Is winning the only thing? – Examining the “win ratio” concept in synchronous colorectal liver metastasis

Abstract

The dilemma of sequencing therapies in synchronous colorectal liver metastasis (CRLM) has been a seemingly continual topic of interest, particularly as a more aggressive surgical approaches to liver resection have emerged in recent decades. Improvement in perioperative management has driven morbidity and, more notably, mortality rates to low levels in even the most complex clinical circumstances. This has provided the oncology team with three distinct pathways to choose from for surgical management: synchronous resection of the primary tumor and liver disease, a liver-first approach, or a primary tumor-first approach. The potential benefit of synchronous resection is consolidating surgical management into a single surgical procedure to render the patient into a “no evidence of disease” status, balanced with concerns for increased morbidity and mortality by combining liver and colorectal surgery. The liver-first approach has been of increasing interest as the hepatic disease status appears to be a primary driver of cancer-related mortality in CRLM. Addressing the liver disease first allows for the patient to return to intended oncologic therapy in timely fashion while the patient remains asymptomatic from their primary tumor. This may also facilitate neoadjuvant radiotherapy prior to rectal resections. Staged surgery likely reduces morbidity and mortality concerns, though also comes with increased total length of stay and potential for disease progression in the perioperative interval while off systemic therapy. Finally, a primary tumor-first approach can be utilized but would typically be reserved for symptomatic tumor causing refractory bleeding or obstruction.