"Liver-first" approach for synchronous colorectal liver metastases: is this a justifiable approach?
Department of Hepatobiliary and Pancreatic Surgery, E Floor, West Block, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK. Journal of Hepato-Biliary-Pancreatic Sciences
(Impact Factor: 2.99).
01/2013; 20(3). DOI: 10.1007/s00534-012-0583-x
To review the outcomes of patients with synchronous colorectal liver metastases (CRLM) treated by the "liver-first" approach.
Relevant articles were reviewed from the published literature using the Medline database. The search was performed using the keywords "colorectal cancer", "liver-first", "reverse strategy", "liver metastases", "liver resection" and "hepatectomy".
There have been four retrospective studies that have reported the outcomes of patients with synchronous CRLM following the reverse strategy. The number of patients included ranged from 16 to 27. One study included patients with advanced rectal cancer and synchronous liver metastases only. None of the studies defined resectability for the CRLM. Overall, the morbidity and mortality rates were low. The recurrence rate ranged from 25 to 70 %. One study did not report survival data, and the overall 5 year survival ranged from 31 to 41 %.
The "liver-first" approach may be beneficial to a selected group of patients with synchronous CRLM. Patient selection is likely to be determined by their response to down-staging chemotherapy with or without biological agents.
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- "De Rosa et alsummarized the indications for the liver-first approach or patients with a high or low liver disease burden with a locally advanced primary tumor. In fact, the ideal patient is likely to be someone who has advanced synchronous liver metastatic disease and rectal cancer. In our study, 12 patients had locally advanced liver metastases and 4 patients had initially unresectable liver tumors. "
Available from: Tamara Gall
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ABSTRACT: Up to a quarter of patients with rectal cancer have synchronous liver metastases at the time of diagnosis. This is a predictor of poor outcome. There are no standardized guidelines for treatment. We reviewed the outcomes of our patients with synchronous rectal liver metastases treated with a curative intent by neo-adjuvant chemotherapy with or without chemoradiotherapy followed by resection of primary tumor and then liver metastases.
Between 2004 and 2012, patients who presented with rectal cancer and synchronous liver metastasis were treated with curative intent with perioperative systemic chemotherapy as the 1(st) line of treatment. Responders to chemotherapy underwent resection of the primary tumor with or without preoperative chemoradiotherapy (CRT) followed by hepatic resection.
Fifty-three rectal cancer patients with 152 synchronous liver lesions were identified. After a median follow-up of 29.6 months, the median survival was 41.4 months. Overall survival (OS) was 59.0% at 3 years and 39.0% at 5 years.
Rectal resection before hepatic resection, combined with neoadjuvant chemotherapy is associated with promising clinical outcome. It allows down-staging of liver lesions and removal of the primary tumor before the progression of further micrometastases. Furthermore, patients that do not respond to chemotherapy can be identified and may avoid major surgical intervention. This article is protected by copyright. All rights reserved.
Available from: Silvio Nadalin
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The ALPSS procedure has been recently introduced as an alternative to PVE for liver volume augmentation in cases of planned right trisectionectomy with small future RLV and high risk of PHLF. We retrospectively analysed our single centre experience with 15 ALPPS procedures in order to better assess the limits and indications of the procedure.
Patients and methods:
The following volumetric parameters were evaluated: total liver volume (TLV), remnant liver volume (RLV), remnant liver volume to total liver volume ratio (RLV/TLV), remnant liver volume to body weight ratio (RLV/BWR) and median volume gain. The ALPPS procedure was usually considered when RLV/TLV < 25 % or RLV/BWR < 0.5. The ALPPS procedure consisted of phase 1 (in situ splitting of the liver), interphase (waiting for liver regeneration) and phase 2 (completion of right trisectionectomy). Postoperative complications were reported according to the Dindo-Clavien classification. Patient survival, late complications and tumour recurrence were analysed.
Between November 2010 and September 2013, we performed 15 ALPPS procedures in 10 patients with primary liver tumours (5 h-CCA, 4 i-CCA and 1 HCC) and in 5 with CRLM. The preoperative RLV/TLV ratio was 22.6 % (15.7 - 29.2) and the RLV/BWR 0.46 (0.22 - 0.66). After 10 days (range 8 - 16) the RLV/TLV ratio and RLV/BWR increased up to 36.3 % (30 - 59.2 %) and 0.67 (0.5 - 1.2) respectively, with a median volume gain of 87.2 % (23.8 - 161 %). The time interval between phases 1 and 2 was 13 days (9 - 18). An R0 status was reached in 13 patients and R1 in 2. The overall postoperative morbidity was 66.7 %. After phase 1, 8 patients experienced 19 complications and 7 none. After phase 2, 11 patients experienced 36 complications and 4 none. Four patients died postoperatively after 22 days (9 - 36 days) resulting in a postoperative mortality of 28.7 %. After a median follow-up of 17 months (1 - 33), 10 out of 15 patients are still alive (survival rate 66.6 %). Four patients (2 i-CCA, 1 CRLM, 1 HCC) developed tumour recurrences (2 intrahepatic and 2 extrahepatic). One patient with i-CCA died at POM 4 secondary to peritoneal carcinosis.
The actual high morbidity and mortality rates related to the ALPPS procedure should lead us to a more cautious selection of the candidates for this operation and restriction of the indications through an accurate work-up based on interdisciplinary cooperation among hepatologists, oncologists, radiologists and surgeons.
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