Multisocietal European consensus on the terminology, diagnosis, and management of patients with synchronous colorectal cancer and liver metastases: an E-AHPBA consensus in partnership with ESSO, ESCP, ESGAR, and CIRSE

Abstract

Background Contemporary management of patients with synchronous colorectal cancer and liver metastases is complex. The aim of this project was to provide a practical framework for care of patients with synchronous colorectal cancer and liver metastases, with a focus on terminology, diagnosis, and management. Methods This project was a multiorganizational, multidisciplinary consensus. The consensus group produced statements which focused on terminology, diagnosis, and management. Statements were refined during an online Delphi process, and those with 70 per cent agreement or above were reviewed at a final meeting. Iterations of the report were shared by electronic mail to arrive at a final agreed document comprising 12 key statements. Results Synchronous liver metastases are those detected at the time of presentation of the primary tumour. The term ‘early metachronous metastases' applies to those absent at presentation but detected within 12 months of diagnosis of the primary tumour, the term ‘late metachronous metastases’ applies to those detected after 12 months. ‘Disappearing metastases’ applies to lesions that are no longer detectable on MRI after systemic chemotherapy. Guidance was provided on the recommended composition of tumour boards, and clinical assessment in emergency and elective settings. The consensus focused on treatment pathways, including systemic chemotherapy, synchronous surgery, and the staged approach with either colorectal or liver-directed surgery as first step. Management of pulmonary metastases and the role of minimally invasive surgery was discussed. Conclusion The recommendations of this contemporary consensus provide information of practical value to clinicians managing patients with synchronous colorectal cancer and liver metastases.

Local Treatment of Colorectal Liver Metastases in the Presence of Extrahepatic Disease: Survival Outcomes from the Amsterdam Colorectal Liver Met Registry (AmCORE)

“… Categorical variables are reported as number of patients (%); continuous variables are reported as mean (SD). a = Fisher’s exact test; b = independent t -test; c = Pearson’s chi-squared test; RAS = rat sarcoma viral oncogene homolog; BRAF = V-raf murine sarcoma viral oncogene homolog B; wt = wildtype; mut = mutation; MSS = microsatellite stability; MSI = microsatellite instability; d = synchronous—within 8 weeks of diagnosis primary tumor; e = early metachronous—within 1 year after diagnosis primary tumor; f = late metachronous, ≥1 year after diagnosis primary tumor [ 32 ]; ASA = American Society of Anesthesiologists score; TA= thermal ablation—includes microwave ablation (MWA) and radiofrequency ablation (RFA); IRE = irreversible electroporation; SABR = stereotactic body radiation. …”

Contemporary Surgical Management of Colorectal Liver Metastases

“…Nonetheless, the theoretical benefit does exist, as the recent literature has noted a complete pathologic response in the primary rectal tumor in 6% of patients who underwent the LF approach [ 53 ]. Indeed, recent consensus recommendations have recognized the LF approach as a viable treatment strategy, particularly for rectal primaries or in patients with borderline resectable hepatic disease [ 63 ]. There are some notable issues with the LF approach that should be highlighted, however.…”

“…These survival data are in line with the previously published literature, including a network meta-analysis and the only randomized clinical trial on the subject [ 69 , 70 ]. Consensus guidelines recommend that a simultaneous approach can be undertaken when the hepatectomy and colectomy are both of low complexity [ 63 , 71 ].…”

“…The optimal treatment sequence for chemotherapy is still debated, but most societal recommendations still include perioperative chemotherapy, especially in the setting of synchronous disease [ 63 ].…”

Percutaneous image‐guided ablation for hepatic metastases

“…31 Technically challenging and high-risk cases may benefit from multidisciplinary tumour board discussions, wherein experts in different local therapies weigh in on the most appropriate treatment plan. 32 Any underlying coagulopathy must be corrected prior to ablation, with recommended thresholds by the Society of Interventional Radiology of <1.5-1.8 for the international normalized ratio (INR) and for platelets above 50,000/lL. 33…”