Metástasis identificadas durante la cirugía

Una de las situaciones más frecuentes y a la vez más difíciles de manejar para el cirujano es encontrar me­tástasis hepáticas durante la resección de un tumor primario de colon o recto. Esto puede suceder cuando el tumor primario se inicia con obstrucción, perforación o ambas, haciendo urgente la cirugía, sin estudios previos de extensión, o cuando las metástasis no se detectan con los estudios de imágenes.

Esto último es cada vez menos frecuente, ya que la sensibilidad y la especificidad de la tomografía axial y la resonancia magnética son cada vez mayores para detectar metástasis cada vez más pequeñas; sin embargo, es bien sabido que su rendimiento diagnóstico disminuye cuando las lesiones son de menos de un cm y se pueden pasar por alto metástasis hepáticas 101-103.

Cuando el tiempo que transcurre entre las imágenes y la cirugía es prolongado, se corre el riesgo de que se presente progresión tumoral e, incluso, aparezcan nue­vas metástasis que no se identificaban en los estudios imaginológicos; por esta razón, se recomienda que no deben pasar más de cuatro semanas entre el estudio imaginológico y el procedimiento quirúrgico.

Un factor determinante para decidir la conducta en este tipo de situaciones, es la disponibilidad de un ciru­jano hepatobiliar que pueda practicar el procedimiento hepático en ese momento. En caso de no estar disponible este especialista, se recomienda resecar la lesión prima­ria, independientemente de los demás factores, ya que el paciente se encuentra anestesiado y preparado para dicho procedimiento quirúrgico. Cuando el cirujano he­patobiliar esté disponible, se debe determinar si el tumor primario es sintomático o asintomático y establecer el tamaño de las metástasis hepáticas sincrónicas (figura 5).

Figura 5. Tratamiento de las metástasis hepáticas sincrónicas no conocidas previamente y diagnosticadas durante la cirugía

Conclusiones

Las metástasis hepáticas en el cáncer colorrectal son fre­cuentes y, tradicionalmente, se consideraban irresecables, por lo cual solamente se ofrecía tratamiento paliativo. Actualmente, las alternativas terapéuticas han aumen­tado a tal punto, que se puede optar por procedimientos curativos con impacto significativo en la supervivencia, todos los cuales involucran la resección quirúrgica de las lesiones y la quimioterapia sistémica.

El entendimiento a fondo de la enfermedad y el cono­cimiento de los esquemas terapéuticos disponibles, tanto en caso de metástasis sincrónicas como metacrónicas, permiten ofrecerles al paciente y a su familia alterna­tivas de tratamiento que permiten, no solo aumentar la supervivencia de la enfermedad, sino también, una mejor calidad de vida.

Hepatic metástases in colorectal cancer: therapeutic strategies and current recommendations

Abstract

Metastatic colorectal cancer in the liver is a frequent pathology that until a few years ago was considered only for palliative management. However, with the recent advent of new techniques and advances to improve the resectability of such lesions and the new schemes of chemotherapy, oncological resection of these lesions can be performed, extracting all macroscopic tumor and achieving a positive impact on patient´s survival.

Multiple schemes have been postulated for the management of synchronous lesions in order to improve patient survival, although there is no consensus about which is the best scheme in these cases; it seems that the most important factor is to complete successfully the proposed scheme. In general, the current trend is to perform the liver resection first unless the primary tumor is symptomatic, in which case a colectomy should be performed as the initial approach. Simultaneous resections are part of the therapeutic arsenal in these patients. Many groups suggest not to associate a low rectal resection with a major hepatectomy. On the other hand, metachronic lesions should be resected based on their size and the possibility of resection should be considered once the diagnosis has been made.

It is important to take into account that even if a complete resection of the tumor and R0 margins are achieved, recurrences are frequent because microscopic tumor dissemination is already present; therefore, the addition of chemotherapy regimens should be mandatory to Improve the oncological prognosis of these patients.

Key words: Neoplasms; liver; colonic neoplasms; neoplasm metastasis; neoplasms, second primary; hepatectomy; clinical protocols; survival.

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Correspondencia: Camilo Naranjo, MD
Correo electrónico: canasa89@gmail.com
Medellín, Colombia