Preface

We can identify two recent developments that have propelled cytoreductive surgery and metastasectomy from relative obscurity to the forefront of a rapidly evolving field of surgical oncology: advances in systemic and regional cytotoxic and biologic therapy and the establishment of safe and effective surgical techniques for metastasectomy and cytoreduction. Nowhere is this better illustrated than in the treatment of colorectal cancer metastases and peritoneal malignancies. It is therefore not surprising that a large part of this issue of Surgical Oncology Clinics of North America is dedicated to these disease entities.

It is particularly for colorectal cancer metastases that a paradigm shift has occurred for the role of surgical resection. The boundary that existed between R0 and R1 resection for the indication of surgical therapy is being challenged by effective systemic chemotherapy and targeted biologic therapy. With long-term survival now seen after metastasectomy even in the presence of extrahepatic disease and metastatic disease in multiple organs, traditional indications for surgery have given way to new criteria for resectability. Surgical limitations based on disease burden have been replaced by a strategy in which metastasectomy is limited only by the function of the remnant organ. The goal of maximum cytoreduction has vastly increased the number of patients eligible for metastasectomy. Recent data from centers throughout the world show that extensive and repeat metastasectomy and cytoreductive surgery as part of a multimodality treatment plan can lead to long-term survival in a sizable percentage of patients. The price, however, is high and one must be cognizant of the toll that long-term chemotherapy and repeat surgery demand of these patients. As surgeons, we need to remind ourselves that we owe the expanded indications for surgery in the metastatic setting to the scientific accomplishments in the development of effective systemic and regional therapy. We should also familiarize ourselves with the advances in surgical techniques that allow us to expand the limits of organ resection for metastatic disease and cytoreductive surgery. Repeat hepatectomy and peritonectomy is not for the faint of heart. It demands special attention to modern surgical principles. Simply knowing one technique is not sufficient.

Cure remains elusive for most patients afflicted by metastatic cancer, but we are a step closer to making solid cancer disease a chronic condition. There is a roadmap to achieve this goal where there used to be none a decade or two ago. It is our responsibility to seize this opportunity to give our patients appropriate choices in the treatment of their ailment. This issue is dedicated to modern multimodality treatment of advanced cancer and attempts to demonstrate that, even though biology certainly remains king, our chance to at least delay defeat and maybe outright win has significantly increased.

I wish to thank all authors for their willingness and effort to contribute to this edition. My hope is that the reader will be encouraged to apply and further the knowledge that has improved the fate of those afflicted by metastatic cancer.