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

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 while avoiding the additional physiological stress of liver surgery. The presence of multiple liver metastases in an elderly patient typically indicates advanced disease where complete surgical clearance of metastases may not significantly improve survival but would substantially increase perioperative morbidity and mortality. Chemotherapy can be considered after recovery from the primary resection to address the liver metastases, potentially offering disease control with less physiological stress than extensive surgery. This approach prioritizes quality of life and symptom control in a patient population where aggressive surgical interventions may cause more harm than benefit due to reduced physiological reserve and increased complication rates, as suggested by recent guidelines 1. Some studies suggest that neoadjuvant chemotherapy can reduce tumor size and increase the R0 resection rate, but in elderly patients, the focus should be on minimizing surgical risk and maximizing quality of life 1. Therefore, the primary tumor resection only approach is the most appropriate strategy for this patient population.

Key considerations in this decision include:

• The patient's age and potential for increased surgical risk
• The presence of multiple liver metastases indicating advanced disease
• The potential benefits and risks of chemotherapy in addressing liver metastases
• The importance of prioritizing quality of life and symptom control in elderly patients with metastatic colorectal cancer, as emphasized in recent clinical guidelines 1.

By prioritizing primary tumor resection only, the treatment approach can effectively balance the need to manage the cancer with the need to minimize risk and maximize quality of life for the patient, in line with the principles outlined in 1 and 1.

From the Research

Resection Strategy for Sigmoid Colon Cancer with Liver Metastases

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 at the same time. A study 2 reported a case of a 34-year-old woman who had about 50 liver metastases from an adenocarcinoma of the sigmoid colon, and synchronous treatment of all liver metastases was performed after neoadjuvant chemotherapy.
• 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 who underwent laparoscopic resection of sigmoid colon cancer with multiple liver metastases, followed by chemotherapy.
• Resection of liver metastases only: This approach involves resecting only the liver metastases, without resecting the primary tumor. However, there is limited evidence to support this approach as a standard treatment strategy.
• Resection of primary tumor only: This approach involves resecting only the primary tumor, without resecting the liver metastases. However, this approach may not be suitable for patients with multiple liver metastases, as it may not address the systemic disease.

Considerations for Resection Strategy

When considering the resection strategy, the following factors should be taken into account:

• The number and location of liver metastases
• The presence of extrahepatic disease
• The patient's overall health and performance status
• The potential benefits and risks of each approach A study 4 reported that neoadjuvant chemotherapy can be used to render more patients candidates for resection, and that 13% to 16% of patients with unresectable disease can be rendered resectable. Another study 5 reported a case of a 61-year-old woman who achieved a complete pathological response after chemotherapy, including bevacizumab/FOLFOX6, and underwent sigmoidectomy and lymph node resection.