Pooled survival analysis of series using the liver-first approach to the management of colorectal cancer with synchronous liver-limited metastases demonstrates wide variation in outcome.

Abstract

e14547 Background: Options for the management of patients with colorectal cancer with synchronous liver-limited metastatic disease include synchronous (liver and bowel) resection or sequential surgery: either the classic bowel-first approach or the newer liver-first strategy. This latter approach is popular but has little evidence underlying it. This study undertakes a pooled analysis of protocol and outcome of all reports of the liver-first approach for synchronous metastases. Methods: PubMed, Embase, science citation index, social sciences citation index and the Derwent innovations index were searched using terms describing colorectal cancer, liver metastases and surgery. The literature search identified 417 articles of which 4 cohort study reports described the liver-first approach and reported survival data and constitute the study population. A pre-defined protocol for data extraction was utilised to retrieve data on design, distribution of primary and hepatic metastatic disease, chemotherapy, surgery, patients completing treatment algorithm, outcome and survival. Data were extracted to populate a PRIZMA quality-control chart. Results: The 4 studies comprised 121 patients starting treatment of whom 90 (74%) completed the specified treatment protocol (83 rectal primary, 33 colon primary and primary site unreported in 5). Disease progression during the protocol period occurred in 23 (19%). Ninety six (79%) of the starting cohort of 121 reached the stage of liver resection with disease progression or death during chemotherapy being the principal causes of failure. Preferred algorithm was systemic chemotherapy (median 3 to 6 cycles) followed by hepatectomy with colorectal resection as the last step. There was wide variation between the reports in terms of their survival data. Conclusions: The liver-first approach is technically feasible in patients with colorectal cancer and synchronous hepatic metastases. About 20% will fail to complete the full treatment protocol because of disease progression. To date, there are no data to suggest superiority of outcome over the classic approach or synchronous surgery.