Multidisciplinary management of metastatic colorectal cancer

Fusobacterium nucleatum, immune responses, and metastatic organ diversity in colorectal cancer liver metastasis

The presence of Fusobacterium nucleatum is associated with an immunosuppressive tumor immune microenvironment (TIM) in primary colorectal cancer (CRC), contributing to tumor progression. Its persistence in CRC liver metastasis tissues raises questions about its role in modulating local and systemic immune responses and influencing recurrence patterns. This retrospective cohort study of 218 patients with CRC liver metastasis investigated the association of F. nucleatum in CRC liver metastasis tissues with systemic inflammation, TIM alterations, and the number of metastatic organs involved in recurrence. Two-step polymerase chain reaction (PCR), including digital PCR, detected F. nucleatum in 42% (92/218) of fresh-frozen specimens of CRC liver metastases. Compared with the F. nucleatum-none group, the F. nucleatum-high group showed higher C-reactive protein levels (0.82 vs. 0.22 mg/dL; Ptrend = 0.02), lower numbers of CD8+ cells (33.2 vs. 65.3 cells/mm2; Ptrend = 0.04) and FOXP3+ cells (11.3 vs. 21.7 cells/mm2; Ptrend = 0.01) in the TIM, and a greater number of metastatic organs involved in recurrence (1.6 vs. 1.1; p < 0.001). The presence of F. nucleatum in CRC liver metastasis tissues was associated with increased systemic inflammation, TIM alterations, and a greater number of metastatic organs involved in recurrence. These findings suggest a potential contribution of F. nucleatum to the metastatic propensity of CRC cells and could inform future research to enhance understanding of the interaction between tumor, host, and microbes in the metastatic process.

Are academic hospitals better at treating metastatic colorectal cancer?

BACKGROUND

There is a strong association between hospital volume and surgical outcomes in resectable colorectal cancer. The purpose of our study was to investigate the association between hospital facility type and survival of patients with metastatic colorectal cancer.

METHODS

Adults from the National Cancer Database (2010-2015) with a primary diagnosis of colorectal metastases were included and stratified by facility type: community cancer program, comprehensive community cancer program, and academic/research program. The primary outcome was 5-year overall survival, analyzed using Kaplan-Meier survival curves, log-rank test, and the Cox proportional hazards regression model.

RESULTS

Among the 52,958 included patients, 13.72% were treated at a community cancer program, 49.89% at a comprehensive community cancer program, and 36.29% at an academic/research program. A significant increase in the proportion of patients being treated in an academic/research program has been observed from 2010 to 2015. An academic/research program tended to use more chemotherapy with colorectal radical resection and liver or lung resection and immunotherapy with chemotherapy. In adjusted analysis, the academic/research program had decreased risk of mortality in comparison to the community cancer program and the comprehensive community cancer program (hazard ratio 0.90, 95% confidence interval 0.86-0.94; 0.87, 0.85-0.90; each P < .001; respectively). Similar results were seen after stratifying by metastatic site and treatment type.

CONCLUSION

The prognosis and overall survival of patients with metastatic disease is better in an academic/research program compared with a community cancer program or a comprehensive community cancer program, with this difference persisting across sites of metastatic disease and treatment types. Further studies are required to validate these results and investigate disparities in the management of metastatic colorectal cancer.

Predicting complications in hepatic resection for colorectal liver metastasis: the lymphocyte-to-monocyte ratio

BACKGROUND

Colorectal cancer is one of the most common malignancies worldwide; whilst approximately 20% of patients have hepatic disease at presentation. Hepatic resection remains the gold standard of care; however, it is associated with significant morbidity. We sought to establish whether the lymphocyte-to-monocyte ratio (LMR) could help predict post-operative complications, thus improving patient outcomes.

METHODS

We performed a retrospective cohort study of patients undergoing hepatic resection at a single centre. Baseline demographics and complications within 30 days following surgery were recorded. White blood cell counts and C-reactive protein (CRP) were recorded pre-operatively, and until post-operative day 7.

RESULTS

A total of 188 operations were included. About 47.3% of resections had a complicated recovery, of which 31.46% were major. The median LMR was 1.29 across the cohort, 1.60 for uncomplicated procedures, 1.14 for those with complications and 0.85 in major complications. For detecting major complications versus an uncomplicated recovery, median LMR was the best parameter (area under the curve 0.78), whilst it was the only parameter to accurately predict such complications within 48 hours of surgery (area under the curve 0.72 on day 1). It was consistently the most accurate parameter at detecting uncomplicated versus complicated recovery, minor versus major complications, and major complications versus an uncomplicated recovery, at numerous timepoints over the post-operative period.

