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. 2021 Dec;28(13):8198-8208.
doi: 10.1245/s10434-021-10220-w. Epub 2021 Jul 1.

Liver-First Approach for Synchronous Colorectal Metastases: Analysis of 7360 Patients from the LiverMetSurvey Registry

Felice Giuliante  1 , Luca Viganò  2 , Agostino M De Rose  3 , Darius F Mirza  4 , Réal Lapointe  5 , Gernot Kaiser  6 , Eduardo Barroso  7 , Alessandro Ferrero  8 , Helena Isoniemi  9 , Santiago Lopez-Ben  10 , Irinel Popescu  11 , Jean-Francois Ouellet  12 , Catherine Hubert  13 , Jean-Marc Regimbeau  14 , Jen-Kou Lin  15 , Oleg G Skipenko  16 , Francesco Ardito  3 , René Adam  17
Affiliations

Liver-First Approach for Synchronous Colorectal Metastases: Analysis of 7360 Patients from the LiverMetSurvey Registry

Felice Giuliante et al. Ann Surg Oncol. 2021 Dec.

Abstract

Background: The liver-first approach in patients with synchronous colorectal liver metastases (CRLM) has gained wide consensus but its role is still to be clarified. We aimed to elucidate the outcome of the liver-first approach and to identify patients who benefit at most from this approach.

Methods: Patients with synchronous CRLM included in the LiverMetSurvey registry between 2000 and 2017 were considered. Three strategies were analyzed, i.e. liver-first approach, colorectal resection followed by liver resection (primary-first), and simultaneous resection, and three groups of patients were analyzed, i.e. solitary metastasis, multiple unilobar CRLM, and multiple bilobar CRLM. In each group, patients from the three strategy groups were matched by propensity score analysis.

Results: Overall, 7360 patients were analyzed: 4415 primary-first, 552 liver-first, and 2393 simultaneous resections. Compared with the other groups, the liver-first group had more rectal tumors (58.0% vs. 31.2%) and higher hepatic tumor burden (more than three CRLMs: 34.8% vs. 24.0%; size > 50 mm: 35.6% vs. 22.8%; p < 0.001). In patients with solitary and multiple unilobar CRLM, survival was similar regardless of treatment strategy, whereas in patients with multiple bilobar metastases, the liver-first approach was an independent positive prognostic factor, both in unmatched patients (3-year survival 65.9% vs. primary-first 60.4%: hazard ratio [HR] 1.321, p = 0.031; vs. simultaneous resections 54.4%: HR 1.624, p < 0.001) and after propensity score matching (vs. primary-first: HR 1.667, p = 0.017; vs. simultaneous resections: HR 2.278, p = 0.003).

Conclusion: In patients with synchronous CRLM, the surgical strategy should be decided according to the hepatic tumor burden. In the presence of multiple bilobar CRLM, the liver-first approach is associated with longer survival than the alternative approaches and should be evaluated as standard.

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Figures

Fig. 1
Fig. 1
Overall survival in patients with solitary metastasis according to the treatment strategy. a Whole population, b liver-first group versus primary-first group after PSM, c liver-first group versus simultaneous group after PSM. PSM propensity score matching
Fig. 2
Fig. 2
Overall survival in patients with multiple unilobar metastases according to the treatment strategy. a Whole population, b liver-first group versus primary-first group after PSM, c liver-first group versus simultaneous group after PSM. PSM propensity score matching
Fig. 3
Fig. 3
Overall survival in patients with multiple bilobar metastases according to the treatment strategy. a Whole population, b liver-first group versus primary-first group after PSM, c liver-first group verss simultaneous group after PSM. PSM propensity score matching
Fig. 4
Fig. 4
Treatment strategy of synchronous colorectal liver metastases according to hepatic tumor burden and scheduled hepatectomy. CRLM colorectal liver metastases
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Comment in

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