Treatment strategies for colorectal carcinoma with synchronous liver metastases: Which way to go?

AIM: To offer an up-to-date review of all availabletreatment strategies for patients with synchronous colorectal liver metastases(CLM).METHODS: A comprehensive literature search was performed to identify articles related to the management of patients with synchronous CLM. A search of the electronic databases PubMed, MEDLINE, and Google Scholar was conducted in September 2014.The following search terms were used: synchronous colorectal liver metastases, surgery, stage Ⅳ colorectal cancer, liver-first approach, and up-front hepatectomy.These terms were employed in various combinations to maximize the search. Only articles written in English were included. Particular attention was devoted to studies and review articles that were published within the last six years(2009-2014). Additional searches of the cited references from primary articles were performed to further improve the review. The full texts of all relevant articles were accessed by two independent reviewers.RESULTS: Poor long-term outcomes of patients with synchronous CLM managed by a traditional treatment strategy have led to questions about the timing and sequence of possible therapeutic interventions. Thus,alternative paradigms called reverse strategies have been proposed. Presently, there are four treatment strategies available:(1) primary first approach(or traditional approach) comprises resection of the primary colorectal tumor followed by chemotherapy;subsequent liver resection is performed 3-6 mo after colorectal resection(provided that CLM are still resectable);(2) simultaneous resection of the primary colorectal tumor and CLM during a single operation presents intriguing options for a highly select group of patients, which can be associated with significant postoperative morbidity;(3) liver-first(or chemotherapy-first) approach comprises preoperative chemotherapy(3-6 cycles) followed by liver resection,adjuvant chemotherapy, and resection of the primary colorectal tumor(it is best suited for patients withasymptomatic primary tumors and initially unresectable or marginally resectable CLM); and(4) up-front hepatectomy(or "true" liver-first approach) includes liver resection followed by adjuvant chemotherapy,colorectal resection, and adjuvant chemotherapy(strategy can be offered to patients with asymptomatic primary tumors and initially resectable CLM).CONCLUSION: None of the aforementioned strategies appears inferior. It is necessary to establish individual treatment plans in multidisciplinary team meetings through careful appraisal of all strategies.

Ectopic liver: Different manifestations, one solution

Developmental abnormalities are rare in the liver.This study presents two case reports of ectopic liver.The first case was a 31-year-old male with clinical indication for laparoscopic appendectomy.Laparoscopy identified a perforated appendix and an unknown tumorous lesion in the ligamentum hepato umbilicalis.The patient underwent a laparoscopic appendectomy,intraoperative lavage of the peritoneal cavity,and extirpation of the lesion in the ligamentum hepato umbilicalis.Histpathological examination of the excised tumor revealed that it comprised liver tissue with fibrinous changes.The tumor was completely separate from the liver with no connection.It was classified as an ectopic liver.No further therapy was required.The second case was a59-year-old male with a tumor on the upper pole of the spleen,incidentally diagnosed in an ultrasound examination.The biopsy raised suspicion of hepatocellular carcinoma.A positron emission tomography-computed tomography examination revealed accumulation of F-18 fluorodeoxyglucose only in the tumor.The patient underwent a splenectomy with a resection and reconstruction of diaphragm.After the hepatocellular carcinoma was confirmed,adjuvant therapy(sorafenib)was initialized.The operations and postoperative recoveries were uncomplicated in both cases.Despite the low incidence of ectopic liver and rare complications,it is necessary to maintain awareness of this possibility.The potential malignancy risk for ectopic liver tissue is the basis for radical surgical removal.Therapy for hepatocellular carcinoma in an ectopic liver follows the same guidelines as those followed for treating the"mother"liver.