Conversion Therapy for Colorectal Cancer Liver Metastasis: Surgical Timing and Quality Management | Prof. Xing Baocai, Dept. of Hepatobiliary Surgery I, Peking University Cancer Hospital | Panda Patie

Among colorectal cancer patients, liver metastasis accounts for a significant proportion. Many places still consider it an untreatable, late-stage condition. In fact, some patients who undergo surgery for colorectal cancer liver metastasis achieve survival of over ten years. Therefore, choosing the correct treatment direction is especially important.

So, what should you do after a diagnosis of colorectal cancer liver metastasis?

Professor Xing Baocai from the Department of Hepatobiliary Surgery I at Peking University Cancer Hospital has dedicated over 20 years to the treatment and research of this condition. His department's treatment philosophy, strategies, and surgical techniques are at the forefront nationally and globally.

The department specializes in comprehensive patient management, including preoperative treatment plans, timing and selection of local therapies, and postoperative care, providing reasonable recommendations for each case. They have extensive experience in managing multiple liver metastases and complex situations, helping many patients achieve curative opportunities.

On September 19, 2024, Prof. Xing Baocai and Han Kai held an in-depth discussion on patients' most pressing concerns. This article records the session, divided into two main parts: treatment techniques and the clinical consultation process, which we will detail below.

Article Summary | Wuxian
Article Proofreading | Han Kai
Responsible Editor | Xianning
[ Conference Date: September 19, 2024 ]

Treatment Techniques for Colorectal Cancer Liver Metastasis
The Importance of Imaging Examinations

01
What are the differences between various imaging examinations?

For general patients, the diagnostic accuracy for colorectal cancer liver metastasis is 80% for contrast-enhanced CT, 92% for contrast-enhanced MRI, and 96%-98% for Primovist-enhanced MRI. PET-CT has limited value for intrahepatic lesions; it is mainly used to detect extrahepatic metastases and is not sensitive to inactivated lesions after treatment.

Therefore, for multiple and tiny lesions (more than five), Primovist-enhanced MRI plays a crucial role.

02
Why is it necessary to redo baseline imaging?

Imaging helps clarify the number, size, location of liver metastases, and their relationship with major blood vessels. If baseline imaging is incomplete, the resulting treatment strategy is likely to be incorrect.

The MRI parameters at Peking University Cancer Hospital are specifically optimized for gastrointestinal tumors, offering higher quality and accuracy. This makes it easier to detect tiny lesions, giving patients a greater chance of achieving a radical cure.

03
Can imaging from other hospitals be used for treatment planning?

High-level treatment relies on high-quality diagnosis.

Imaging quality varies across hospitals. Relying on external imaging leads to incorrect treatment strategies in about 25% of cases, potentially missing tiny lesions and preventing radical postoperative outcomes.

04
How to schedule examinations at Peking University Cancer Hospital?

First-time visits have a green channel, allowing all examinations to be completed within a week. For follow-ups, examination requests can be issued and scheduled in advance. Patients can also swap appointments in support groups, and the imaging department occasionally releases extra slots. With careful planning, most patients can get their scans done promptly.

Treatment Techniques for Colorectal Cancer Liver Metastasis
When Can Patients with Multiple Liver Metastases Undergo Surgery?

01
Proportion of liver metastases eligible for surgical resection

Initially, 20% of colorectal cancer liver metastasis cases are resectable, while 80% are not. However, after conversion therapy, a portion of the initially unresectable cases can become resectable.

At our department, the treatment philosophy, strategies, and surgical platform exceed the average level. Statistics show that the combined rate of initially resectable and conversion-therapy-resectable cases is approximately 45%.

02
Is surgery possible for more than 10 lesions?

As of May 2023, our department has performed over 300 surgeries for liver metastases with more than 10 lesions, achieving a 5-year survival rate of 31.9%.

The following conditions are required for optimal outcomes:

From the patient's perspective:

1. The lesions must be resectable.

2. Chemotherapy must be effective.

3. The tumor must remain stable for a prolonged period.

From the doctor's perspective:

1. High-quality examinations (imaging, pathology, etc.) are essential.

2. Doctors must carefully review and mark lesions on imaging repeatedly.

3. Availability of intraoperative ultrasound and contrast-enhanced ultrasound platforms and equipment.

03
Should the liver and intestine be resected simultaneously or separately?

Colorectal cancer liver metastasis falls into four scenarios:

1. Light tumor burden in both liver and intestine: simultaneous resection is possible.

2. Heavy tumor burden in both, with bleeding risk in the liver and leakage risk in the intestine: staged resection is required.

3. Severe intestinal lesions or obstruction: prioritize intestinal resection.

4. Heavy liver tumor burden: prioritize liver resection. Resecting the intestine first may allow liver lesions to progress, losing the surgical window.

In summary, whether to perform simultaneous or staged resection, and the timing, must prioritize safety.

04
Is chemotherapy needed between staged liver and intestinal resections?

If the patient's condition allows, the primary intestinal tumor should be addressed as soon as possible after liver surgery to prevent further metastasis.

