In order to discuss the role of preoperative chemo-therapy for colorectal liver metastases which is used frequently before hepatic resection even in patients with resectable Motesanib Diphosphate (AMG-706) disease at presentation we herein report the development of Motesanib Diphosphate (AMG-706) two complications partial portal vein thrombosis and hepatic steatosis with lobular inflammation during the course of preoperative chemotherapy with FOLFIRI plus bevacizumab for colorectal liver metastases which recognition led Motesanib Diphosphate (AMG-706) to timely discontinuation of chemotherapy as well as a change in the surgical strategy to resect the tumors and the damaged liver through advanced techniques. of chemotherapy-induced liver injury. Keywords: Chemotherapy Colorectal liver metastases Resection INTRODUCTION Surgical resection of colorectal liver metastases is nowadays a standard of care for resectable disease with 5-year survival rate approaching 60%[1-3]. Because of several theoretical benefits preoperative systemic chemotherapy has been frequently used to downsize the disease. We report here the development of two complications partial portal vein thrombosis and hepatic steatosis with lobular inflammation during the course of preoperative chemotherapy with FOLFIRI plus bevacizumab for colorectal liver metastases and discuss the surgical management and implications. CASE REPORT A 61-year-old woman was referred for treatment of synchronous multiple bilobar colorectal liver metastases. Six months after a laparoscopic right hemicolectomy for a pT3N2 colon cancer a multiphase spiral computed tomography (CT) performed without and with intravenous (IV) contrast revealed bilateral disease with a total of five lesions distributed in segmentsI II IVA VI and VII amenable to hepatic resection (Physique ?(Figure1).1). Because of the known Motesanib Diphosphate (AMG-706) high risk of disease recurrence after liver resection for multiple bilobar and synchronous metastases in patients with N2 classification of primary tumor the patient was treated with six courses of preoperative chemotherapy with FOLFIRI (irinotecan 5 and high-dose leucovorin) plus bevacizumab. Physique 1 Contrast enhanced CT at the level of the portal bifurcation before treatment shows metastasis in segment I (arrowhead) opacified right anterior and posterior segmental portal veins (white arrows) and opacified middle and right hepatic veins (open arrows). … Repeat CT performed without and with IV contrast 3 wk after the completion of chemotherapy with bevacizumab showed downsizing Motesanib Diphosphate (AMG-706) of the lesions in segmentsI IVA VI-VII and stable disease in the segment II. Non-contrast images also showed the development of diffuse fatty infiltration of the liver with sparing of segments V and VIII while the images acquired after IV contrast administration revealed absent portal perfusion of the right anterior sector associated with right anterior portal branch occlusion. The lack of portal flow to segments V and VIII explained sparing from steatosis and increased arterial flow to these segments. Some compensatory hypertrophy of the left liver was evident (Physique ?(Figure2).2). The patient had no evidence of hypercoagulation and no other known risk factors for thrombosis. Even though this patient experienced downsizing of bilobar liver metastases the new obtaining of portal vein thrombosis led to discontinuation of chemotherapy and reassessment of the treatment plan. Prior to occurrence of portal vein thrombosis a partial right hepatectomy plus resection of the metastases in segments IVA II andI was planned. The obtaining of right portal vein thrombosis led to a change in operative plan to include resection of the segments involved both by tumor and by portal vein thrombosis in a 2-stage fashion. At the first stage segmental resection of the lesions in segmentsIand II was performed preserving the majority of the parenchyma of the lateral bisegment. Three-dimensional liver volumetry revealed the planned remnant liver (bisegment II/III) was of inadequate volume to permit resection of the right liver plus segment IV. Therefore in order to increase volume and function of the liver remnant prior to the 2-stage resection percutaneous right portal vein embolization extended to segment IV was Rabbit Polyclonal to Smad1. performed. Repeat CT volumetry after 4 wk revealed adequate liver remnant hypertrophy Motesanib Diphosphate (AMG-706) and the remaining diseased liver was resected by extended right hepatectomy (resection of Couinaud segments IV through VIII). The postoperative course after each stage was uneventful. The pathological review of the specimen revealed 50% necrosis in the tumors and moderate-severe steatosis with lobular inflammation in the resected liver. Figure 2 Contrast enhanced CT at the level of the portal bifurcation after treatment shows improved hepatic metastasis in segment I (arrowhead).