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LETTER TO EDITOR
Year : 2013  |  Volume : 50  |  Issue : 1  |  Page : 45
 

Liver metastasectomy after neo adjuvant chemotherapy in colorectal cancer: A word of caution


1 Department of Surgical Oncology, Cancer Institute (WIA), Chennai, India
2 Department of Pathology, Cancer Institute (WIA), Chennai, India

Date of Web Publication20-May-2013

Correspondence Address:
R A Seshadri
Department of Surgical Oncology, Cancer Institute (WIA), Chennai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.112319

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How to cite this article:
Chandrasekar S K, Seshadri R A, Majhi U. Liver metastasectomy after neo adjuvant chemotherapy in colorectal cancer: A word of caution. Indian J Cancer 2013;50:45

How to cite this URL:
Chandrasekar S K, Seshadri R A, Majhi U. Liver metastasectomy after neo adjuvant chemotherapy in colorectal cancer: A word of caution. Indian J Cancer [serial online] 2013 [cited 2020 May 29];50:45. Available from: http://www.indianjcancer.com/text.asp?2013/50/1/45/112319


Dear Sir,

We wish to present a potentially life-threatening but often overlooked complication of liver metastasectomy following neo adjuvant chemotherapy in metastatic colorectal cancers (mCRC). A 51 year old lady diagnosed with synchronous adenocarcinoma of the sigmoid colon and the splenic flexure with a synchronous liver metastasis (in segments 6, 7 and part of segment 5) initially underwent extended left hemi colectomy in our institution due to the obstructing nature of the tumors. In view of the large size of the liver metastasis, the patient then received 6 cycles of chemotherapy using the FOLFOX regimen. PET- CT scan repeated at the end of 6 cycles revealed a decrease in the size and the standard uptake value of the lesion when compared to the PET-CT done at time of diagnosis. She was then considered for metastasectomy. Since a segmental liver resection would have resulted in positive margins, a right hepatectomy had to be performed. The liver was slightly bluish in color. There was excessive intraoperative blood loss necessitating transfusion of two units of blood. Histopathological examination confirmed negative resection margins. However, the surrounding liver showed features of sinusoidal obstruction syndrome (score 2-3) and non alcoholic steatohepatitis (score 4 -5) [Figure 1]. Postoperatively she had features of acute liver failure with ascites and jaundice. With conservative measures, the ascites resolved; however, the serum bilirubin continued to be very high and returned to normal levels nearly 3 months after the surgery.
Figure 1: Photomicrograph of (A) SOS, showing marked sinusoidal dilation and congestion with periportal chronic inflammation (H and E, 40×) and (B) CASH, showing steatosis, ballooning of hepatocytes and lobular inflammation (H and E, 40×)Prior presentation: Poster presentation at 20th Annual Conference of Indian Association of Surgical Gastroenterology at Hyderabad on 9.10.2010.

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Neo adjuvant chemotherapy has been shown to improve progression free survival in mCRC. [1] However, chemotherapy can induce two important pathological changes in the liver- sinusoidal obstruction syndrome (SOS) and chemotherapy associated steatohepatitis (CASH). [2],[3],[4] SOS is seen in 20%-50% of patients receiving oxaliplatin based chemotherapy. [2],[3] Histologic features of SOS include sinusoidal congestion and dilatation, disruption of the sinusoidal membrane and collagen deposition within peri- sinusoidal space. [2] SOS can cause increased intraoperative blood loss and increased post-operative morbidity without increasing the mortality. [4],[5] CASH is a form of non-alcoholic steatohepatitis characterized by the presence of steatosis, lobular inflammation and ballooning of the hepatocytes. It is seen in about 20% of patients receiving irinotecan and assumes clinical significance because it can cause increased transfusion requirements, poor tolerance to warm ischemia and increased post-operative morbidity and mortality. [3],[4],[5] The risk of surgical complications increases if more than 6 cycles of chemotherapy is given pre operatively [5] or if the interval between completion of chemotherapy and surgery is less than four weeks. [6] Hence, surgery should be planned once the metastasis becomes resectable rather than waiting for maximum downsizing. Although preoperative identification of CASH and SOS is difficult, awareness of these pathological changes is essential in planning multimodal treatment in patients with mCRC.

 
  References Top

1.Nordlinger B, Sorbye H, Glimelius B, Poston GJ, Schlag PM, Rougier P, et al. Perioperative chemotherapy with FOLFOX 4 and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC Intergroup trial 40983): A randomized controlled trial. Lancet 2008;371:1007-16.  Back to cited text no. 1
    
2.Rubbia-Brandt L, Audard V, Sartoretti P, Roth AD, Brezault C, Le Charpentier M, et al. Severe hepatic sinusoidal obstruction associated with oxaliplatin-based chemotherapy in metastatic colorectal cancer. Ann Oncol 2004;15:460-6.  Back to cited text no. 2
    
3.Vauthey JN, Pawlik TM, Ribero D, Wu TT, Zorzi D, Hoff PM, et al. Chemotherapy regimen predicts steatohepatitis and an increase in 90-day mortality after surgery for hepatic colorectal metastases. J Clin Oncol 2006;23:2065-72.  Back to cited text no. 3
    
4.Morris-Stiff G, Tan YM, Vauthey JN. Hepatic complications following preoperative chemotherapy with oxaliplatin or irinotecan for hepatic colorectal metastases. Eur J Surg Oncol 2008;34:609-14.  Back to cited text no. 4
    
5.Karoui M, Penna C, Amin-Hashem M, Mitry E, Benoist S, Franc B, et al. Influence of preoperative chemotherapy on the risk of major hepatectomy for colorectal liver metastases. Ann Surg 2006;243:1- 7.  Back to cited text no. 5
    
6.Welsch FK, Tilney HS, Tekkis PP, John TG, Rees M. Safe liver resection following chemotherapy for colorectal metastases is a matter of timing. Br J Cancer 2007;96:1037-42.  Back to cited text no. 6
    


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1 Fluorouracil/folinic acid/oxaliplatin
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