William R. Jarnagin, MD
Over time, novel surgical approaches have led to a shift and evolution in treatment for patients with colorectal cancer (CRC), especially for those who have liver-metastatic disease, according to William R. Jarnagin, MD. These include portal vein embolization, segmental-type resections, and selective internal radiation therapy (SIRT)—albeit, a less common approach.
“Surgery is the most effective treatment for this disease in patients who have liver-confined disease,” Jarnagin said. “And, as the safety of the operations have improved over time, the boundaries have expanded in terms of who should have an operation or who is a candidate for an operation.”
Jarnagin, surgeon, chief, Hepatopancreatobiliary Service, Benno C. Schmidt Chair in Surgical Oncology, Memorial Sloan Kettering Cancer Center, spoke about the necessary role of surgery and novel techniques in patients with CRC in an interview during the 2017 OncLive®
State of the Science SummitTM
on Gastrointestinal Cancers.
OncLive: What did you focus on in your presentation on CRC?
: I gave some historical perspective about how things have changed over time. There have also been advances with chemotherapy that have seen tremendous progress, which has also changed the nature of who should get an operation and who is a candidate for surgery. I spoke about how more can be currently expected of surgery in a contemporary setting and in a high-volume center, and how we are looking at ways to improve the results of surgery as we go forward.
I spoke about SIRT a little bit only because the data in CRC is just not as strong as it is in hepatocellular carcinoma, and its place [in CRC] is a little less well-defined.
How have you noticed that surgery has changed in this landscape?
The operation has become safer over time. We tend to do fewer big resections so we don’t take as much liver as we did in the past, which made it safer. We do things before surgery to help improve the safety, particularly something called portal vein embolization…which increases the amount of functional liver left behind. We are doing a lot of segmental-type resections, which allows us to take patients to the operating room who have more advanced disease with larger tumors and, in doing that more effectively, we remove more of the disease and leave more functioning liver behind. Those are the major safety points that need to be emphasized.
The effectiveness of chemotherapy has changed the way we practice. More patients have been getting chemotherapy before surgery, which is good and bad. It is good because they respond¬—much better than they ever had in the past. There is damage to the liver that happens, which can adversely affect regeneration of the future liver remnant, and can potentially increase the morbidity. It emphasizes more than ever the need for surgeons and medical oncologists to work together to decide how much treatment to give before surgery, when surgery should be given, when to give chemotherapy first, and when not to.
What are some other common sites of metastasis in patients with CRC? Is surgery in these areas trickier?
It is not so much the difficulty of the operation, and that is an important point to understand. It is not that we can’t take these other sites out, it’s more of a question of, “Should we?” When they are spread to the liver plus other sites, the results of surgery on the liver becomes worse; the risk of recurrence is much higher.
There are some people who will benefit from resection of liver, plus lymph nodes and lung, but the majority will not benefit. It is up to the surgeons and medical oncologists to determine who should get an operation and who shouldn’t. We have to be careful. Once there is more advanced disease, the result of surgery in the liver becomes more difficult to predict and most patients don’t benefit.
You have a patient with liver-metastatic CRC come into your clinic. What factors are you looking for to determine whether they’re a good candidate for surgery?
There are several things to consider. The first step is to know whether or not the disease in the liver can be removed from a technical standpoint. If you have 1 or 2 tumors in favorable locations, then resection is certainly possible and that is the first jumping-off point. If they have much more advanced disease, then surgery is not an option and the conversation changes quite dramatically to more palliative measures.