Results of inverse strategy using systemic chemotherapy (CT) first, liver resection second, and primary tumor resection last for patients with advanced synchronous liver metastases (ASLM) from colorectal cancer (CRC)

Abstract

3683 Increasingly efficient CTs allow to consider patients (pts) with ASLM as potentially curable despite the number, the size and the bilobar localization of the lesions. In some pts, however, ASLM progress during treatment of the primary CRC, hindering the intent to cure. We investigated the possibility of giving ASLM-oriented CT first, resecting ASLM second, and removing the primary last. Patients and treatments: 20 pts (11 men) with non obstructive CRC, 50% rectal tumor, median age 56 years (37–68), were treated according to this protocol. The median number of ASLM was 5 (2–21), median size 4 cm (1–14) and the ASLM were bilobar in 70%. Pts were treated with 2 to 6 cycles (median 3) of CT before surgery. 12 pts received OCFL (oxaliplatin 70mg/m2 d1,15, CPT11 100mg/m2 d8,22, leucovorin (LV) 30mg and 5FU 2.3g/m2/24h d1,8,15,22 q5w), 7 OCX (like OCFL with capecitabine 800mg/m2/d d1–28 instead of 5FU/LV) and 1 XELOX (oxaliplatine 130mg/m2 d1, capecitabine 2g/m2 d1–14 q3w). 16 pts were resected. All but two rectal cancer pts received preoperative radiotherapy. Results: 4 pts (20%) could not have their ASLM resected: 1 died of septicemia during CT, 3 progressed of whom 2 died at 5 and 8 months, and 1 was alive with disease (AWD) at 41 months.16 pts (80%) had complete removal of ASLM, 6 by a two-step liver surgery and 2 after right portal embolization. All of these patients had their primary CRC resected, with downstaging observed by histology in 75%. 9 (56%) were free of disease and 4 (25%) AWD at a median follow up of 24 months. 4 pts underwent additional removal of metastases (liver, ovary and lung). Two pts died of disease progression at 44 and 53 months and 1 after repeat surgery at 14 months. Actuarial 1- and 3-year survival rates of resected pts were 100% and 89%, respectively. Conclusions: Initial ASLM-oriented CT followed by ASLM removal appears as a promising concept. It allows to downstage ASLM, to select pts with responding disease avoiding unnecessary surgery, and to deliver state-of-the-art preoperative rectal radiotherapy without the fear that liver metastases will meanwhile progress beyond the possibility of cure. No significant financial relationships to disclose.