Surgical Strategies for Synchronous Colorectal Liver Metastases in 156 Consecutive Patients

Abstract

Background

An increasing number of patients with synchronous colorectal liver metastases (CLM) are candidates for resection. The optimal treatment sequence in these patients has not been defined.

Study Design

Data on 156 consecutive patients with synchronous resectable CLM and intact primary were reviewed. Surgical strategies were defined as combined (combined resection of primary and liver), classic (primary before liver), and reverse (liver before primary) after preoperative chemotherapy. Postoperative morbidity and mortality rates and overall survival were analyzed.

Results

One hundred forty-two patients (83%) had resection of all disease. Seventy-two patients underwent classic, 43 combined, and 27 reverse strategies. Median numbers of CLMs per patient were 1 in the combined, 3 in the classic, and 4 in the reverse strategy group (p = 0.01 classic vs reverse; p < 0.001 reverse vs combined). Postoperative mortality rates in the combined, classic, and reverse strategies were 5%, 3%, and 0%, respectively (p = NS), and postoperative cumulative morbidity rates were 47%, 51%, and 31%, respectively (p = NS). Three-year and 5-year overall survival rates were, respectively, 65% and 55% in the combined, 58% and 48% in the classic, and 79% and 39% in the reverse strategy (NS). On multivariate analysis, liver tumor size >3 cm (hazard ratio [HR] 2.72, 95% CI 1.52 to 4.88) and cumulative postoperative morbidity (HR 1.8, 95% CI 1.03 to 3.19) were independently associated with overall survival after surgery.

Conclusions

The classic, combined, or reverse surgical strategies in patients with synchronous presentation of CLM are associated with similar outcomes. The reverse strategy can be considered as an alternative option in patients with advanced CLM and an asymptomatic primary.

Nearly 25% of patients with colorectal cancer have colorectal liver metastases (CLM) diagnosed at the same time the primary tumor is diagnosed (synchronous presentation). Surgical resection of all tumor sites is the only treatment that enables prolonged survival, but the synchronous presentation of CLM has been associated with poor outcomes.1 Preoperative chemotherapy is widely used in these patients to provide early treatment of metastatic disease, to improve patient selection for surgical resection,2 and 3 and to decrease the recurrence rate after surgery.4

The traditional surgical strategy for patients with resectable synchronous CLM includes resection of the primary tumor followed by chemotherapy and then liver resection. A combined strategy, with simultaneous resection of the primary and liver, has been used to avoid delaying surgical resection of metastatic disease. The main limitation of this strategy is that it can be offered only in selected patients with synchronous disease,5, 6, 7, 8, 9 and 10 and it is associated with an increased risk of postoperative complications when major liver resection is combined with resection of the primary tumor.11, 12 and 13 Recently, a “reverse strategy,” in which preoperative chemotherapy is followed by resection of the CLM and then by resection of the colorectal primary at a second operation, has been proposed for patients with advanced synchronous CLM, and in particular, for patients in whom the primary is located in the rectum.14 The rationale for the reverse strategy is 2-fold: primary-related complications (such as bleeding, obstruction, or perforation) are rare in patients with stage IV colorectal cancer receiving combination chemotherapy15 and 16 and treatment of the metastatic disease is not delayed by local therapy for the primary tumor (surgery, and in the case of rectal cancer, radiotherapy or radiochemotherapy) or by complications of surgical treatment of the primary tumor. However, perioperative outcomes and oncologic results of patients treated using these different treatment strategies have not been compared.

The aim of this study was to compare indications, perioperative results, and oncologic outcomes in patients with a synchronous presentation of a colorectal primary tumor and CLM, according to these different surgical strategies. In addition, we sought to determine predictive factors of survival in patients with synchronous CLM.