Abstract
Patients presenting with synchronous colorectal liver metastases are increasingly being considered for a curative treatment, and the liver-first approach is gaining popularity in this context. However, little is known about the completion rates of the liver-first approach and its effects on survival. A systematic review and meta-analysis of liver-first strategy for colorectal liver metastasis. The primary outcome was an assessment of the completion rates of the liver-first approach. Secondary outcomes included overall survival, causes of non-completion, and clinicopathologic data. Seventeen articles were amenable for inclusion and the total study population was 1041. The median completion rate for the total population was 80% (range 20-100). The median overall survival for the completion and non-completion groups was 45 (range 12-69) months and 13 (range 10.5-25) months, respectively. Metadata showed a significant survival benefit for the completion group, with a univariate hazard ratio of 12.0 (95% confidence interval, range 5.7-24.4). The major cause of non-completion (76%) was liver disease progression before resection of the primary tumor. Pearson tests showed significant negative correlation between median number of lesions and median size of the largest metastasis and completion rate. The liver-first approach offers a complete resection to most patients enrolled, with an overall survival benefit when completion can be assured. One-fifth fails to return to intended oncologic therapy and the major cause is interim metastatic progression, most often in the liver. Risk of non-completion is related to a higher number of lesions and large metastases. The majority of studies stem from primary rectal cancers, which may influence on the return to intended oncologic therapy as well.PROSPERO id no: 170459.
Highlights
Little is known about the completion rates of the liver-first approach and its true effect on survival
This systematic review shows that about one in every five patients undergoing at least a first round of liver resection in a liver-first approach do not return to intended oncologic therapy (RIOT), most commonly caused by progression of metastases in the liver
This review shows that 20% of liver-first patients do not complete intended surgery beyond liver resection, a potentially unnecessary major procedure
Summary
Colorectal cancer remains the second leading cause of cancer death worldwide, and 15% present with synchronous liver metastases.[1,2] The only potentially curative treatment is a resection of the complete cancer burden.[3]. In the early 2000s, the overall 5-year survival for surgically treated stage IV colorectal cancer with isolated liver metastases was around 26%.4. Corresponding author: Roland Andersson Department of Surgery, Skåne University Hospital, Lund SE222 42, Sweden Department of Clinical Sciences, Lund University, Lund SE-221 85, Sweden Roland.Andersson@med. William Torén Department of Clinical Sciences, Lund University, Lund, Sweden Department of Surgery, Skåne University Hospital, Lund, Sweden. The major cause of non-completion (76%) was liver disease progression before resection of the primary tumor. Conclusions: The liver-first approach offers a complete resection to most patients enrolled, with an overall survival benefit when completion can be assured.
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