From the Guidelines
For an old, aged patient with sigmoid colon cancer with multiple metastases in the right liver lobe, the most appropriate resection strategy would be option A: primary tumor resection only. In elderly patients with metastatic colorectal cancer, the treatment approach must balance oncological benefit against surgical risk. Primary tumor resection addresses the immediate risk of complications such as obstruction, bleeding, or perforation from the sigmoid cancer. Given the patient's advanced age and the presence of multiple liver metastases (indicating advanced disease), aggressive surgical approaches like synchronous resection of both primary and metastatic tumors would likely carry excessive morbidity and mortality risks without significantly improving survival. The presence of multiple metastases in one liver lobe suggests a high disease burden that may be better managed with systemic therapy following primary tumor control. Palliative resection of the primary tumor can improve quality of life while avoiding the substantial physiological stress of combined or staged hepatic resection, which would be particularly challenging in an elderly patient with potentially limited physiological reserve. According to the most recent guidelines from the Chinese Society of Clinical Oncology (CSO) 1, for patients with resectable metastatic colon cancer, surgical resection is a potentially curative treatment option, but the technical requirements include sufficient residual liver volume and R0 resection margins. However, in this case, given the patient's advanced age and multiple metastases, a more conservative approach focusing on primary tumor control and systemic therapy may be more appropriate, as also suggested by the CSO guidelines for initially unresectable colon cancer 1. Additionally, the ESMO consensus guidelines for management of patients with colon and rectal cancer also support a personalized approach to clinical decision making, considering factors such as the patient's overall health, tumor characteristics, and potential benefits and risks of different treatment strategies 1. Therefore, the recommended approach is to prioritize primary tumor resection, followed by systemic therapy, rather than attempting a more aggressive surgical approach that may not be tolerated well by the patient.
From the Research
Resection Strategy for Sigmoid Colon Cancer with Multiple Metastases in Right Liver Lobe
The resection strategy for an old, aged patient with sigmoid colon cancer and multiple metastases in the right liver lobe can be considered based on the following options:
- Synchronous resection: This approach involves resecting both the primary tumor and the liver metastases simultaneously. A study 2 reported a case of a 34-year-old woman with sigmoid colon cancer and approximately 50 liver metastases who underwent synchronous resection of the primary tumor and all liver metastases after neoadjuvant chemotherapy, resulting in a remarkable response.
- Staged resection: This approach involves resecting the primary tumor first, followed by resection of the liver metastases. A study 3 reported a case of a 61-year-old woman with sigmoid colon cancer and multiple liver metastases who underwent laparoscopic resection of the primary tumor, followed by chemotherapy and subsequent resection of the liver metastases.
- Resection of liver metastases only: This approach involves resecting only the liver metastases, without resecting the primary tumor. A study 4 reported a case of a 65-year-old man with sigmoid colon cancer and multiple liver metastases who underwent hepatic arterial infusion chemotherapy, followed by partial liver resection for a solitary recurrent liver metastasis.
- Primary resection only: This approach involves resecting only the primary tumor, without resecting the liver metastases. A study 5 reported a case of a 72-year-old man with advanced sigmoid colon cancer and multiple liver metastases who underwent cetuximab monotherapy as first-line treatment, followed by combination chemotherapy, but did not undergo resection of the liver metastases.
Considerations for Resection Strategy
The choice of resection strategy depends on various factors, including the patient's overall health, the extent of the disease, and the potential benefits and risks of each approach. Studies 3, 4, 2, 5, 6 suggest that a multidisciplinary approach, including chemotherapy, surgery, and other treatments, may be necessary to achieve optimal outcomes for patients with sigmoid colon cancer and multiple liver metastases.