CONCLUSION

The LMR appears better at predicting complications following hepatic resection for colorectal liver metastases, as opposed to conventionally measured parameters.

Magnetic resonance-guided laser-induced interstitial thermotherapy of breast cancer liver metastases and other noncolorectal cancer liver metastases: an analysis of prognostic factors for long-term survival and progression-free survival

PURPOSE

The purpose of this study was the evaluation of prognostic factors for long-term survival and progression-free survival (PFS) after treatment of noncolorectal cancer liver metastases through MR-guided laser-induced thermotherapy (LITT).

PATIENTS AND METHODS

We included 401 patients (mean age, 57.3 years) with liver metastases from different primary tumors who were treated with LITT. Long-term survival and progression-free-survival rates were evaluated using the Kaplan-Meier method. A Cox regression model tested different parameters that could be of prognostic value. The tested prognostic factors were as follows: the location of primary tumor, TNM classification, extrahepatic metastases, hepatic resection or neoadjuvant transarterial chemoembolization or systemic chemotherapy before LITT, the number of initial metastases, the volume of metastases, and the quotient of total volumes of metastases and necroses per patient.

RESULTS

The median survival was 37.6 months starting from the date of LITT. The 1-, 2-, 3-, 4-, and 5-year survival rates were 86.5%, 67.2%, 51.9%, 39.9%, and 33.4%, respectively. The median PFS was 12.2 months. The 1-, 2-, 3-, 4-, and 5-year PFS rates were 50.6%, 33.8%, 26%, 20.4%, and 17%, respectively. The initial number of metastases, the volumes of metastases, and the quotient of the volumes of metastases and necroses influenced the long-term survival and the PFS.

CONCLUSIONS

Laser-induced thermotherapy is a minimally invasive method in the treatment of hepatic metastases of noncolorectal cancer, and it shows good results in long-term survival and PFS. The initial number of metastases and their volume are the most important prognostic factors. The status of the lymph nodes, the existence of other extrahepatic metastases, the location of the primary tumor, and different neoadjuvant therapies are of nonprognostic value.

Mortality and morbidity of hepatectomy, radiofrequency ablation, and embolization for hepatocellular carcinoma: a national survey of 54,145 patients

BACKGROUND

Reported mortalities and morbidities of therapeutic procedures for liver tumors vary between studies, because of different designs and small sample sizes. We investigated the mortalities and complication rates for hepatectomy, radiofrequency ablation (RFA), and trans-catheter arterial embolization (TAE) for hepatocellular carcinoma (HCC) in a large sample, using a nationwide Japanese database (the Diagnosis Procedure Combination database).

METHODS

Data from the Diagnosis Procedure Combination database were analyzed for July 1 to December 31, 2007 and the same period in 2008. We identified 54,145 patients with HCC who underwent hepatectomy (n = 5,270), RFA (n = 11,688), or TAE (n = 37,187). In-hospital mortality and morbidity were analyzed for each procedure. The relationships between mortality and factors including patient characteristics and procedural backgrounds were assessed.

RESULTS

In-hospital mortalities associated with hepatectomy, RFA, and TAE were 2.6 % [95 % confidence interval (CI) 2.2-3.1], 0.3 % (0.2-0.4), and 1.0 % (0.9-1.1), and post-procedural complication rates were 14.5 % (13.5-15.5), 4.5 % (4.2-4.9), and 4.5 % (4.3-4.7), respectively. Increased mortality following hepatectomy was significantly associated with older age, extended lobectomy (vs. partial hepatectomy; odds ratio [OR] 3.80, p < 0.001), lower hospital volume (OR 2.74, p < 0.001), and renal comorbidity (OR 3.01, p = 0.02). Older age and cardiac comorbidity (OR 5.14, p = 0.001) were significantly associated with RFA-related mortality, and lower hospital volume was significantly associated with TAE-related mortality (OR 1.60, p < 0.001).

CONCLUSIONS

Mortalities and morbidities associated with therapeutic procedures for liver tumors were acceptably low in Japan, but were affected by patient and institutional characteristics.

