Long-term survival after "liver first" approach for locally advanced rectal cancer and synchronous liver metastases

Abstract

Dear Editor: The traditional treatment of synchronous colorectal liver metastases is initial resection of the primary tumor followed by systemic chemotherapy and then, if possible, resection of the liver metastases. In cases of small liver metastases requiring only minor hepatectomy, synchronous treatment of both the primary tumor and the liver metastases can also lead to acceptable oncological results. Since long-term prognosis in such patients depends on the curative resection of the synchronous liver metastases, on the time of the optimizing of results after systematic chemotherapy, the "liver first" approach or “reverse colectomy” represents a concept which gains ongoing interest. We herein report the long-term follow-up of our first patient primarily treated for her synchronous liver metastases and, afterwards, for the locally advanced rectal cancer: the "liver first" approach. In November 2006, a 55-year-old Caucasian female presented to our department with suspected rectal cancer and synchronous liver metastases. Biopsy of the primary tumor revealed G2 adenocarcinoma of the rectum. Endoscopic ultrasound was impossible to complete because of painful stenosis. A computed tomography (CT) scan showed extensive liver metastases in the right lobe (8 cm in diameter) with involvement of the right hepatic vein and in close proximity to the middle hepatic vein. After an interdisciplinary evaluation, neoadjuvant chemotherapy according to the FOLFOX protocol was initiated, but after the second cycle, side effects led to its discontinuation. Radiological studies to assess the response to chemotherapy and laboratory evaluation were performed ahead of time. With a CT scan showing partial regression of liver metastases and a decrease in CEA level, the patient was considered resectable and was planned for liver surgery. Three weeks after the second course of chemotherapy, the patient underwent partial liver resection of segments 7/8. Histological assessment of the resected liver specimen revealed metastatic rectal G2 adenocarcinoma. All the margins were clear of the tumor. The metastases showed about 70% vital tumor mass. The surrounding liver parenchyma demonstrated chemotherapy-associated steatohepatitis. Resection of the primary tumor was planned within 8 weeks after liver surgery. The patient underwent low anterior rectal resection. Intraoperative colonoscopy showed only scar tissue; further signs of the formerly described tumor mass were no longer detected. Histological assessment revealed few residual tumor cells of the G2 adenocarcinoma invading the muscularis propria. The resected lymph nodes were all clear of tumor (ypT2 ypN0 (0/10) pM1 L0 V0 R0). Postoperatively, seven courses of chemotherapy according to the FOLFIRI protocol were added to complete the neoadjuvant treatment program. Follow-up consisted of endoscopy and CT scan. Thirteen months after the low anterior rectal resection, follow-up CT scan demonstrated a solitary pulmonary lesion in left segment 6. Chemotherapy consisting of irinotecan and cetuximab was initiated, but after the second cycle, side S. Radunz :M. Heuer : Z. Mathe :A. Paul : G. C. Sotiropoulos (*) Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, Hufelandstr. 55, 45122 Essen, Germany e-mail: georgios.sotiropoulos@uni-due.de