Systematic Reviews
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jun 14, 2015; 21(22): 7014-7021
Published online Jun 14, 2015. doi: 10.3748/wjg.v21.i22.7014
Treatment strategies for colorectal carcinoma with synchronous liver metastases: Which way to go?
Peter Ihnát, Petr Vávra, Pavel Zonča
Peter Ihnát, Petr Vávra, Pavel Zonča, Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Ostrava 70300, Czech Republic
Peter Ihnát, Petr Vávra, Pavel Zonča, Department of Surgery, University Hospital Ostrava, Ostrava 70852, Czech Republic
Author contributions: Ihnát P and Zonča P performed the literature search; Ihnát P and Vávra P wrote the paper; Zonča P revised the paper.
Conflict-of-interest: All authors declare that they have no personal, political or financial conflicts of interest.
Data sharing: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Peter Ihnát, MD, PhD, MBA, Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, Ostrava 70300, Czech Republic. peterihnat@yahoo.com
Telephone: + 42-597-375701 Fax: + 42-597-375054
Received: December 28, 2014
Peer-review started: December 29, 2014
First decision: January 22, 2015
Revised: February 6, 2015
Accepted: April 3, 2015
Article in press: April 3, 2015
Published online: June 14, 2015
Processing time: 172 Days and 0.7 Hours
Abstract

AIM: To offer an up-to-date review of all available treatment strategies for patients with synchronous colorectal liver metastases (CLM).

METHODS: A comprehensive literature search was performed to identify articles related to the management of patients with synchronous CLM. A search of the electronic databases PubMed, MEDLINE, and Google Scholar was conducted in September 2014. The following search terms were used: synchronous colorectal liver metastases, surgery, stage IV colorectal cancer, liver-first approach, and up-front hepatectomy. These terms were employed in various combinations to maximize the search. Only articles written in English were included. Particular attention was devoted to studies and review articles that were published within the last six years (2009-2014). Additional searches of the cited references from primary articles were performed to further improve the review. The full texts of all relevant articles were accessed by two independent reviewers.

RESULTS: Poor long-term outcomes of patients with synchronous CLM managed by a traditional treatment strategy have led to questions about the timing and sequence of possible therapeutic interventions. Thus, alternative paradigms called reverse strategies have been proposed. Presently, there are four treatment strategies available: (1) primary first approach (or traditional approach) comprises resection of the primary colorectal tumor followed by chemotherapy; subsequent liver resection is performed 3-6 mo after colorectal resection (provided that CLM are still resectable); (2) simultaneous resection of the primary colorectal tumor and CLM during a single operation presents intriguing options for a highly select group of patients, which can be associated with significant postoperative morbidity; (3) liver-first (or chemotherapy-first) approach comprises preoperative chemotherapy (3-6 cycles) followed by liver resection, adjuvant chemotherapy, and resection of the primary colorectal tumor (it is best suited for patients with asymptomatic primary tumors and initially unresectable or marginally resectable CLM); and (4) up-front hepatectomy (or “true” liver-first approach) includes liver resection followed by adjuvant chemotherapy, colorectal resection, and adjuvant chemotherapy (strategy can be offered to patients with asymptomatic primary tumors and initially resectable CLM).

CONCLUSION: None of the aforementioned strategies appears inferior. It is necessary to establish individual treatment plans in multidisciplinary team meetings through careful appraisal of all strategies.

Keywords: Colorectal cancer; Liver-first approach; Reverse strategy; Simultaneous resection; Up-front hepatectomy

Core tip: There are four treatment strategies available for synchronous liver metastases of colorectal carcinoma (CLM): (1) primary first approach comprises resection of the primary colorectal tumor followed by chemotherapy and liver resection; (2) simultaneous resection of liver and colorectal primary tumor; (3) liver-first (or chemotherapy-first) approach comprises preoperative chemotherapy, liver resection, adjuvant chemotherapy, and resection of the primary colorectal tumor (best for asymptomatic primary tumors and initially unresectable or marginally resectable CLM); and (4) up-front hepatectomy (or “true” liver-first approach) includes liver resection followed by adjuvant chemotherapy and colorectal resection (for asymptomatic primary tumors and initially resectable CLM).