The liver-first approach in treatment of rectal cancer patients with synchronous liver metastases

Objective: to evaluate feasibility and short-term results of the liver-first approach in our center.

Materials and methods. Retrospective study of prospectively gathered group of patients who were treated in N. N. Blokhin National Medical Research Center of Oncology between 2017 and 2019. Patients with asymptomatic primary tumor located in rectum and rectosigmoid junction with synchronous resectable / borderline resectable metastasis in liver. 22 patients were planned to undergo the liver-first approach. Post-operative morbidity and mortality (Clavien–Dindo) as well as tumor regression grading (Dworak) were evaluated.

Results. Of the 17 patients planned to undergo the liver-first strategy, the approach was completed in 15 (88,2 %) patients. The main reason for treatment failure was disease progression. Post-operative morbidity and mortality were 13,3 % and 0 %, respectively.

Conclusions. Liver-first approach is justified in two cases: during waiting period after last day of chemoradiotherapy in patients with locally advanced (invasion depth T4a, positive circumferential resection margin, N+ status) mid-to-low rectal cancer and in patients with multiple borderline resectable bilobar liver damage.

1. Manfredi S., Lepage C., Hatem C. et al. Epidemiology and management of liver metastases from colorectal cancer. Ann Surg 2006;244(2):254–9. DOI: 10.1097/ 01.sla.0000217629.94941.cf.

2. Abdalla E. K., Ribero D., Pawlik T. M. et al. Resection of hepatic colorectal metastases involving the caudate lobe: perioperative outcome and survival. J Gastrointest Surg 2007;11(1):66–72.

3. Nikfarjam M., Shereef S., Kimchi E. T. et al. Survival outcomes of patients with colorectal liver metastases following hepatic resection or ablation in the era of effective chemotherapy. Ann Surg Oncol 2009;16(7):1860–7. DOI: 10.1245/s10434‑008‑0225‑3.

4. Patyutko Yu. I., Pylev A. L., Sagaydak I. V. et al. Surgical and combination treatment of patients with liver and regional lymph node metastases from colorectal cancer. Khirurgiya. Zhurnal im. N. I. Pirogova = Surgery. N. I. Pirogov Journal 2010;(7):49–54. (In Russ.)

5. Goyer P., Karoui M., Vigano L. et al. Single-center multidisciplinary management of patients with colorectal cancer and resectable synchronous liver metastases improves outcomes. Clin Res Hepatol Gastroenterol 2013;37(1):47–55. DOI: 10.1016/j.clinre.2012.03.003.

6. Jegatheeswaran S., Mason J. M., Hancock H. C., Siriwardena A. K. The liver-first approach to the management of colorectal cancer with synchronous hepatic metastases: a systematic review. JAMA Surg 2013;148:385–91.

7. Aliev V. A., Barsukov Yu. A., Mamedli Z. Z. et al. Comprehensive treatment of rectal cancer patients with synchronous distant metastases. Onkologicheskaya Koloproktologiya = Colorectal Oncology 2018;8(4):47–59. (In Russ.)].

8. Mentha G., Majno P. E., Andres A. et al. Neoadjuvant chemotherapy and resection of advanced synchronous liver metastases before treatment of the colorectal primary. Br J Surg 2006;94(3):872–8. DOI: 10.1002/bjs.5803.

9. Lam V. W., Laurence J. M., Pang T. et al. A systematic review of a liver-first approach in patients with colorectal cancer and synchronous colorectal liver metastases. HPB (Oxford) 2014;16(2):101–8. DOI: 10.1111 / hpb. 12083.

10. Verhoef C., van der Pool A. E., Nuyttens J. J. et al. The liver-first approach for patients with locally advanced rectal cancer and synchronous liver metastases. Dis Colon Rectum 2009;52(1):23–30. DOI: 10.1007/DCR.0b013e318197939a.

11. Brouquet A., Mortenson M. M., Vauthey J. N. et al. Surgical strategies for synchronous colorectal liver metastases in 156 consecutive patients: classic, combined or reverse strategy? J Am Coll Surg 2010;210(6):934–41. DOI: 10.1016/j.jamcollsurg.2010.02.039.

12. De Rosa A., Gomez D., Hossaini S. et al. Stage IV colorectal cancer: outcomes following the liver-first approach. J Surg Oncol 2013;108(7):444–9. DOI: 10.1002/jso.23429.

13. De Haas R. J., Adam R., Wicherts D. A. et al. Comparison of simultaneous or delayed liver surgery for limited synchronous colorectal metastases. Br J Surg 2010;97(8):1279–89. DOI: 10.1002/bjs.7106.

14. De Jong M. C., van Dam R. M., Maas M. et al. The liver-first approach for synchronous colorectal liver metastasis: a 5‑year single-centre experience. HPB (Oxford) 2011;13(10):745–52. DOI: 10.1111/j.1477-2574.2011.00372.x.

15. Valdimarsson V. T., Syk I., Lindell G. et al. Outcomes of liver-first strategy and classical strategy for synchronous colorectal liver metastases in Sweden. HPB (Oxford) 2018;20(5):441–7. DOI: 10.1016/j.hpb.2017.11.004.

16. Nierop P. M.H., Verseveld M., Galjart B. et al. The liver-first approach for locally advanced rectal cancer and synchronous liver metastases. Eur J Surg Oncol 2019;45(4):591–6. DOI: 10.1016/j.ejso.2018.12.007.