The current role of minimally invasive therapies in the management of liver tumors

This is a review of minimally invasive therapy options for liver tumors, such as highly focused ultrasound, microwave ablation, and irreversible electroporation, as well as new aspects of radiofrequency ablation. Radiofrequency ablation is recommended for patients with early-stage HCC with up to 3 lesions with a tumor diameter within 3 cm and for patients with non-resectable liver metastasis. Indications and contraindications to treatment are designated, and different modalities for image-based therapy guidance are compared. Options for therapy monitoring and controlling are reviewed, namely intraprocedural tools, imaging and functional parameters and their evolution during therapy. Prevention and control of local recurrences is discussed. We also present a short review of current clinical results in treating liver metastasis and primary liver tumors.

Outcome after laparoscopic radiofrequency ablation of technically resectable colorectal liver metastases

BACKGROUND

There continues to be controversy surrounding the appropriate use of radiofrequency ablation (RFA) for the treatment of colorectal liver metastases (CRLM). This study analyzes outcomes data of CRLM patients who underwent laparoscopic RFA. Outcomes of patients determined to be technically resectable were compared to patients with unresectable disease.

METHODS

Data from all patients with CRLM who underwent laparoscopic RFA between 1996 and 2006 were retrospectively reviewed. A blinded independent hepatobiliary-trained surgical oncologist reviewed preoperative diagnostic imaging studies to determine resectability. Outcomes data for patients with disease deemed anatomically resectable and unresectable were analyzed and compared. Survival was calculated by the Kaplan-Meier method. The log rank test was performed to assess significance in survival.

RESULTS

A total of 113 patients who underwent laparoscopic RFA for CRLM were identified. Twelve patients who underwent concurrent hepatic resection were excluded. Of the remaining patients, 64 were determined to have disease that was be technically resectable and 37 unresectable as a result of tumor number and/or distribution. Median and 5-year survival of the potentially resectable group was 4.3years and 48.7%, compared to 2.2 years and 18.4% in the unresectable group (P = 0.002). Median disease-free survival in the resectable group was 15.0 months, compared to 16.4 months in the unresectable group (P = 0.796). No postoperative mortality was reported in the technically resectable group, and the rate of major complications was 3.1%.

CONCLUSIONS

Laparoscopic RFA of resectable CRLM can produce comparable long-term survival to hepatic resection in carefully selected patients, with favorable morbidity and mortality.

Repeated transarterial chemoembolization in the treatment of liver metastases of colorectal cancer: prospective study

PURPOSE

To evaluate local tumor control and survival data after transarterial chemoembolization with different drug combinations in the palliative treatment of liver metastases in patients with colorectal cancer.

MATERIALS AND METHODS

The study was approved by institutional review board, and informed consent was obtained from all patients included in the study. A total of 463 patients (mean age, 62.5 years; range, 34.7-88.1 years) with unresectable liver metastases of colorectal cancer that did not respond to systemic chemotherapy were repeatedly treated with chemoembolization in 4-week intervals. In total, 2441 chemoembolization procedures were performed (mean, 5.3 sessions per patient). Of 463 patients, 67.4% had multiple (five or more) metastases, 8% had one metastasis, 10.4% had two metastases, and 14.3% had three or four metastases. The local chemotherapy protocol consisted of mitomycin C alone (n = 243), mitomycin C with gemcitabine (n = 153), or mitomycin C with irinotecan (n = 67). Embolization was performed with lipiodol and starch microspheres for vessel occlusion. Tumor response was evaluated with magnetic resonance imaging. The change in tumor size was calculated and the response was evaluated according to the Response Evaluation Criteria in Solid Tumors. Survival rates from first diagnosis and from first chemoembolization session were calculated according to the Kaplan-Meier method. Follow-up imaging was performed until patient death.

RESULTS

Evaluation of local tumor control resulted in partial response (68 patients [14.7%]), stable disease (223 patients [48.2%]), and progressive disease (172 patients [37.1%]). The 1-year survival rate after chemoembolization was 62%, and the 2-year survival rate was 28%. Median survival from date of diagnosis of liver metastases was 38 months and from the start of chemoembolization treatment was 14 months. There was no statistically significant difference between the three treatment protocols.

CONCLUSION

Chemoembolization is a minimally invasive therapy option for palliative treatment of liver metastases in patients with colorectal cancer, with similar results among three chemoembolization protocols.

Tumor escape from endogenous, extracellular matrix-associated angiogenesis inhibitors by up-regulation of multiple proangiogenic factors

PURPOSE

Thrombospondin-1 (Tsp1), endostatin, and tumstatin are extracellular matrix-associated proteins that inhibit angiogenesis. We examined the mechanisms by which tumor cells may bypass the antiangiogenic effects of these endogenous regulators.

