Is a liver-first approach advised in metastatic colorectal cancer?

Liver-First Approach in Metastatic Colorectal Cancer

For patients with metastatic colorectal cancer with synchronous liver metastases, a liver-first approach is advised in cases of asymptomatic primary tumors with extensive liver metastases, or in rectal cancer with limited or advanced synchronous liver metastases requiring downstaging therapy to make curative liver resection possible. 1

Rationale for Liver-First Approach

• The liver-first strategy focuses on controlling synchronous hepatic metastases first, which can optimize potentially curative hepatic resection and long-term survival 1
• Patients with synchronous colorectal liver metastases generally have lower survival than those with metachronous metastases, making the treatment sequence critical 1, 2
• This approach helps avoid complications from primary tumor surgery that might delay or prevent systemic therapy and subsequent liver resection 1

Patient Selection for Liver-First Approach

• Appropriate candidates include:

  • Patients with asymptomatic colorectal primary tumors but extensive liver metastases 1
  • Patients with rectal cancer in early stage with limited or advanced synchronous liver metastases 1
  • Patients requiring downstaging therapy to make curative liver resection possible 1

• Contraindications to liver-first approach:

  • Symptomatic primary lesions (hemorrhage or obstruction) should have primary disease addressed first 3
  • Patients with disease progression during systemic chemotherapy should not undergo hepatic resection 1

Alternative Approaches

Classical Approach (Primary First)

• Traditionally, the primary tumor is resected first, followed by chemotherapy and then liver metastases resection 2
• This approach may be preferred when the primary tumor is symptomatic 3

Simultaneous Resection

• Combined resection of primary tumor and liver metastases can be considered for accessible small metastases 3
• Should be performed only in high-volume centers with appropriate experience in liver resectional surgery 3
• Not advisable to pursue synchronous primary resection with complex liver procedures like ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy) due to increased morbidity and mortality 3

Role of Systemic Therapy

• Initial systemic chemotherapy is recommended for patients with colorectal tumor stage IV, as these patients have systemic disease 1
• Neoadjuvant chemotherapy can downsize initially unresectable liver metastases, making them amenable to curative resection 3
• Response to chemotherapy may serve as a surrogate marker for subsequent liver resection rates with curative intent 3
• Patients showing progression during chemotherapy have poor prognosis despite resection and should not undergo hepatic resection 1

Surgical Considerations

• The goal of surgery is complete (R0) resection within safety limits regarding quantity and quality of the remaining liver 2
• Evaluation process should focus not on what is to be removed but rather on what will remain 2
• For bilobar disease, staged procedures combining neoadjuvant chemotherapy, limited resections, portal vein embolization, and major resection may be considered 2
• Five-year survival rates after complete resection of liver metastases can reach up to 40% 4

Decision Making Process

• All treatment decisions should be made by a multidisciplinary team including colorectal surgeons, hepatobiliary surgeons, medical oncologists, and radiologists 3, 1
• Patient selection should be individualized based on disease extent, patient factors, and institutional expertise 1
• The presence of extrahepatic disease is no longer an absolute contraindication for surgery if R0 resection can be achieved 2

Follow-up After Liver Resection

• Follow-up should continue for five years according to local protocol using CT chest, liver imaging, and CEA monitoring 3
• Any abnormality should prompt referral back to the liver center for consideration of re-resection or ablation 3
• Re-resection can be considered for recurrent liver metastases with similar outcomes to initial hepatectomy 3

The liver-first approach represents an important strategic option in the multidisciplinary management of metastatic colorectal cancer, particularly for patients with asymptomatic primaries and significant liver disease burden requiring downstaging.