Intersurgeon Variability in Local Treatment Planning for Patients with Initially Unresectable Colorectal Cancer Liver Metastases: Analysis of the Liver Expert Panel of the Dutch Colorectal Cancer Group

Abstract

Background Consensus on resectability criteria for colorectal cancer liver metastases (CRLM) is lacking, resulting in differences in therapeutic strategies. This study evaluated variability of resectability assessments and local treatment plans for patients with initially unresectable CRLM by the liver expert panel from the randomised phase III CAIRO5 study. Methods The liver panel, comprising surgeons and radiologists, evaluated resectability by predefined criteria at baseline and 2-monthly thereafter. If surgeons judged CRLM as resectable, detailed local treatment plans were provided. The panel chair determined the conclusion of resectability status and local treatment advice, and forwarded it to local surgeons. Results A total of 1149 panel evaluations of 496 patients were included. Intersurgeon disagreement was observed in 50% of evaluations and was lower at baseline than follow-up (36% vs. 60%, p < 0.001). Among surgeons in general, votes for resectable CRLM at baseline and follow-up ranged between 0–12% and 27–62%, and for permanently unresectable CRLM between 3–40% and 6–47%, respectively. Surgeons proposed different local treatment plans in 77% of patients. The most pronounced intersurgeon differences concerned the advice to proceed with hemihepatectomy versus parenchymal-preserving approaches. Eighty-four percent of patients judged by the panel as having resectable CRLM indeed received local treatment. Local surgeons followed the technical plan proposed by the panel in 40% of patients. Conclusion Considerable variability exists among expert liver surgeons in assessing resectability and local treatment planning of initially unresectable CRLM. This stresses the value of panel-based decisions, and the need for consensus guidelines on resectability criteria and technical approach to prevent unwarranted variability in clinical practice.

CAIRO5 study from a surgical perspective

“…Thus, this type of approach should become the benchmark for future trials in this field. Bond et al ( 9 ) have already presented preliminary results in the past highlighting a limited rate of agreement by the panel of experts (about a third of cases) and it has been confirmed in this latest update of the CAIRO5 study, with an overall agreement at diagnosis not exceeding 66%. This relatively low rate, comparable to other studies ( 10 ), reflects the difficulty of assessing resectability and argues in favour of regular multidisciplinary and multicentric resectability boards among high-volume centres.…”

Trends and overall survival after combined liver resection and thermal ablation of colorectal liver metastases: a nationwide population-based propensity score-matched study

“…4 This can be explained partly by variation in availability and expertise of thermal ablation in different centres, or by a reduced confidence by hepatobiliary surgeons in the effectiveness of thermal ablation in reaching local control. 8 To date, no clear guideline exists. Multidisciplinary teams consisting of hepatobiliary surgeons and interventional radiologists have to consider which therapy best fits each individual patient (e.g., resection, ablation or combined treatment).…”

Colorectal Liver Metastases: Exploring the Extent of Agreement

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Bond et al should be commended on their in-depth analysis of > 1000 resectability assessments in patients with advanced colorectal liver metastases (CRLM). 1 Although resection of CRLM is the best option for achieving longterm survival, it remains greatly underutilized. While 30% of patients with CRLM would potentially benefit from surgery, only approximately 15% actually undergo resection.

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