The liver-first approach for synchronous colorectal liver metastasis: a 5-year single-centre experience

Jong, Mechteld C. de; Dam, Ronald M. van; Maas, Monique; Bemelmans, M. H. A.; Damink, Steven W. M. Olde; Beets, Geerard L.; Dejong, Cornelis H. C.

doi:10.1111/j.1477-2574.2011.00372.x

Cited by 68 publications

(95 citation statements)

References 44 publications

(87 reference statements)

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“…28,29 For many patients, especially those with marginally resectable hepatic metastases and those with significant hepatic tumor burdens, the initial intervention should be contemporary multidrug systemic therapy. 30 The observation that patients with non-resectable metastatic disease do not need to have their primary tumors resected as a matter of routine supports this …”

Section: Discussionmentioning

confidence: 88%

Is There a Role for Simultaneous Hepatic and Colorectal Resections? A Contemporary View from NSQIP

Worni

Mantyh

Akushevich

et al. 2012

Journal of Gastrointestinal Surgery

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Introduction The optimal timing of primary and metastatic tumor management in patients with synchronous hepatic colorectal metastases remains controversial. We aimed to compare perioperative outcomes of simultaneous colorectal/liver resection (SCLR) with isolated resections utilizing a national clinical database. Methods NSQIP data from 2005 to 2009 were examined to construct risk-adjusted generalized linear models and to calculate group-specific predicted estimates. These were used to compare 30-day perioperative outcomes among patients undergoing SCLR with colorectal (CR) and liver resections (LR) only in patients with metastatic colorectal cancer. Results A total of 3,983 patients were identified, who underwent SCLR (192), LR (1,857), or CR (1,934). Rectal resection was performed in 45 (23.4 %) SCLR patients and 269 (13.9 %) CR patients (p<0.001). Major hepatectomy was performed in 69 (35.9 %) SCLR patients and 774 (41.7 %) LR patients (p00.12). Median adjusted operation time (SCLR: 273 min, 95 % CI: 253-295; CR: 172, CI: 168-177; LR: 222, CI: 217-228; p<0.001) and median adjusted length of hospital stay (SCLR: 9.5 days, CI: 8.8-10.4; CR: 8.1, CI: 7.9-8.3; LR: 6.4, CI: 6.3-6.6; p<0.001) were longer for SCLR compared to CR and LR. Adjusted predicted risks for at least one postoperative complication were higher in SCLR (36.3 %) than in CR (26.6 %) and LR (19.8 %) (p<0.003), mostly due to infectious/ cardiopulmonary issues. Discussion In SCLR patients, the risk of 30-day adverse outcomes is higher, and median operation time as well as length of hospital stay is longer compared to CR and LR patients. However, the expected combined morbidities of staged procedures though likely favor SCLR in carefully selected patients undergoing even complex hepatic and colorectal resections and should be considered.

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Section: Discussionmentioning

confidence: 88%

Is There a Role for Simultaneous Hepatic and Colorectal Resections? A Contemporary View from NSQIP

Worni

Mantyh

Akushevich

et al. 2012

Journal of Gastrointestinal Surgery

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“…This approach can be performed with acceptable perioperative mortality and morbidity rates. Although this represents a highly selected group of patients with synchronous liver metastases from CRC, particularly when the primary tumor is predominantly in the rectum, requiring a neoadjuvant treatment strategy, a considerable OS benefit can be achieved [95].…”

Section: Initially Unresectable Patientsmentioning

confidence: 99%

The Oncosurgery Approach to Managing Liver Metastases from Colorectal Cancer: A Multidisciplinary International Consensus

et al. 2012

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ABSTRACTpatients receive in different centers. Based on current evidence, the group agreed on a number of issues including the following: (a) the primary aim of treatment is achieving a long disease-free survival (DFS) interval following resection; (b) assessment of resectability should be performed with high-quality cross-sectional imaging, staging the liver with magnetic resonance imaging and/or abdominal computed tomography (CT), depending on local expertise, staging extrahepatic disease with thoracic and pelvic CT, and, in selected cases, fluorodeoxyglucose positron emission tomography with ultrasound (preferably contrastenhanced ultrasound) for intraoperative staging; (c) optimal first-line chemotherapy-doublet or triplet chemotherapy regimens combined with targeted therapy-is advisable in potentially resectable patients; (d) in this situation, at least four courses of first-line chemotherapy should be given, with assessment of tumor response every 2 months; (e) response assessed by the Response Evaluation Criteria in Solid Tumors (conventional chemotherapy) or nonsize-based morphological changes (antiangiogenic agents) is clearly correlated with outcome; no imaging technique is currently able to accurately diagnose complete pathological response but high-quality imaging is crucial for patient management; (f) the duration of chemotherapy should be as short as possible and resection achieved as soon as technically possible in the absence of tumor progression; (g) the number of metastases or patient age should not be an absolute contraindication to surgery combined with chemotherapy; (h) for synchronous metastases, it is not advisable to undertake major hepatic surgery during surgery for removal of the primary CRC; the reverse surgical approach (liver first) produces as good an outcome as the conventional approach in selected cases; (i) for patients with resectable liver metastases from CRC, perioperative chemotherapy may be associated with a modestly better DFS outcome; and (j) whether initially resectable or unresectable, cure or at least a long survival duration is possible after complete resection of the metastases, and MDT treatment is essential for improving clinical and survival outcomes. The group proposed a new system to classify initial unresectability based on technical and oncological contraindications.

