Liver-first approach of colorectal cancer with synchronous hepatic metastases: A reverse strategy

Abstract

Recently, there has been a change in the strategy of how synchronous colorectal hepatic metastases are attributed to the development of more valuable protocols of chemotherapy and radiotherapy for neoadjuvant treatment of colorectal neoplasms and their hepatic metastases. There is a consensus that patients with synchronous colorectal hepatic metastases have lower survival than those with metachronous colorectal hepatic metastases. Currently, controversy remains concerning the best approach is sequence in a patient with colorectal cancer and synchronous hepatic metastases resection. To obtain a better patient selection, the authors have suggested the initial realization of systemic chemotherapy in the circumstance of patients with colorectal tumor stage IV, since these patients have a systemic disease. The rationale behind this liver-first strategy is initially the control of synchronous hepatic metastases of colorectal carcinoma, which can optimize a potentially curative hepatic resection and longstanding survival. The liver-first strategy procedure is indicated for patients with colorectal hepatic metastases who require downstaging therapy to make a curative liver resection possible. Thus, the liver-first strategy is considered an option in cases of rectal carcinoma in the early stage and with limited or advanced synchronous colorectal hepatic metastases or in case of patients with asymptomatic colorectal carcinoma, but with extensive liver metastases. Patients undergoing systemic chemotherapy and with progression of neoplastic disease should not undergo hepatic resection, because it does not change the prognosis and may even make it worse. To date, there have been no randomized controlled trials on surgical approach of colorectal synchronous hepatic metastases, despite the relatively high number of available manuscripts on this subject. All of these published studies are observational, usually retrospective, and often non-comparative. The patient selection criteria for the liver-first strategy should be individualized, and the approach of these patients should be performed by a multidisciplinary team so its benefits will be fully realized.

Keywords: Colorectal neoplasms, Neoplasm metastasis, Liver neoplasms, Liver/surgery, Hepatectomy, Drug therapy, Survival, Prognosis

Core tip: The liver-first approach or reverse strategy is a downstaging regimen, and it consists of systemic chemotherapy, chemoradiotherapy and/or biological agents, followed by resection of colorectal hepatic metastases prior to removal the primary colorectal tumor. It is a promising strategy in patients with synchronous colorectal liver metastases. The rationale behind this liver-first strategy is initially control of synchronous hepatic metastases of colorectal carcinoma, which can optimize the opportunity of a potentially curative liver resection and longstanding survival. The liver-first strategy can be applied for patients with early stage colorectal carcinoma and synchronous hepatic metastases. Extensive or locally advanced rectal carcinoma with limited or advanced synchronous hepatic metastases and asymptomatic colonic carcinoma with extensive synchronous hepatic metastases may be submitted to the liver-first strategy.