Management of Colorectal Liver Metastases with Fistulous Invasion

Introduction to Management

The American Society of Clinical Oncology recommends a multidisciplinary evaluation for combined surgical resection preceded by neoadjuvant chemotherapy for patients with fistulous invasion, as this represents locally advanced disease that demands aggressive multimodality treatment to achieve any chance of cure 1, 2

High-quality CT chest/abdomen/pelvis is required to assess the extent of duodenal invasion, number and distribution of liver metastases, and exclude extrahepatic disease, as recommended by the National Comprehensive Cancer Network 1, 2
Assessment of liver remnant volume is necessary, with a requirement of more than 30% functional liver volume remaining after resection, according to the American Hepato-Pancreato-Biliary Association 2

The European Society for Medical Oncology recommends initiating 2-3 months of neoadjuvant systemic chemotherapy before any surgical intervention to evaluate tumor biology and chemosensitivity, treat micrometastatic disease, and downsize liver metastases to improve resectability 4, 5, 2
The chemotherapy regimen should include FOLFOX or FOLFIRI as the backbone, with the addition of bevacizumab for unselected patients or those with KRAS mutations, and cetuximab for wild-type KRAS, left-sided tumors, as suggested by the National Cancer Institute 4, 2

The Society of Surgical Oncology recommends proceeding with hepatic resection only if complete R0 resection of all liver metastases is technically achievable, there is adequate future liver remnant, no disease progression on neoadjuvant chemotherapy, no unresectable extrahepatic disease, and the patient has adequate performance status and nutritional state 4, 1, 2

The American Society of Clinical Oncology recommends completing the 6-month perioperative chemotherapy regimen postoperatively using the same backbone that showed efficacy, and a surveillance protocol for 5 years including CT chest and liver imaging, and CEA monitoring 4, 2, 3

The American Cancer Society notes that realistic expectations must be discussed, with a 3-year survival for colon cancer with duodenal invasion approximately 54%, and 5-year survival dropping to 9%, but if complete R0 resection of both primary and liver metastases is achieved, 5-year disease-free survival of 20-45% is possible 3

The European Society for Medical Oncology advises never proceeding directly to surgery without neoadjuvant chemotherapy, not attempting complex combined procedures outside high-volume hepatobiliary centers, not operating if R0 resection is not achievable, not ignoring nutritional status, and not exceeding 6 months total perioperative chemotherapy 4, 5, 2