What is the optimal resection strategy for an elderly patient with sigmoid colon cancer and multiple metastases in the right liver lobe?

Optimal Resection Strategy for Elderly Patient with Sigmoid Colon Cancer and Multiple Right Liver Lobe Metastases

For an elderly patient with sigmoid colon cancer and multiple metastases in the right liver lobe, a staged approach with primary tumor resection followed by liver metastases resection (option D) is the preferred strategy to minimize perioperative morbidity and mortality.

Rationale for Staged Approach

• The EORTC consensus recommendations (2025) clearly state in Recommendation 20: "If simultaneous resection and/or ablation is not feasible (i.e., patients with poor performance status or requiring major liver and/or colorectal surgery), resection and/or ablation of the liver metastases followed by resection of the primary tumour should be the preferred approach for patients with synchronous CRCLM and no symptoms or impending risk of complications related to the primary tumour" 1.

• For elderly patients specifically, a staged approach is preferred as:

  • Advanced age increases the risk of postoperative complications
  • Simultaneous major resections should be avoided in elderly patients due to higher physiological stress
  • Staged approach allows for recovery between procedures

Treatment Algorithm

1. Initial Assessment:

   • Complete staging with CT chest/abdomen/pelvis
   • Liver-specific imaging to assess extent of metastases
   • Comprehensive evaluation of patient's physiological status and comorbidities

2. First Surgery:

   • Sigmoid colon resection with appropriate lymphadenectomy
   • Goals: remove symptomatic primary tumor, prevent complications, allow recovery

3. Interval Period:

   • Consider neoadjuvant or interval chemotherapy based on EORTC recommendations:
     • For pMMR/MSS tumors: Chemotherapy followed by surgery 1
     • For RAS/BRAF wild-type, left-sided tumors: Chemotherapy plus anti-EGFR antibody 1
     • For RAS/BRAF mutant tumors: Triplet chemotherapy plus bevacizumab 1
   • Close surveillance with imaging to detect disease progression

4. Second Surgery:

   • Right hepatectomy or multiple segmentectomies depending on:
     • Number and location of metastases
     • Liver function and volume
     • Patient's condition
   • Goal: remove all macroscopic disease with clear margins while preserving sufficient functioning liver (at least one-third of standard liver volume) 2

Important Considerations

• Liver Volume: Ensure at least one-third of standard liver volume will remain after resection 2

• Elderly-Specific Concerns:

  • Elderly patients have 2-3 fold increased risk of postoperative mortality following liver resection 2
  • Laparoscopic approach for liver resection has shown significantly lower postoperative morbidity in elderly patients 2

• Contraindications for Liver Resection:

  • Uncontrollable extrahepatic disease
  • Insufficient future liver remnant
  • Medical unfitness for surgery 2

Why Not Other Approaches?

• Primary only (Option A): Suboptimal as it leaves metastatic disease untreated, which is the main driver of mortality 3

• Secondaries only (Option B): Not recommended as the primary tumor may cause complications if left in place

• Synchronous resection (Option C): Higher risk in elderly patients due to increased physiological stress of combined major surgeries 2

• Reverse approach (liver first): While mentioned in the literature 4, the EORTC guidelines recommend primary tumor resection first in the absence of symptoms or impending risk of complications related to the primary tumor 1

The evidence strongly supports a staged approach (Option D) as the optimal strategy for elderly patients with sigmoid colon cancer and multiple liver metastases, balancing oncological outcomes with perioperative risk.