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Metastasis from
Colorectal Cancer
Stage 0 month 30 m 60 m
% Survival % Survival % Survival
I 100 96.1 93.2
IIa 100 91.0 84.7
IIb 100 80.2 72.2
IIIa 100 91.4 83.4
IIIb 100 77.3 64.1
IIIc 100 67.1 52.3
IIId 100 57.3 43.0
IIIe 100 43.1 26.8
IV 100 17.3 8.1
O’ConnellJB, Maggard MA, Ko CY: Colon Cancer Survival Rates with The New American Joint
Committee on Cancer, Sixth Edition Staging. J Natl Cancer Inst 2004;96:1423.
Colorectal Cancer Mortality
Advances Treatment of
Stage IV CRC
1980 1985 1990 1995 2000 2005 2010 2015
BSC
35 5-
FU Irinotecan
30
Capecitabine
25 Oxaliplatin
OS (monthas)
20 Cetuximab
Bevacizumab
15 Panitumumab
10 Aflibercept
Regorafenib
5 median overall BBP
survival
0
198 1985 1990 1995 2000 2005 2010 2015
0
Results of Hepatic Resection for
Patients with mCRC
Survival (%)
Author (year) No.Pt Mortality Median Survival 1-year 5-year
Hughes et al 607 --- --- --- 33
(86)
Gayowski et al 204 0 33 mo 91 32
(94)
Scheele et al 469 4 40 mo 83 39
(95)
Fong et al (95) 577 4 40 mo 85 35
Jamison et al 280 4 33 mo 84 27
(97)
Fong et al (99) 1001 3 42 mo --- 36
En= Enhancement
Hepatectomy in mCRC
40
• Mortality : 5% or less 35
• Morbidity : 20-50% 30
0
5Years 10Years
Management of mCRC
JNCCN 2017
Traditional Definition of
Resectability
• Metachronous detection
• Unilobar disease
• <4 metastases
• <5 cm largest metastasis
• >1 cm resection margin
Rees et al 1997
Technically “Unresectable”
1.Direct invasion into
hepatic/portal
veins
2.Multicentric tumors
or satellite nodules
3.Proximity to major
vascular structures
4.Severe cirrhosis
with lacking
functional hepatic
reserve
Resectable vs Unresectable
Lesion
Resectable Lesion Parenchymal obliteration
19
Resectable vs Unresectable
Lesion
Resectable or Unresectable Lesion?
20
Change in Paradigm
What is
What is left
resected
21
New Definition of Resectability
Factors considered
Important Evaluation
• Medical fitness (Tolerate to surgery)
• Child-Pugh score
• Adequate functional liver after
surgery
• Adequate portal flow
• Adequate hepatic venous out-flow
• Adequate biliary drainage
Child-Pugh Score
Resectability
Concept
1I
440 cc
IV
I
2
41
Male, 60yo, Liver Metastasis
Rectal Adenocarcinoma
42
Simultaneous Sigmoid Resection and
Left Lateral Segmentectomy
Female 49 yo
Synchronous Liver Metastasis
Cures >
Surgery
30%
Alone
of Patients