Published online Jul 27, 2014. doi: 10.4254/wjh.v6.i7.513
Revised: May 15, 2014
Accepted: May 28, 2014
Published online: July 27, 2014
AIM: To assess a protocol for treating patients with multiple synchronous colonic cancer liver metastases, which are unresectable in one stage.
METHODS: Patients enrolled in the “liver first” protocol presented with colon-only (not rectal) cancer and multiple synchronous hepatic metastases (type II or III). All patients showed good performance status (ECOG PS 0-1) and were treated with curative intent. Complete oncologic staging including positron emission tomography-computed tomography was performed in order to rule out extrahepatic disease. If bowel obstruction was imminent, an intraluminal colonic stent was placed endoscopically. Subsequently, all patients received standardised neo-adjuvant chemotherapy, that is, FOLFOX or XELOX regimens combined with an antiangiogenic agent (bevacizumab or cetuximab). Provided that a response to chemotherapy was observed, patients underwent either one or two hepatectomies with or without portal vein embolization followed by the indicated colectomy. Further chemotherapy was administered after each procedure. Re-staging was performed after each chemotherapeutic treatment. Disease progression at any stage resulted in discontinuation of the protocol and conversion to palliative disease management.
RESULTS: Prospectively recorded data from 11 consecutive patients (8 men) were analysed for this study. Their mean age at the time of their first assessment was 65.7 (SD ± 15.3) years. Six (54.6%) patients presented with type III metastatic disease. The minimum and maximum follow-up periods were 7.3 and 39.6 mo, respectively. The mean overall survival of all patients was 16.5 (95%CI: 10.0-23.2) mo. A colonic stent had to be placed in 5 (45.5%) patients due to the onset of an intraluminal obstruction. Four (36.4%) patients succeeded in completing all planned surgical operations. Their mean overall survival was 27.2 (95%CI: 15.1-39.3) mo and the mean disease-free survival was 7.7 (95%CI: 3.0-12.5) mo. Patients, who were obliged to shift to palliative treatment due to disease progression, had a mean overall survival of 10.5 (95%CI: 8.6-12.4) mo. None of these patients underwent palliative colectomy. No postoperative mortality was recorded.
CONCLUSION: The implementation of a structured “liver first” approach protocol for the treatment of patients with extensive, liver-limited colon cancer metastatic disease may be beneficial.
Core tip: Complete tumour burden resection remains the only possible curative therapy for liver-limited colon cancer metastatic disease. However, there are different approaches regarding treatment of the primary tumour and its hepatic metastases, if the latter are synchronous and unresectable with one surgical procedure. For this subgroup of patients, a “liver first” approach protocol is introduced in order to assess standardised treatment as well as to prevent overtreatment in cases of undetected extra-hepatic metastatic dissemination or disease progression.