The impact of multidisciplinary team management on outcome of hepatic resection in liver-limited colorectal metastases

Abstract

Hepatic resection is the gold standard treatment for patients affected by liver-limited colorectal metastases. Reports addressing the impact of multidisciplinary team (MDT) evaluation on survival are controversial. The aim of this study was to evaluate the benefit of MDT management in these patients in our Institution experience. The objective of the analysis was to compare survivals of patients managed within our MDT (MDT cohort) to those of patients referred to surgery from other hospitals without MDT discussion (non-MDT cohort). Of the 523 patients, 229 were included in the MDT cohort and 294 in the non-MDT cohort. No difference between the two groups was found in terms of median overall survival (52.5 vs 53.6 months; HR 1.13; 95% CI, 0.88-1.45; p = 0.344). In the MDT cohort there was a higher number of metastases (4.5 vs 2.7; p < 0.0001). The median duration of chemotherapy was lower in MDT patients (8 vs 10 cycles; p < 0.001). Post-operative morbidity was lower in the MDT cohort (6.2 vs 21.5%; p < 0.001). One hundred and ninety-seven patients in each group were matched by propensity score and no significant difference was observed between the two groups in terms of OS and DFS. Our study does not demonstrate a survival benefit from MDT management, but it allows surgery to patients with a more advanced disease. MDT assessment reduces the median duration of chemotherapy and post-operative morbidities. Colorectal cancer (CRC) is the third most commonly diagnosed cancer in developed countries 1 , ranking second in frequency in Europe 2 , and, despite recent improvements in diagnosis and treatment, is still the third leading cause of cancer-related death. About 25% of CRC patients present at diagnosis with liver metastases and up to half will develop liver metastases over the course of their disease. The introduction of modern combination chemotherapy regimens and targeted therapies 3 and the recent advances in surgical techniques 4 have dramatically improved the survival of patients with liver-limited colorectal metastases over the last decade 5. Nowadays, hepatic resection is the gold standard treatment for patients with liver-limited colorectal metastases with 5-and 10-years survival rates reaching up to 60% and 20%, respectively 6,7. The use of liver remodelling strategies (including portal vein ligation or embolization) and effective conversion treatments with chemotherapeutic (irinotecan and oxaliplatin) and targeted (bevacizumab, cetuximab and panitumumab) agents has contributed to increase to about 25% the rate of patients suitable for surgery 8 .

Evolution of Surgical Treatment of Colorectal Liver Metastases in the Real World: Single Center Experience in 1212 Cases

“…When focusing on disease with characteristics of high technical complexity [ 25 ] and high CRS [ 22 ], a different trend was observed. Aside from the increase in the absolute number of cases, which parallels the policy of broader inclusion to surgical treatment, the proportion of cases with high compared to low complexity and cases with high CRS compared to those with lower CRS significantly increased.…”

“…Metastases were defined synchronous when they were present at the moment of primary tumor diagnosis. Preoperative chemotherapy was routinely administered in patients with initially unresectable liver metastases until conversion to resectability was achieved, and in patients with initially borderline/easily resectable liver disease with neoadjuvant intent unless a Clinical Risk Score (CRS) < 3 [ 22 ] (see later for details) was calculated. The same behavior was maintained over the whole study period.…”

Multidisciplinary Tumor Board in the Management of Patients with Colorectal Liver Metastases: A Single-Center Review of 847 Patients

“…In such a complex scenario, the role of an MDT should be the coordination and delivery of the appropriate cancer care, considering all the different therapeutic options that can be combined to offer the best chance of cure [ 21 ]. However, while the literature suggests that the MDT could be helpful in revising tumor stage and diagnosis, modifying management plans, and improving the adherence to clinical guidelines, its role in managing such new multimodality curative approaches is less clear [ 22 , 23 , 24 , 25 ].…”

Non-colorectal non-neuroendocrine liver metastasis: a narrative review of surgical treatment

“…In addition, technical advances, technological innovation, and patient selection have remarkably improved the safety of liver surgery and let push the boundaries with extensive LR becoming more feasible (1). To date, LR is considered the gold standard for the treatment of patients with colorectal metastases limited to the liver, achieving 5-and 10-year survival rates of up to 60% and 20%, respectively (2). The liver is the main site of metastatic disease, and cancer metastases remain the main limit to successfully managing the malignant disease.…”