Patients with colorectal cancer metastases to the liver and one or both lungs often face the unwelcome prospect of two operations and two recovery periods. But a novel surgical approach enables the liver and lung lesion resections to be performed during the same operation.
A surgical team performs a simultaneous resection of liver and lung metastases in a patient with colorectal cancer. In this procedure, the liver lesions are resected first, and the lung lesions are resected through an incision in the diaphragm. Image courtesy of Dr. Yoshihiro Mise.
To reduce the sequelae that result from separate operations for patients with metastatic disease in both the liver and lungs—the two most common sites of colorectal cancer metastases—surgeons at The University of Texas MD Anderson Cancer Center developed a technique to resect the lung metastases using a transdiaphragmatic approach immediately following the liver resection.
“We can combine the thoracic and hepatic procedures under one anesthesia induction for the benefit of the patient,” said Reza Mehran, M.D., a professor in the Department of Thoracic and Cardiovascular Surgery.
Benefits of complete metastasectomy
“For patients with colorectal cancer metastases in the liver and lungs, complete resection of the metastases in both organs offers the best survival outcomes,” said Jean-Nicolas Vauthey, M.D., a professor and chief of the liver and pancreas section in the Department of Surgical Oncology. This survival advantage was demonstrated in a recent study in which Drs. Mehran and Vauthey collaborated with Yoshihiro Mise, M.D., Ph.D., and other MD Anderson researchers. The retrospective study compared 3- and 5-year overall survival rates among patients with liver and lung metastases from colorectal cancer. Patients who underwent chemotherapy plus resection of only the liver metastases had higher survival rates than did patients who underwent chemotherapy only but lower survival rates than did patients who underwent chemotherapy plus resection of both the lung and liver metastases.
Although that study included patients whose liver and lung lesion resections were done as separate surgeries, another MD Anderson study showed that patients who underwent simultaneous liver and transdiaphragmatic wedge lung resections had similar operative outcomes but less blood loss compared with patients who underwent separate resections.
“The novelty of the new approach is that we can do both resections at the same time with a single incision, avoiding a thoracic incision,” Dr. Vauthey said.
All patients with colorectal cancer metastases in the liver and one or both lungs whose liver metastases are completely resectable are considered for simultaneous resection of their lung metastases. This includes patients whose liver disease requires a two-stage resection; the lung lesion resection could be performed during either stage.
Although liver resections may be performed on patients who are not candidates for lung metastasis resections, lung metastasis resections usually are not performed on patients with unresectable liver metastases because of the patients’ poor prognosis.
At MD Anderson, patients with colorectal cancer metastases in the liver and lungs typically receive chemotherapy for 2–3 months before surgery. Computed tomography (CT) scans taken before and after chemotherapy help determine whether a patient is a candidate for liver resection and/or lung metastasectomy.
“We diagnose the lung metastases based on their change in size and appearance on CT following chemotherapy,” Dr. Vauthey said.
Patients whose liver or lung metastases have grown during chemotherapy have a poor prognosis and are not typically candidates for metastasectomy. In 70%–80% of patients, however, the lung lesions respond to chemotherapy or are stable. Patients whose disease responds are candidates for surgery.
Patients whose lung lesions remain stable after chemotherapy present a dilemma because the lesions could be tumors or merely scar tissue. These cases are reviewed by a multidisciplinary team of physicians, and the decision whether to resect the lung lesions is made on a case-by-case basis. “If the tumors are large and not calcified, we will likely decide to operate,” Dr. Vauthey said. “The complication rate for the transdiaphragmatic procedure is low, so you can make the case for removing a suspicious lung lesion even though you’re not 100% sure that it’s cancer.”
Small lung tumors are less likely to be resected. “If the tumor is too small for the surgeon to palpate, we prefer to wait,” Dr. Mehran said. “We tell the patient to come back in a year for another CT study, and if the tumor has grown, then we take it out.”
The location of the lung lesions also affects the decision whether to operate. “If the tumor is too deep for wedge resection, we prefer to use radiation therapy,” Dr. Mehran said.
During a simultaneous resection of liver and lung metastases, a double-lumen endotracheal tube is used to allow one-lung ventilation. The hepatic surgeon makes an abdominal incision and performs an open hepatectomy. Dr. Vauthey said that this part of the procedure is done exactly as it would be done if the lung surgery were not planned.
When the liver resection is finished, the thoracic surgeon takes over. The lung with the metastases is deflated, and the surgeon makes an incision in the diaphragm large enough to reach through. The thoracic surgeon then cuts the inferior pulmonary ligament to mobilize the lung.
Next, the thoracic surgeon, who knows the locations of the tumor or tumors from CT scans, reaches through the diaphragm incision and palpates the lung to find each tumor. Working by touch, the surgeon then performs a wedge resection using a surgical stapler. “I hold the tumor with my fingers and staple around it to free it from the surrounding tissue,” Dr. Mehran said.
Dr. Vauthey added that the transdiaphragmatic approach has been done in patients with bilateral lung metastases. “We make an incision in the right side of the diaphragm and remove the lesions in the right lung, and then we close the diaphragm, re-inflate the right lung, and deflate the left lung and make an incision in the left side of the diaphragm,” he said.
Once the resection is complete, a chest tube is inserted, the diaphragm is closed, and the abdominal incision is closed.
The chest tube usually is removed the day after surgery. The typical hospital stay is the same as that for a liver resection alone, which is about 6 days.
“We’ve had no complications so far in patients who have undergone simultaneous resections of liver and lung metastases. The procedure is very well tolerated,” Dr. Mehran said. “Simultaneous resection is very patient friendly. The benefit is that the patient doesn’t have to undergo a second surgery, a second anesthesia induction, and a second source of pain to achieve the same objective, which is to make the patient cancer-free.”
Mise Y, Mehran RJ, Aloia TA, et al. Simultaneous lung resection via a transdiaphragmatic approach in patients undergoing liver resection for synchronous liver and lung metastases. Surgery. 2014;156:1197–203.
Mise Y, Kopetz S, Mehran RJ, et al. Is complete liver resection without resection of synchronous lung metastases justified? Ann Surg Oncol. 2014. doi: 10.1245/s10434-014-4207-3. [Epub ahead of print]
For more information, contact Dr. Reza Mehran at 713-563-3908 or Dr. Jean-Nicolas Vauthey at 713-792-2022.
OncoLog, January 2015, Volume 60, Issue 1