EXPERIMENTAL DESIGN

CT26 colon and RenCa renal carcinoma cells were stably transfected with Tsp1, endostatin, or tumstatin cDNA. Subcutaneous and metastatic tumor growth in syngeneic mice was analyzed. Expression of proangiogenic factors in resulting tumors was measured by quantitative real-time PCR. The combination of Tsp1 and vascular endothelial growth factor (VEGF) receptor-2 inhibition was also examined.

RESULTS

There was significant suppression of angiogenesis in flank tumors and liver metastases formed from cells overexpressing Tsp1, endostatin, or tumstatin. However, all tumors ultimately escaped angiogenesis inhibition. The combination of all three angiogenesis inhibitors had no additive effect beyond overexpression of a single inhibitor. Using quantitative real-time PCR, we found that VEGF and platelet-derived growth factor (PDGF)-A levels were routinely up-regulated at least 5-fold in all CT26 tumors overexpressing any antiangiogenic protein, and there were variable increases in angiopoietin 2 (Ang2), basic fibroblast growth factor, and PDGF-B. In contrast, RenCa tumors, which have high baseline levels of VEGF and PDGF-B, relied on basic fibroblast growth factor, Ang1, and PDGF-A up-regulation to counteract Tsp1 overexpression. Growth of CT26 cells with Tsp1 overexpression was suppressed when anti-VEGFR-2 treatment was added.

CONCLUSIONS

Cancer cells with overexpression of three different endogenous angiogenesis inhibitor eventually escape angiogenesis inhibition by up-regulation of various proangiogenic factors. Tsp1, endostatin, and tumstatin may be functionally redundant in this system. These endogenous angiogenesis inhibitors are likely best used in combination with the blockade of proangiogenic pathways or with traditional chemotherapy or radiation therapy.

Two-Stage Surgical Treatment of Unresectable Obstructive Rectal Cancer with Synchronous Hepatic Metastases

Unresectable obstructing rectal cancer with synchronous hepatic metastases is usually a fatal disease. This prospective study was scheduled to treat this difficult condition using a multimodal curative strategy combined with a two-stage surgical treatment. Patients with T4N2 or N3M1 rectal cancer and hepatic metastases underwent a two-stage surgical treatment; in the first stage, a decompressing colostomy plus radiofrequency ablation (RFA) in liver metastases. In the second stage, a colectomy was done with stoma closing and resection of superficial necrotic hepatic tumors, plus repetition of RFA in recurrent or new hepatic tumors. Four patients were included, with 1 to 8 (total 20) hepatic metastases, each <5 cm in diameter. In the first stage, two patients were operated on by open approach and two laparoscopically. All hepatic tumors were treated by RFA to produce at least a 1-cm tumor-free margin. After chemoradiation of the rectal tumor, the second stage of surgical treatment was successful in colectomies and stoma closing. Three had complete necrosis of hepatic tumors and one a recurrent tumor plus two new metastases treated by RFA. Two patients died 14 and 42 months after the first stage of surgical treatment, and the other two patients are alive. One of them is disease-free 54 months after the first stage and the other with new recurrence 52 months after the first stage of the procedure. The multimodal curative strategy for the treatment of unresectable obstructing rectal cancer with synchronous hepatic metastases, containing a two-stage surgical treatment with RFA of hepatic metastases and chemoradiation of the rectal tumor between the two stages of the procedure, is a promising method. A larger number of patients with long-term follow-up is necessary to confirm these findings.

Liver resective surgery: a multivariate analysis of postoperative outcome and complication

INTRODUCTION

Notwithstanding technical advances and high experience of liver resection of specialized centers, the rate of complications after surgical resection could be high. In this study, we analyzed causes and foreseeable risk factors linked to postoperative morbidity on the ground of data derived from a single center surgical population.

MATERIALS AND METHODS

From September 1989 to March 2005, 134 consecutive patients had liver resection for Hcc and 153 consecutive patients with liver metastasis (derived from either colorectal cancer or noncolorectal cancer) at our department. We performed 22 major hepatectomy, 20 left hepatectomy, 14 trisegmentectomy, 77 bisegmentectomy and/or left lobectomy, 74 segmentectomy, and 80 wedge resection.

