“Liver fist approach“ in the management of synchronous liver metastases from colorectal cancer: Preliminary non-randomized study results
Authors:
J. Pudil 1; S. Batko 2; K. Menclová 1; M. Bláha 3; M. Ryska 1
Authors‘ workplace:
Chirurgická klinika 2. LF Univerzity Karlovy a ÚVN, Praha
přednosta: prof. MUDr. M. Ryska, CSc.
1; Onkologická klinika 2. LF Univerzity Karlovy a FN Motol, Praha
přednosta: doc. MUDr. J. Prausová, PhD., MBA
2; Institut biostatistiky a analýz, Masarykovy univerzity, Brno
ředitel: doc. RNDr. L. Dušek, Ph. D.
3
Published in:
Rozhl. Chir., 2015, roč. 94, č. 12, s. 522-525.
Category:
Original articles
Overview
Introduction:
Liver metastases are diagnosed in 60% of patients with colorectal cancer, both at the time of diagnosis or later in the course of their management. Surgical treatment is the sole potentially curable method with 5–year overall survival of approximately 50%. However, only less than 20% of patients underwent liver resection. A joint effort of medical oncologists and surgeons is to increase the numbers of resected patients. The “liver first approach” (LFA) is one of approaches aimed at increasing resecability. The authors present their preliminary results using this method.
Methods:
102 patients were included in the multicentre study supported by the grant IGA NT 13660 − Evaluation of quality of multimodal treatment for patients with colorectal cancer liver metastases – conducted at the Central Military Hospital between September 2012 and January 2015. We used LFA in 12 patients (12%). Patients were indicated for liver resection based on good response to neoadjuvant systemic therapy. Multiple bilobar liver involvement (>4 metastases) was present in 11 cases and one large solitary metastasis in the right liver lobe in one case. The primary tumor was located in the rectum in 9 patients, in the rectosigmoid in 3 patients; 3 patients had a colostomy. Others showed no signs of bowel obstruction.
Results:
We have performed R0 resections in 11 cases, and two-stage hepatectomy with portal vein embolisation was indicated 3 times (in one case we did not finish the second stage due to quick progression after PVE). We performed major resections 7 times, along with sever extraanatomic resections, incl. 11 RFA (6 times in combination with major resections). Perioperative mortality was 0%, morbidity 33% (Dindo-Clavien >2). Ten patients underwent adjuvant chemotherapy, in 7 cases including radiotherapy of the small pelvis due to a local advanced primary tumor. Resection of the primary tumor was done in 7 patients (58%). Two patients died recently because of disease progression (17%); progression was observed in 6 patients (50%).
Conclusion:
We deem the LFA suitable especially for patients with metastatic rectal tumors where adjuvant systemic therapy can be combined with radiotherapy. The timing of the resection of the primary tumor still remains a question: it is necessary to rule out potential recurrence of liver metastases, which affected more than 50% of the patients. The benefit of LFA must be confimed by randomised studies.
Key words:
colorectal cancer − liver metastases − liver first approach
Sources
1. Parkin DM, Bray F, Ferlay J, et al. Global cancer statistics, 2002. CA Cancer J Clin 2005;55:74–108.
2. Strnad R, Ryska M, Bělina F, et al. Predikce léčebné odpovědi na adjuvantní lokoregionální chemoterapii po resekci jater pro metastázy kolorektálního karcinomu – předběžné výsledky. Rozhl Chir 2006;85:124−8.
3. Žaloudík J, Coufal O, Kocáková I, et al. Patofyziologie jaterních metastáz kolorektálního karcinomu a důsledky pro terapii. Bull HPB 2001;9:27−8.
4. Třeška V. Technika jaterních resekcí – současné možnosti. Rozhl Chir 2007;86:335–6.
5. Mentha G, Majno PE, Andres A, et al. Neoadjuvant chemotherapy and resection of advanced synchronous liver metastases before treatment of the colorectal primary. Br J Surg 2006;93:872–8.
6. Reddy SK, Pawlik TM, Zorzi D, et al. Simultaneous resections of colorectal cancer and synchronous liver metastases: a multi-institutional analysis. Ann Surg Oncol 2007;14:3481–91.
7. Jegatheeswaran S, Mason JM, Hancock HC, et al. The liver-first approach to the management of colorectal cancer with synchronous hepatic metastases: a systematic review. JAMA Surg 2013;148:385–91.
8. Lam VW, Laurence JM, Pang T, et al. A systematic review of a liver-first approach in patients with colorectal cancer and synchronous colorectal liver metastases. HPB (Oxford) 2014;16:101−8.
9. De Rosa A, Gomez D, Brooks A, et al. „Liver-first“ approach for synchronous colorectal liver metastases: is this a justifiable approach? J Hepatobiliary Pancreat Sci 2013;20:263−70.
10. Mentha G, Roth AD, Terraz S, et al. The ‘Liver first’ approach in the treatment of colorectal cancer with synchronous liver metastases. Dig Surg 2008;25:430–5.
11. De Jong MC, van Dam RM, Maas M, et al. The liver-first approach for synchronous colorectal liver metastasis: a 5-year single-centre experience. HPB 2011;13:745–52.
12. Verhoef C, van der Pool AEM, Nuyttens JJ, et al. The liver-first approach for patients with locally advanced rectal cancer and synchronous liver metastases. Dis Colon Rectum 2009;52:23–30.
13. Brouquet A, Mortenson MM, Vauthey JN, et al. Surgical strategies for synchronous colorectal liver metastases in 156 consecutive patients: classic, combined or reverse strategy? J Am Coll Surg 2010;210:934–41.
14. de Rosa A, Gomez D, Hossaini S, et al. Stage IV colorectal cancer: outcomes following the liver-first approach. J Surg Oncol 2013;108:444−9.
15. McCahill LE, Yothers G, Sharif S, et al. Primary mFOLFOX6 plus bevacizumab without resection of the primary tumor for patients presenting with surgically unresectable metastatic colon cancer and an intact asymptomatic colon cancer: definitive analysis of NSABP trial C-10. 1. J Clin Oncol 2012;30:3223–8.
16. Zitt M. Bowel first? Simultaneous resection? Liver first? Treatment options in patients with colorectal cancer and resectable synchronous liver metastases. Mag Eur Med Oncol 2011;4:79–81.
17. Damjanov N, Weiss J, Haller DG. Resection of the primary colorectal cancer is not necessary in nonobstructed patients with metastatic disease. Oncologist 2009;14:963–9.
18. Aloia TA, Fahy BN. A decision analysis model predicts the optimal treatment pathway for patients with colorectal cancer and resectable synchronous liver metastases. Clin Colorectal Cancer 2008;7:197–201.
19. Wicherts DA, Miller R, de Haas RJ, et al. Long-term results of two-stage hepatectomy for irresectable colorectal cancer liver metastases. Ann Surg 2008;248:994−1005.
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