Preliminary Results of ‘Liver-First' Reverse Management for Advanced and Aggressive Synchronous Colorectal Liver Metastases: A Propensity-Matched Analysis

Abstract

Background: Although a ‘liver-first' approach recently has been advocated in treating synchronous colorectal metastases, little is known about how results compare with those of the classical approach among patients with similar grades of liver metastases. Methods: Propensity-score matching was used to select study subjects. Oncologic outcomes were compared between 10 consecutive patients with unresectable advanced and aggressive synchronous colorectal liver metastases treated with the reverse strategy and 30 comparable classically treated patients. Results: Numbers of recurrence sites and recurrent tumors irrespective of recurrence sites were greater in the reverse group then the classic group (p = 0.003 and p = 0.015, respectively). Rates of freedom from recurrence in the remaining liver and of freedom from disease also were poorer in the reverse group than in the classical group (p = 0.009 and p = 0.043, respectively). Among patients treated with 2-stage hepatectomy, frequency of microvascular invasion surrounding macroscopic metastases at second resection was higher in the reverse group than in the classical group (p = 0.011). Conclusions: Reverse approaches may be feasible in treating synchronous liver metastases, but that strategy should be limited to patients with less liver tumor burden.

Tumor response and outcome after reverse treatment for patients with synchronous colorectal liver metastasis: a cohort study

“…The completion rate of 93% in the present study was even higher than described in previous series (65 and 84%) [17][18][19][20]. Feared colonic complications such as occlusion or perforation during neoadjuvant treatment occurred only in 11% of the patients and did not preclude the completion of the whole sequence provided complications were adequately treated.…”

“…Previous studies reported morbidity ranging from 17 to 45% [18,[21][22][23][24][25][26][27][28], and major complication rates were 0 to 27.3% when reported [19,[22][23][24][25][26]. Our high complication rate could be explained by the aggressive surgical strategy for patients with high oncologic burden with 40% portal vein embolization and 61% major hepatectomies, compared to 11-60% portal vein embolization [18,21,22,28,29] and 36-89% major hepatecomies [18-20, 22-26, 29, 30] in other reports. However, there was no mortality within 90 postoperative days, while the highest reported mortality rate of 2% in the series from Welsh et al [19].…”

The liver-first approach for synchronous colorectal liver metastases: more than a decade of experience in a single centre

“…Their tumour burden within the liver, however, seemed to be comparable. In line with this, Tanaka et al 18 reported a 100% recurrence rate in their cohort of 10 patients with aggressive initially unresectable metastases, who underwent the liver-first approach. However, this group of patients is a highly selected population with a substantial tumour burden (also reflected by the low feasibility of 20%) and these results can therefore not be projected on a more general patient group with synchronous CRLM.…”

“…[13][14][15] However, most series contain relatively small patients numbers. [14][15][16][17][18][19] Moreover, the follow-up within these cohorts is often relatively short, 15,[17][18][19] as also in our previous series. 12 Furthermore, none of these studies provides robust data on long-term outcomes, 14,16 with regard to survival and other oncologic outcomes.…”

“…With regards to the CRLM, most patients had bilobar hepatic lesions (n = 51; 55.4%), while the median number of lesions was three [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20].…”