Liver metastases from colorectal cancer. Different strategies and outcomes

Abstract: Patients with colorectal liver metastases (CRLM) increasingly undergo liver resections. The belief is that the resection or ablation of a tumor, when possible, is the only possibility of a cure. The classical strategy is where the primary colorectal tumor is resected as the first intervention, followed by resection of the liver metastasis at a second stage. The liver-first strategy is where preoperative chemotherapy is given, followed by resection of the liver metastases and then resection of the colorectal primary tumor at a second stage. The third option is the simultaneous strategy where the patient undergoes both liver and primary tumor resection during the same operation. The patient selection and drop-out from the planned intervention are poorly known. None of the three strategies have demonstrated any clear advantage or disadvantage in terms of survival. A repeated hepatectomy, for patients with recurrent CRLM, is increasingly performed with mostly unknown postoperative functional liver volume (FLV). Specific aims to investigate:I. Why do patients scheduled for the liver-first strategy not complete both the planned liver and primary resections? II. Compare the liver-first to the classical strategy for patients presenting with synchronous CRLM (sCRLM). III. Compare the simultaneous strategy with the classical strategy for patients presenting with sCRLM, focusing on patients undergoing major liver resections. IV. Measure liver regeneration and survival data after a repeated liver procedure (resection or ablation) for recurrent CRLM. Results and conclusions:I. Up to 35% of patients with sCRLM do not complete the planned treatment. II. The liver-first and the classical strategy did not show any overall survival difference. III. Simultaneous resections appeared to have more complications, shorter total length-of-stay but similar overall survival as patients chosen for the classical strategy. IV. We found a small change in FLV after two hepatic procedures but with a considerable inter-individual variation. Patients selected for a repeated hepatic procedure for recurrent CRLM had an acceptable survival.When choosing different strategies for sCRLM patients, our results imply that we should select according to treatment logistics, tumor symptoms, and surgical feasibility. When patients present with recurrent CRLM, a high variance in liver volume after repeated resection can be expected when planning future repeated resections.