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Sommariva Liver metastases and HIPEC
[4]
20 months has been obtained . However, all the data SURGERY FOR PERITONEAL AND LIVER
presently available refer to patients with un-specified MCC
metastatic disease (liver, lung, peritoneum) and the
role of modern systemic chemotherapy for treatment
of isolated PC has been adequately investigated in The introduction of oxaliplatin/irinotecan and VEGF
inhibitors based chemotherapy has improved response
only a few retrospective studies [5-7] .
rate and prolonged overall survival of patients with
MCC . Despite that the absolute survival benefit
[4]
The role of radical surgery for MCC has gained obtained with modern systemic chemotherapy has
increasing attention in the oncological community been constantly increasing and the expected median
[8]
and has been proposed in selected cases for liver , survival of more than 20 months is predictable, surgical
[9]
lung and peritoneal metastases [10] . Although approach to MCC has gained increasing interest and
the role of surgery in presence of multiple sites of LR has become the only chance of cure for resectable
MCC is almost un-explored, the combined and/ liver metastases [16] . Although early experience has
or sequential resection of liver, lymph nodes, lung identified patients with LM associated with extra-hepatic
metastases in various combinations has been disease as a group with a poor prognosis, surgery
tested with encouraging outcomes in very selected for limited and stable disease has been frequently
cases [11] . Radical surgery for concomitant liver and offered to patients with lung, peritoneal and other
extra-hepatic MCC has shown results that seem site metastases [11] . Small series of patients suggest
comparable to those obtained for isolated hepatic that resection of the liver combined with other sites
metastases [12-15] . For colorectal liver metastases (LM), can offer a survival benefit, but the argument is still
radical surgery offers a chance of cure in at least under investigation and the results of the few available
17% of patients and liver resection (LR) has become studies are influenced by a high selection bias.
the standard treatment for patients with resectable
disease [16] . In isolated PC, the role of surgery is less Data on surgery for peritoneal and liver MCC are
defined and is generally restricted in the context of very limited. Although, in one study, patients who
the multimodal approach of cytoreductive surgery underwent liver and extra-hepatic disease resection
(CS) + hyperthermic intraperitoneal chemotherapy seem to have a worse prognosis [14] , a single center
(HIPEC), which appears as the only chance of cure experience reported a 28% 5-year survival rate in
in selected patients [17-20] . CS + HIPEC has been patients who underwent an R0 resection of extra-
shown to be superior over systemic chemotherapy hepatic disease simultaneously with hepatectomy
[12]
in one randomized controlled trial [17] and in several for colorectal liver metastasis . Unexpected
uncontrolled studies that reported a median overall peritoneal disease at time of planned liver resection
[7]
survival of 33 months and 5-year survival of 43% . was estimated in 3% of cases in a large single
[21]
Patients with low tumor load and in whom a complete center experience . After multivariate analysis,
cytoreduction (CCR-0) is obtainable are those who risk factors for peritoneal implants in this subset of
benefit most from CS + HIPEC [18,19] , but research for patients were previous peritoneal carcinomatosis,
T4 primary tumor and bilobar LM. In patients with
further selection criteria (clinical and biological) is still completely resected and limited PC (PCI less than
ongoing. 2), the 5-year overall survival was 18% with a median
survival of 42 months, regardless of the extent of
Until a few years ago, the presence of peritoneal LM. These findings suggest that an accurate pre-
carcinomatosis with concomitant liver metastases operative radiological evaluation not only of the
was considered an absolute contraindication to liver but also of the peritoneal cavity is warranted,
CS + HIPEC and these patients were referred for based on the risk of peritoneal implants (primary T4,
systemic palliative treatment. The coexistence of resected PC or bilobar LM). Laparoscopic evaluation
liver metastases (haematogenous metastases) and before surgery for colorectal LM combined with PC
peritoneal metastases (loco-regional metastases) should be considered after a complete and accurate
was considered not amenable to curative surgical radiologic work-up, considering that the occurrence
treatment due to the spread of the disease and to of unresectable disease is 5% inpatients selected
the complexity of a combined surgical approach. In for liver resection only [22] . Diagnostic laparoscopy to
the last decade a growing number of publications discover peritoneal implants should be selectively
have reported patients treated with CS + HIPEC and considered in groups undergoing surgery for LM, as
LR, but it is still not clear which patients should be the efficacy to discover peritoneal disease is very
selected for this surgical approach. high [23] . This allows the selection of patients for the

Journal of Cancer Metastasis and Treatment ¦ Volume 3 ¦ December 21, 2017 363