If liver recurrence occurs and is detected early while lesions are still small and favorably located, ablation can be evaluated. Post-ablation, chemotherapy or observation may follow.

05
Multiple liver metastases have a high postoperative recurrence rate. Is surgery still beneficial?

Generally, subsequent local treatments after recurrence provide greater survival benefits than systemic drug therapy alone.

For about 3 liver metastases detected within 3 months, these are usually previously invisible tiny lesions that have grown. They differ biologically from new metastases and can be directly evaluated for ablation. Chemotherapy or observation can follow.

A crucial point is to create an opportunity for patients to achieve NED (No Evidence of Disease).

06
For repeated liver recurrences, how many times can surgery be performed?

Repeated liver surgeries become increasingly challenging and time-consuming. However, if the patient's tumor biology is favorable and local treatment offers benefits, but ablation or radiotherapy is unsuitable, actively pursuing surgery can offer longer survival opportunities.

07
If liver tumors disappear after chemotherapy, can they still be resected?

In this scenario, a high-quality baseline MRI is crucial to locate the original state of the disappeared lesions and determine if tiny lesions are metastatic.

Additionally, the concept of "disappeared" varies across imaging modalities. Higher precision means a lower disappearance rate. Compared to post-treatment outcomes where only 5% achieve pCR, surgical resection is generally more reliable.

Therefore, controlling the extent of preoperative drug therapy is vital. The goal should not be to make lesions disappear, but to avoid complete disappearance to ensure surgical targets remain visible.

Treatment Techniques for Colorectal Cancer Liver Metastasis
Selection of Preoperative Treatment Plans

01
How to choose first-line therapy for initially unresectable patients?

First, contrast-enhanced liver MRI determines resectability.

Second, genetic testing is required to understand tumor biology. If biology is poor but resectable, neoadjuvant therapy is needed. If surgically unresectable, conversion therapy is pursued regardless of biology.

Third, doctors use experience and imaging to estimate the distance to successful conversion and determine the appropriate regimen intensity.

Generally, the first four months are critical for conversion success.

02
Managing indications for different genetic types

Treatment goals vary by genetic type. Left-sided wild-type tumors have the best survival rates, while right-sided mutated tumors respond less favorably to chemotherapy.

The timing and indications for local therapy must be decided based on tumor biology.

For patients with less favorable biology, FOLFOXIRI + bevacizumab is typically used to strive for surgical opportunities.

For BRAF V600E mutated patients, more comprehensive examinations (e.g., PET-CT, preoperative laparoscopic exploration) are needed. Surgery remains beneficial, doubling survival compared to no surgery.

Treatment Techniques for Colorectal Cancer Liver Metastasis
Different Local Treatment Modalities

01
When is ablation therapy suitable?

Suitability depends on tumor size and location. Recurrence rates rise sharply as tumor diameter increases.

Ablation indications: lesions <2cm, depth >1cm, away from major vessels. Intraoperatively, lesions <1cm are generally treated with ablation.

For unresectable lesions with high ablation recurrence risk, additional chemotherapy cycles are recommended to reach a low-recurrence state before local treatment.

02
How small can intraoperative contrast-enhanced ultrasound detect?

Our department first introduced intraoperative contrast-enhanced ultrasound in China in April 2020. It can detect lesions larger than 2mm, significantly reducing the chance of missing lesions during surgery.

03
Which post-liver surgery lesions require radiotherapy?

Radiotherapy is needed for tiny lesions adhering to major vessels where resection would sacrifice excessive liver volume, and ablation cannot achieve complete clearance.

Currently, for lesions adjacent to (but not infiltrating) major vessels, surgical dissection is possible. Even if R0 resection isn't achieved, R1 resection can yield similar outcomes.

04
Application scenarios for hepatic arterial infusion

For patients resistant to first- and second-line therapies, third-line systemic treatments have limited effects on liver lesions. Hepatic arterial infusion offers an intermediate option.

When intravenous chemotherapy is limited, using the same dose via arterial infusion remains effective in about 30% of cases, with some patients successfully converting to resectable status.

Peking University Cancer Hospital Clinical Pathway for Colorectal Cancer Liver Metastasis
Outpatient Consultation

01
How to communicate efficiently with doctors during outpatient visits?

High-quality medical resources are limited. To accommodate more patients, Prof. Xing does not limit additional appointments, seeing 60-80 patients per session. Accurately and concisely expressing your medical needs is crucial.

The Panda support group provides a disease course template to help patients organize their history, extracting the most valuable information to assist doctors in determining treatment strategies.

02
Why is a pathology consultation mandatory for treatment at a cancer hospital?

Beijing Municipal Health Commission regulations require a pathology report before doctors can formulate a treatment plan, regardless of the hospital.

03
Why is it not recommended to take a treatment plan from Beijing and return to local hospitals for chemotherapy?

Some local hospitals, prioritizing safety, may avoid strong regimens or full doses, which can compromise conversion therapy. They may also lack experience in managing chemotherapy side effects.

