Liver First Approach for Synchronous Colorectal Liver Metastasis: Is First Approach the Best Approach?

Abstract

Introduction: Liver first approach (LFA) for synchronous colorectal liver metastasis (CRLM) is an upcoming strategy for improving survival among patients with stage IV colorectal carcinoma. We share our experience of managing such patients using the LFA and their treatment outcome. Methods: We retrospectively studied 1038 patients who presented with synchronous CRLM over a 10 year period. The clinical history, management strategy and outcomes of patients undergoing the LFA were analysed in detail. Results: We formulated an algorithm for management of patients presenting with synchronous CRLM (picture). Out of 1038 such patients, 31 were selected for the LFA. 29 recto-sigmoid, one caecal and one descending colon carcinoma were part of the LFA group. All of them underwent neo-adjuvant short course radiotherapy with systemic chemotherapy and proceeded to have liver resection. Following this, 11 patients had disease progression and only 20 (64.5%) proceeded to have their primary tumor resected. The peri-operative characteristics and outcomes of patients who completed the LFA are listed in the table below. Among the patients who completed the LFA, the recurrence rate was 70% (n=14) and the median time to recurrence was 418.5 days (IQR 407). The 1-year, 3-year and 5-year survival rates for the LFA were 90%, 85% and 65% respectively, with a median survival of 1112.5 days (IQR 1025) which is similar to the conventional methods. Conclusions: LFA for synchronous CRLM better serves patients when appropriately selected and combined with a multi-modality approach especially in patients with a large disease burden in the liver.Tabled 1Demographics Mean age60.77 years Male : Female ratio13 : 7Tumor characteristics Primary locationRectum 19, Caecum 1 Average number of liver metastasis3.85 Average size of largest metastasis49.8 mm Bilobar liver metastasis11 (55%)Hepatic resection Right hepatectomy5 Right hepatectomy with non-anatomical resections3 Non-anatomical resection3 Extended left hepatectomy3 Extended right hepatectomy1 Left lateral sectionectomy2 Left hepatectomy with right posterior sectionectomy1 Central hepatectomy2Post hepatic resection Major morbidity (Clavien Dindo ≥3b)1 (5%) Mortality0 R1 margin5 (25%)Colorectal resection Anterior resection15 Abdomino-perineal resection4 Right hemicolectomy1Post colorectal resection Major morbidity (Clavien Dindo ≥3b)3 (15%) Mortality2 (10%) Open table in a new tab