RESULTS

In-hospital mortality rate was 4.5%, about 7% in Hcc cases and 2.6% in liver metastasis. Morbidity rate was 47.7%, caused by the rising of ascites (10%), temporary impairment liver function (19%), biliary fistula (6%), hepatic abscess (25%), hemoperitoneum (10%), and pleural effusion (30%) sometimes combined each other. Some variables, associated with the technical aspects of surgical procedure, are responsible of the rising of complication as: Pringle maneuver length of more than 20 minutes (p=0.001); the type of liver resection procedure [major hepatectomy (p=0.02), left hepatectomy (p=0.04), trisegmentectomy (p=0.04), bisegmentectomy and/or left lobectomy (p=0.04)]; and the request of an amount of blood transfusion of more than 600 cc (p=0.04). Also, both liver dysfunction, in particular Child A vs B and C (p=0.01), and histopathological grading (p=0.01) are associated with a high rate of postsurgical complication in Hcc cases.

CONCLUSION

We make the following recommendations: every liver resection should be planned after intraoperative ultrasonography, anatomical surgical procedure should be preferred instead of wedge resection, and modern devices should be used, like Argon Beam and Ligasure dissector, to reduce the incidence of both intraoperative and postoperative bleeding and biliary leakage.

Surgical resection of hepatic and pulmonary metastases from colorectal carcinoma

BACKGROUND

Patients with hepatic and pulmonary metastases from colorectal cancer (CRC) may benefit from aggressive surgical therapy. We examined the longterm outcomes of patients who underwent both lung and liver resections for colorectal metastases over a 10-year period.

STUDY DESIGN

Four hundred twenty-three hepatectomies were performed for metastatic CRC between 1992 and 2002 at two university-affiliated hospitals. Patients who underwent both lung and liver resections for metastatic CRC were studied. Demographic, perioperative, and survival data were evaluated by retrospective chart review. Disease-free survival (DFS) and overall survival (OS) were evaluated by Kaplan-Meier analysis and survival curves were compared using the log-rank test.

RESULTS

Thirty-nine patients underwent both lung and liver resections for metastatic CRC. Eleven patients (28%) underwent staged liver and lung metastasectomy from synchronously identified metastases. Twenty-eight patients (72%) underwent sequential metastasectomy because of recurrent disease. The median disease-free and overall survivals after initial metastasectomy were 19.8 and 87 months, respectively. Serial metastasectomy was common in this patient population. The mean number of metastasectomies performed was 2.6 per patient (range 1 to 4). There was no difference in overall survival for patients with synchronous versus metachronous presentation of liver and lung metastases (p=0.45). The site of first recurrence after initial metastasectomy was, most commonly, the lung (n=19, 49%), followed by the liver (n=8, 21%). Nineteen patients (49%) underwent subsequent resections for recurrences. Seven patients (18%) underwent 2 or more liver resections for recurrent disease, and 12 (31%) underwent multiple lung resections.

CONCLUSIONS

An aggressive multidisciplinary surgical approach should be undertaken for recurrent CRC metastases. In selected patients, serial metastasectomy for recurrent metastatic disease is safe and results in excellent longterm survival after CRC resection.

Long-term follow-up of patients of intrahepatic malignancies treated with iodine-125 brachytherapy

PURPOSE

We investigated the role of intraoperative iodine-125 (125I) brachytherapy as a treatment option for unresectable primary and metastatic liver tumors.

METHODS AND MATERIALS

Between 1989 and 2002, 64 patients with unresectable or residual disease after surgical resection for intrahepatic malignancies underwent 160-Gy permanent 125I brachytherapy.

RESULTS

The median length of follow-up was 13.2 years. The overall 1-year, 3-year, and 5-year actuarial intrahepatic local control rates were 44%, 22%, and 22%, respectively, with a median time to liver recurrence of 9 months (95% CI, 6-12 months). The 5-year actuarial intrahepatic control was higher for patients with solitary metastasis (38%) than for those with multiple metastases (6%, p = 0.04). The 1-year, 3-year, and 5-year actuarial overall survival rates were 73%, 23%, and 5%, respectively (median, 20 months; 95% CI, 16-24; longest survival, 7.5 years). Overall survival was higher for patients with smaller-volume implants (p = 0.003) and for patients without prior liver resection (p = 0.002). No mortality occurred. Radiation-related complications were minimal.

CONCLUSIONS

For select patients with unresectable primary and metastatic liver tumors for whom curative surgical resection is not an option, 125I brachytherapy is a safe and effective alternative to other locally ablative techniques and can provide long-term local control and increased survival.