The surgical window is brief. Taking a wrong path or making a mistake at any node may permanently eliminate the chance for surgery.

Peking University Cancer Hospital Clinical Pathway for Colorectal Cancer Liver Metastasis
Hospitalization

01
Will Prof. Xing perform the surgery?

In our department, the doctor who issues the hospitalization admission slip takes full responsibility for patient safety, including preoperative planning, key intraoperative steps, and postoperative management.

Surgery is just one part of liver metastasis treatment. Every step in the process is vital for achieving good outcomes and prognosis.

02
How is the attending physician assigned?

Attending physicians are generally assigned randomly. However, the entire department follows unified treatment principles, with minimal variation between teams. For special circumstances, patients can communicate with the director during ward rounds or outpatient visits.

03
How long after receiving an admission slip can surgery be scheduled?

Previously, waiting times of 2-3 months caused significant patient anxiety. We have optimized the scheduling process, and patients can typically be hospitalized for surgery within one month of receiving the admission slip.

04
What if the tumor progresses while waiting for surgery?

With the current one-month wait, significant progression is unlikely.

If waiting extends to 2-3 months, bridging chemotherapy is necessary. Tumor progression is a negative factor for surgery. However, for patients already on third-line therapy, if progression occurs and no effective drugs remain, surgery can still be pursued to strive for another opportunity.

Postscript

This discussion allowed Prof. Xing to address questions that couldn't be fully covered during busy outpatient hours. Doctors and patients share the same goal: to create more opportunities and maximize survival benefits for patients.

"We are responsible for every patient who visits us!" is a phrase Prof. Xing often says and strives to uphold.

Let us foster more mutual understanding and tolerance between doctors and patients.

▼ Prevention is the highest wisdom ▼

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Patient Stories | Click text to jump

Beijing middle-aged man's fight against late-stage colon cancer | Panda Star's anti-cancer magic | A Ming: Accompanying my mother through 2 years of treatment for colorectal cancer with liver and lung metastasis | Qingcao: Sharing treatment for colorectal cancer liver metastasis | Siblings' bond: 4 years of treatment for colorectal cancer liver metastasis | Xiao Li: Patient's self-account of fighting cancer | Sister Xiuxiu: Treatment journey for colorectal cancer with liver and ovarian metastasis | Brother Guo: Resilient treatment path for colorectal cancer peritoneal metastasis | Naonao: Self-rescue journey after recurrence of colorectal cancer at age 27 | Sister Tudou: 7-year anti-cancer journey with lung and brain metastasis | Anti-cancer beauty Yuanyuan: Living with a smile | Jinxia: 4-year treatment path for HER2-positive gastric cancer | Grumpy grandpa's fight against gastric cancer | Mickey: Late-stage gastric cancer treatment at age 31 | Summary from a colon cancer patient's family (including care guide) | Alison: Treatment for HER2-positive advanced colorectal cancer | From stage IV gastric cancer to complete remission | 78 liver metastasis lesions do not mean a death sentence | The late-stage cancer patient who entered the ICU due to infection is now tumor-free | Panda Group Story: Weihua 1 | From diagnosis to recurrence | Panda Group Story Yang Yong | As heaven moves vigorously, the gentleman strives unceasingly | The harsh truth behind treatment value: Why some patients are not advised to seek treatment in Beijing, Shanghai, or Guangzhou | Anti-cancer blogger Fengzi passes away, who will care for young patients fighting cancer alone? | Panda & Friends | Old Chen: Experience participating in CAR-T clinical trials, over 3 years with colorectal cancer liver and lung metastasis | Sister Yangguang: Life should not lose its color due to illness

Doctor-Patient Communication | Click text to jump

Peking University Cancer Hospital Shen Lin: 2023 Progress in Colorectal Cancer Immunotherapy | Step-by-step guide for colorectal and gastric cancer patients on how to seek medical care

Peking University Cancer Hospital Xing Baocai: Doctor-patient communication on colorectal cancer liver metastasis

Guangzhou Sun Yat-sen University Cancer Center Chen Gong: Can surgery be performed directly after colorectal cancer diagnosis? | Discussion on surgery for colorectal peritoneal metastasis | Treatment strategies for colorectal liver and lung metastasis | Maintenance therapy and neoadjuvant chemotherapy for colorectal cancer | Patient group case analysis Q&A (Part 1) | Patient group case analysis Q&A (Part 2)

Fudan University Shanghai Cancer Center Cai Guoxiang: Patient group communication Q&A record

Guangzhou Sun Yat-sen University Cancer Center Wang Fenghua: Patient group communication record

Guangzhou Sixth Affiliated Hospital of Sun Yat-sen University Xiao Jian: Chemotherapy, targeted therapy, and immunotherapy for advanced gastric cancer

Beijing Friendship Hospital Yao Hongwei: Examinations required for rectal cancer patients and how to read reports

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