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. 2023 Sep;30(9):5376-5385.
doi: 10.1245/s10434-023-13510-7. Epub 2023 Apr 28.

Intersurgeon Variability in Local Treatment Planning for Patients with Initially Unresectable Colorectal Cancer Liver Metastases: Analysis of the Liver Expert Panel of the Dutch Colorectal Cancer Group

Marinde J G Bond  1 , Babette I Kuiper  2   3 , Karen Bolhuis  4   5 , Aysun Komurcu  6 , Martinus J van Amerongen  7 , Thiery Chapelle  8 , Cornelis H C Dejong  9   10 , Marc R W Engelbrecht  11 , Michael F Gerhards  12 , Dirk J Grünhagen  13 , Thomas van Gulik  2 , John J Hermans  14 , Koert P de Jong  15 , Joost M Klaase  15 , Niels F M Kok  16 , Wouter K G Leclercq  17 , Mike S L Liem  18 , Krijn P van Lienden  19 , I Quintus Molenaar  20 , Ulf P Neumann  9   10 , Gijs A Patijn  21 , Arjen M Rijken  22 , Theo M Ruers  16 , Cornelis Verhoef  13 , Johannes H W de Wilt  23 , Geert Kazemier  2   3 , Anne M May  1 , Cornelis J A Punt  1   4 , Rutger-Jan Swijnenburg  24   25
Affiliations

Intersurgeon Variability in Local Treatment Planning for Patients with Initially Unresectable Colorectal Cancer Liver Metastases: Analysis of the Liver Expert Panel of the Dutch Colorectal Cancer Group

Marinde J G Bond et al. Ann Surg Oncol. 2023 Sep.

Abstract

Background: Consensus on resectability criteria for colorectal cancer liver metastases (CRLM) is lacking, resulting in differences in therapeutic strategies. This study evaluated variability of resectability assessments and local treatment plans for patients with initially unresectable CRLM by the liver expert panel from the randomised phase III CAIRO5 study.

Methods: The liver panel, comprising surgeons and radiologists, evaluated resectability by predefined criteria at baseline and 2-monthly thereafter. If surgeons judged CRLM as resectable, detailed local treatment plans were provided. The panel chair determined the conclusion of resectability status and local treatment advice, and forwarded it to local surgeons.

Results: A total of 1149 panel evaluations of 496 patients were included. Intersurgeon disagreement was observed in 50% of evaluations and was lower at baseline than follow-up (36% vs. 60%, p < 0.001). Among surgeons in general, votes for resectable CRLM at baseline and follow-up ranged between 0-12% and 27-62%, and for permanently unresectable CRLM between 3-40% and 6-47%, respectively. Surgeons proposed different local treatment plans in 77% of patients. The most pronounced intersurgeon differences concerned the advice to proceed with hemihepatectomy versus parenchymal-preserving approaches. Eighty-four percent of patients judged by the panel as having resectable CRLM indeed received local treatment. Local surgeons followed the technical plan proposed by the panel in 40% of patients.

Conclusion: Considerable variability exists among expert liver surgeons in assessing resectability and local treatment planning of initially unresectable CRLM. This stresses the value of panel-based decisions, and the need for consensus guidelines on resectability criteria and technical approach to prevent unwarranted variability in clinical practice.

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Conflict of interest statement

C.J.A.P. has an advisory role for Nordic Pharma. K.B. reports having an advisory role for Amgen. J.H.W.d.W. has an unrestricted grant from Medtronic. U.P.N. reports presentations or contribution to research for Roche, Astra Zeneca, Merck AG, Sanofi, Grünenthal, Johnson & Johnson and Astellas. This funding is not related to the current research. The remaining authors declare no potential conflicts of interest.

Figures

Fig. 1
Fig. 1
Resectability and local treatment plans. The definition of the majority depended on the number of surgeons who voted for resectable CRLM. Two surgeons: majority absent. Three surgeons: at least two similar plans. Four surgeons: at least three similar plans
Fig. 2
Fig. 2
Assessment of resectability by individual surgeons at baseline. In total there were 1836 resectability assessments by panel surgeons at baseline, of which 1835 are represented in this figure (one surgeon with one evaluation was excluded)
Fig. 3
Fig. 3
Assessment of resectability by individual surgeons at follow-up. In total there were 2728 resectability assessments by panel surgeons at follow-up
Fig. 4
Fig. 4
Local treatment plans proposed by individual surgeons in patients with resectable CRLM. In total there were 972 proposed plans, of which 12 plans by two surgeons were excluded because they evaluated < 10 cases. Ext = extended; HH = hemihepatectomy; local resection = wedge resection and/or segmental resection
See this image and copyright information in PMC

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References

    1. Lam VWT, Spiro C, Laurence JM, et al. A systematic review of clinical response and survival outcomes of downsizing systemic chemotherapy and rescue liver surgery in patients with initially unresectable colorectal liver metastases. Ann Surg Oncol. 2012;19(4):1292–1301. doi: 10.1245/s10434-011-2061-0. - DOI - PubMed
    1. Bolhuis K, Kos M, van Oijen MGH, Swijnenburg RJ, Punt CJA. Conversion strategies with chemotherapy plus targeted agents for colorectal cancer liver-only metastases: a systematic review. Eur J Cancer. 2020;141:225–238. doi: 10.1016/j.ejca.2020.09.037. - DOI - PubMed
    1. Ignatavicius P, Oberkofler CE, Chapman WC, et al. Choices of therapeutic strategies for colorectal liver metastases among expert liver surgeons: A throw of the dice? Ann Surg. 2020;272(5):715–722. doi: 10.1097/SLA.0000000000004331. - DOI - PubMed
    1. Young AL, Adair R, Culverwell A, et al. Variation in referral practice for patients with colorectal cancer liver metastases. Br J Surg. 2013;100(12):1627–1632. doi: 10.1002/bjs.9285. - DOI - PubMed
    1. Ksienski D, Woods R, Speers C, Kennecke H. Patterns of referral and resection among patients with liver-only metastatic colorectal cancer (MCRC) Ann Surg Oncol. 2010;17(12):3085–3093. doi: 10.1245/s10434-010-1304-9. - DOI - PubMed