Propensity score-matched outcomes analysis of the liver-first approach for synchronous colorectal liver metastases

Abstract

Patients with sCRLM selected for a liver-first approach had more oncologically advanced disease and a poorer prognosis. They had inferior cumulative DFS than those undergoing a classical approach, a difference negated by matching preoperative BPI.

Prognosis in patients with synchronous colorectal cancer metastases after complete resection of the primary tumor and the metastases

“…A clear superiority of this concept has not yet been established, however, a study by Brouquet et al revealed that patients in the liver‐first group had more extensive disease and needed more complex procedures than patients with simultaneous or primary‐first surgery. This assumption was confirmed by a propensity score‐matched analysis in which differences in survival disappeared after matching for a predictive index taking the extent of disease into account . This is a strong indication that patients with more extensive disease benefit from the liver‐first approach.…”

“…Another challenge represents the need for a mutual understanding of the disciplines involved in treatment of CRC with synchronous metastases. Potentials, risks, and limitations of each form of the considered treatment must be evaluated to achieve the best results for the patients . Especially the expertise of colorectal, hepatobiliary, thoracic, and peritoneal surface surgeons next to medical and radiation oncologists, interventional radiologists, gastroenterologists, and pathologists should be available within the MDT .…”

Treatment sequencing for simultaneous colorectal liver metastases

“…Increased recognition of chemotherapy‐associated postoperative morbidity has led to increased utilization of “liver‐first” approaches in select patients . In most reported series, patients first receive chemotherapy (or radiation in the case of rectal cancer), followed by liver resection, followed by further chemotherapy or colorectal resection depending on the primary tumor . The approach is theoretically appealing in the context of initially unresectable or borderline metastases (numerous/large metastases or questionable liver remnant) requiring conversion chemotherapy and/or staged hepatectomy approaches with asymptomatic primary tumors.…”

“…80 In most reported series, patients first receive chemotherapy (or radiation in the case of rectal cancer), followed by liver resection, followed by further chemotherapy or colorectal resection depending on the primary tumor. [81][82][83] The approach is theoretically appealing in the context of initially unresectable or borderline metastases (numerous/large metastases or questionable liver remnant) requiring conversion chemotherapy and/or staged hepatectomy approaches with asymptomatic primary tumors. It is also appealing for patients with simultaneous liver metastases from asymptomatic locally advanced rectal cancer in whom primary tumor downstaging or organ preservation is desirable, 84 When and how to include radiation treatment for the rectal primary tumor is of particular importance in the liver-first approach and highlights the importance of multidisciplinary planning for patients with simultaneous metastases.…”

“…Selected studies comparing morbidity and hospital stay for combined vs staged resections for metastatic colorectal cancer Proponents of the liver-first approach cite a low level (generally 10%-20%) of primary tumor-related complications while on chemotherapy, comparable survival rates to other treatment sequences, and the possibility of organ preservation in the case of rectal cancer with complete clinical response to chemotherapy or chemoradiation 80,[86][87][88]. Reported perioperative morbidity and long-term outcomes are similar when compared to colon/rectum-first treatment sequences, especially when accounting for patients' clinical recurrence risk 82,89. Because up to 8% to 33% of rectal tumors will demonstrate a complete pathological response to preoperative chemotherapy and/or chemoradiation, the liver-first approach is particularly appealing to patients and clinicians interested in rectal organ preservation 90,91.…”