Which surgical strategy for colorectal cancer with synchronous hepatic metastases provides the best outcome? A comparison between primary first, liver first and simultaneous approach.

Abstract

There is no clear consensus about the best surgical strategy for patients with colorectal cancer (CRC) and synchronous liver metastases (SCRLM). Between 2009 and 2019, patients with CRC and SCRLM considered for curative treatment were included. Perioperative and follow-up data were analysed to examine the safety and survival outcomes of primary first (PF), liver first (LF) and simultaneous resection (SR) strategies. 204 patients were identified, consisting of PF (n = 129), LF (n = 26) and SR (n = 49). Forty-five patients (22.1%) failed to have either the primary or the liver metastases resected following initial LF (n = 11, 42.3%) or PF (n = 34, 26.4%), respectively (p < 0.001). The postoperative morbidity rates were 31.0%, 38.4% and 40.8% in PF, LF and SR group, respectively (p = 0.409); the mortality rates were 2.3%, 0% and 4.1%, respectively (p = 0.547). The 1-, 3- and 5-year overall survival (OS) were 94%, 72%, 53% in the PF group, 74%, 54%, 36% in the LF group, and 91%, 74%, 63% in the SR group. LF group had the worst OS compared to PF and SR (p = 0.040, p = 0.052). The 1-, 3- and 5-year disease-free survival (DFS) were 31%, 15%, 10% in PF, 21%, 9% and 9% in LF and 45%, 28% and 28% in SR group, respectively. SR group had a better DFS compared to PF and LF (p = 0.005, p = 0.008). At the multivariate analysis, there was no difference between the three strategies in terms of OS (PF vs SR OS-HR 1.090, p = 0.808; LF vs SR OS-HR 1.582, p = 0.365) and the PF had a worse DFS compared to the SR approach (PF vs SR DFS-HR 1.803, p = 0.007; LF vs SR DFS-HR 1.252, p = 0.492). PF, LF and SR had comparable postoperative morbidity and mortality. The three surgical strategies had similar OS outcomes. The PF strategy was associated with a worse DFS than SR, while the LF approach was associated with a high failure rate to progress to the second stage (primary tumour resection).