Chemotherapy and regional therapy of hepatic colorectal metastases: expert consensus statement. Ann Surg Oncol 2006;13:12841292.

    • Search Google Scholar
    • Export Citation
  • 14.

    Mulcahy MF, Lewandowski RJ, Ibrahim SM. Radioembolization of colorectal hepatic metastases using yttrium-90 microspheres. Cancer 2009;115:18491858.

    • Search Google Scholar
    • Export Citation
  • 15.

    Hendlisz A, Van den Eynde M, Peeters M. Phase III trial comparing protracted intravenous fluorouracil infusion alone or with yttrium-90 resin microspheres radioembolization for liver-limited metastatic colorectal cancer refractory to standard chemotherapy. J Clin Oncol 2010;28:36873694.

    • Search Google Scholar
    • Export Citation
  • 16.

    Pawlik TM, Olino K, Gleisner AL. Preoperative chemotherapy for colorectal liver metastases: impact on hepatic histology and postoperative outcome. J Gastrointest Surg 2007;11:860868.

    • Search Google Scholar
    • Export Citation
  • 17.

    Vauthey JN, Pawlik TM, Ribero D. Chemotherapy regimen predicts steatohepatitis and an increase in 90-day mortality after surgery for hepatic colorectal metastases. J Clin Oncol 2006;24:20652072.

    • Search Google Scholar
    • Export Citation
  • 18.

    Abdalla EK, Adam R, Bilchik AJ. Improving resectability of hepatic colorectal metastases: expert consensus statement. Ann Surg Oncol 2006;13:12711280.

    • Search Google Scholar
    • Export Citation
  • 19.

    Benson AB III, Bekaii-Saab T, Chan E. Metastatic colon cancer, version 3.2013: featured updates to the NCCN Guidelines. J Natl Compr Canc Netw 2013;11:141152; quiz 152.

    • Search Google Scholar
    • Export Citation
  • 20.

    Bujko K, Nowacki MP, Nasierowska-Guttmejer A. Long-term results of a randomized trial comparing preoperative short-course radiotherapy with preoperative conventionally fractionated chemoradiation for rectal cancer. Br J Surg 2006;93:12151223.

    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 175 118 10
PDF Downloads 34 29 4
EPUB Downloads 0 0 0