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Colorectal Cancer
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Editor’s Recommendations
Timing of Resection in Patients with Colorectal Neuroendocrine Carcinomas Arising in Ulcerative
Carcinoma and Synchronous Liver Metastases Colitis: Coincidences or Possible Correlations?
Hopt UT, Drognitz O, Neeff H, Zentralbl Chir, 2009;134(5):425–9. Grassia R, Bodini P, Dizioli P, et al., World J Gastroenterol, 2009;15(33):4193–5.
Timing of surgical therapy in patients with synchronous Patients with inflammatory bowel disease (IBD) are at increased
colorectal liver metastases is becoming more complex. The risk of colorectal malignancies. Adenocarcinoma is the most
standard therapy for most patients remains resection of the common type of colorectal neoplasm associated with ulcerative
colorectal cancer first followed six weeks later by liver colitis (UC) and Crohn’s disease, but other types of epithelial and
resection. Simultaneous colon and liver resection is safe and non-epithelial tumour have also been described in inflamed
advisable in cases of minor liver resections and right-sided bowels. With regard to non-epithelial malignancies, lymphomas
colon tumours. Major liver resections in combination with and sarcomas represent the largest group of tumours reported
resection of the colorectal cancer carry the risk of increased in association with IBD, especially in immunosuppressed
post-operative morbidity and mortality. They should be patients. Carcinoids and in particular neuroendocrine
considered for selected patients only. An additional prerequisite neoplasms other than carcinoids (NENs) are rare tumours and
is special expertise of the operating surgeon in colorectal as are infrequently described in the setting of IBD. Thus, this
well as in hepatobiliary surgery. If the synchronous liver association requires further investigation. We report two cases
metastases are near to essential anatomical structures, the liver of neoplasms arising in mild left-sided UC with immuno-
resection should be performed before the bowel resection. The histochemical staining for neuroendocrine markers: a large-cell
same holds true if the metastases are technically resectable but and a small-cell neuroendocrine carcinoma of the rectum.
the future liver remnant seems to be too small. Using well- The two patients had different ages (35 versus 77 years) and
known techniques, the future liver remnant should be increased disease durations (11 versus 27 years), and neither had ever
and the liver metastases resected before treatment of the received immunosuppressant drugs. Although the patients
colonic primary tumour. The risk of local complications is very underwent regular endoscopic and histological follow-up,
low when leaving the colorectal tumour in situ during treatment the two neoplasms were locally advanced at diagnosis. One
of liver metastases. When synchronous liver metastases are of the two patients developed multiple liver metastases and
technically not resectable or carry a high risk of an R1 resection, died 15 months after diagnosis. These findings confirm the
patients should be treated first with systemic neoadjuvant aggressiveness and the poor prognosis of NENs compared with
chemotherapy. If sufficient downsizing of the metastases can be colorectal adenocarcinoma. While carcinoids seem to be
achieved, liver resection should be performed before bowel coincidentally associated with IBD, NENs may also arise in this
resection. Close co-operation between the oncologist and the setting. In fact, long-standing inflammation could be directly
hepatobiliary surgeon is most important, since the window for responsible for the development of pancellular dysplasia
curative surgery is rather limited in these patients. In patients involving epithelial, goblet, Paneth and neuroendocrine cells. It
with resectable synchronous liver metastases, the advantage of has yet to be established which IBD patients have a higher risk
a neoadjuvant chemotherapy has not yet been proved. n of developing NENs. n
72 EUROPEAN GASTROENTEROLOGY & HEPATOLOGY REVIEW
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