Treatment of unresectable lung metastases with transpulmonary chemoembolization: preliminary experience

Transpulmonary chemoembolization (TPCE) was evaluated as a new treatment for unresectable lung metastases. Institutional review board approval and patient consent were obtained. In 23 patients, 26 lung metastases of different origins were treated locally by using a transpulmonary approach. After femoral vein puncture, tumor-supplying pulmonary arteries were selectively explored, and 5-10 mg mitomycin C and 5-10 mL iodized oil and microsphere particles were applied with balloon protection. Diagnosis and follow-up (3-month intervals) were performed with unenhanced and contrast material-enhanced computed tomography (CT). Treatment was well tolerated in all patients, with no major side effects or complications. As indicated by using morphologic criteria, volume regression of embolized areas was achieved in eight patients, while stable disease was revealed at follow-up in six patients. In nine patients, progression of treated intrapulmonary metastases was recorded. TPCE could be a well-tolerated palliative treatment option in patients with pulmonary metastases.

Liver metastases: neoadjuvant downsizing with transarterial chemoembolization before laser-induced thermotherapy

PURPOSE

To evaluate a treatment protocol with repeated transarterial chemoembolization (TACE) before laser-induced thermotherapy (LITT) in patients with unresectable liver metastases that are too large for LITT alone.

MATERIALS AND METHODS

One hundred sixty-two patients who had unresectable liver metastases, with the largest lesion as large as 80 mm in diameter, and no more than four lesions were treated with repeated TACE between March 1999 and December 2001. TACE was performed with a maximum of 10 mg/m2 mitomycin for chemotherapy and a maximum of 15 mL/m2 of iodized oil and microspheres for vessel occlusion. Tumor volume before and during treatment was measured at magnetic resonance (MR) imaging. If the diameter of the tumor decreased to less than 50 mm, the patients were treated with MR imaging-guided LITT 4-6 weeks following embolization.

RESULTS

Eighty-two patients (62 with metastases from colorectal cancer, 14 with metastases from breast cancer, and six with metastases from other primary tumors) responded to TACE, with a mean reduction in tumor size of 35% +/- 14 (SD), and were treated with LITT. Each patient underwent two to seven TACE treatments (mean, 4.3) prior to LITT. In 47 patients, no reduction in tumor size was achieved, which led to further follow-up. In 33 patients, disease progression was found, with either an increasing size of the lesions (n = 18) or newly developing metastases (n = 15), and these results led to further TACE treatments or change to systemic chemotherapy. Median survival of patients who responded to this combined treatment was 26.2 months; in patients treated with only TACE, median survival was 12.8 months (range, 0.3-29.4 months).

CONCLUSION

With repeated TACE, reduction in size of primary unresectable hepatic metastases is achieved in 50.6% of cases and allows local ablative treatments such as MR imaging-guided LITT.

Current treatment for liver metastases from colorectal cancer

The liver is the commonest site of distant metastasis of colorectal cancer and nearly half of the patients with colorectal cancer ultimately develop liver involved during the course of their diseases. Surgery is the only therapy that offers the possibility of cure for patients with hepatic metastatic diseases. Five-year survival rates after resection of all detectable liver metastases can be up to 40%. Unfortunately, only 25% of patients with colorectal liver metastases are candidates for liver resection, while the others are not amenable to surgical resection. Regional therapies such as radiofrequency ablation and cryotherapy may be offered to patients with isolated unresectable metastases but no extrahepatic diseases. Hepatic artery catheter chemotherapy and chemoembolization and portal vein embolization are often used for the patients with extensive liver metastases but without extrahepatic diseases, which are not suitable for regional ablation. For the patients with metastatic colorectal cancer beyond the liver, systemic chemotherapy is a more appropriate choice. Immunotherapy is also a good option when other therapies are used in combination to enhance the efficacy. Selective internal radiation therapy is a new radiation method which can be used in patients given other routine therapies without effects.

Surgical treatment of colon and rectal cancer

There are many indications for surgical intervention in the current treatment of cancer of the colon and rectum. The hallmark of surgical therapy remains en bloc resection of the primary tumor, accompanied by removal of the mesenteric lymph nodes. Surgical resection is also the principal and most successful treatment for local recurrences and isolated metastases. Although the application of minimally invasive techniques is growing in all aspects of surgery and is accepted in the treatment of benign lesions of the colon, laparoscopic resection for colorectal cancer cannot be recommended apart from randomized, controlled trials. Similarly, the role of sentinel lymph node biopsy in the surgical treatment of colorectal cancer remains to be defined. Various surgical modalities have been developed for the treatment of unresectable colorectal cancer metastatic to the liver. Further studies should help to elucidate the exact role of these therapies in the treatment of this common clinical problem. In summary, surgical treatment plays an important role in multiple aspects of the care of the patient with colorectal cancer.