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“…The liver first approach avoids possible liver metastases progression into an inoperable state while operating on primary [1][2][3]. Moreover, anastomotic complication after rectal resection in classical, "rectum first" approach may lead to a delay of systemic treatment, again with a possible conversion of initially resectable liver disease into an advanced inoperable state [2,4]. A generally lower hepatectomy complication rate [5][6][7][8][9][10] compared to complication rate after rectal resection, seems to apply to the liver first approach as well (27.3 % vs 44.4 % reported by de Jong et al in the liver first approach) [4].…”

mentioning

confidence: 99%

“…Moreover, anastomotic complication after rectal resection in classical, "rectum first" approach may lead to a delay of systemic treatment, again with a possible conversion of initially resectable liver disease into an advanced inoperable state [2,4]. A generally lower hepatectomy complication rate [5][6][7][8][9][10] compared to complication rate after rectal resection, seems to apply to the liver first approach as well (27.3 % vs 44.4 % reported by de Jong et al in the liver first approach) [4]. The reversed strategy therefore, seems to give a better opportunity for the patient to get addressed both, liver disease and primary [11].…”

mentioning

confidence: 99%

“…The reversed strategy therefore, seems to give a better opportunity for the patient to get addressed both, liver disease and primary [11]. The proportion of patients who complete their full treatment protocol after liver first approach is reported about 73-81 % by several authors [4,6,12,13]. In 2012 analysis based on LiverMetSurvey by Andres et al, up to 80 % of patients resected liver first successfully underwent the complete treatment plan, compared to less than 30 % of those undergoing the classical rectum first approach [14].…”

mentioning

confidence: 99%

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Up front hepatectomy for metastatic rectal carcinoma – reversed, liver first approach. Early experience with 15 patients.

Straka¹,

Škrovina²,

Soumarová³

et al. 2014

neo

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Timing and sequence of therapeutic interventions in patients with colorectal cancer (CRC) and synchronous liver metastases is a matter of ongoing discussion. The aim of this report is to show the feasibility and safety of a reversed strategy in patients with up front resectable synchronous liver metastases.Consecutive series of 15 patients with locally advanced rectal carcinoma and liver synchronous metastases where up front liver resection was carried out as an initial intervention is presented. Local treatment of both, metastatic disease and primary tumor, was preferred. Liver resection was followed by neoadjuvant (preoperative) concomitant radiochemotherapy (RCT) for local pelvic disease control and subsequent resection of rectum. Systemic adjuvant chemotherapy was placed at the end of the entire treatment cycle.All 15 patients after up front hepatectomy were able to proceed with their treatment plan. 14 patients completed their RCT for primary tumor and subsequent rectal resection was successfully caried out in 12 of them. 3 patients showed complete clinical response on cross sectional imaging and a careful "wait-and-see" policy was adopted for them. In two patients metastatic disease progression was noticed during the treatment cycle.Liver first approach in patients with up front resectable colorectal liver metastases (CRLM) is safe and feasible. Local neoadjuvant treatment after CRLM resection may result in preoperative downsizing or even complete clinical response of the primary tumor. Reversed strategy may to a degree eliminate negative oncologic impact of surgical complications after rectal surgery as CRLM has been already addressed.

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The liver-first approach for synchronous colorectal liver metastasis: a 5-year single-centre experience

Cited by 68 publications

References 44 publications

Is There a Role for Simultaneous Hepatic and Colorectal Resections? A Contemporary View from NSQIP

Is There a Role for Simultaneous Hepatic and Colorectal Resections? A Contemporary View from NSQIP

The Oncosurgery Approach to Managing Liver Metastases from Colorectal Cancer: A Multidisciplinary International Consensus

Up front hepatectomy for metastatic rectal carcinoma – reversed, liver first approach. Early experience with 15 patients.

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