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World J Gastrointest Surg. Sep 27, 2022; 14(9): 877-886
Published online Sep 27, 2022. doi: 10.4240/wjgs.v14.i9.877
Oncologic aspects of the decision-making process for surgical approach for colorectal liver metastases progressing during chemotherapy
Raphael L C Araujo, Camila G C Y Carvalho, Carlos T Maeda, Jean Michel Milani, Diogo G Bugano, Pedro Henrique Z de Moraes, Marcelo M Linhares
Raphael L C Araujo, Carlos T Maeda, Jean Michel Milani, Marcelo M Linhares, Department of Surgery, Universidade Federal de São Paulo, São Paulo 04024-002, Brazil
Raphael L C Araujo, Diogo G Bugano, Pedro Henrique Z de Moraes, Department of Oncology, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
Raphael L C Araujo, Camila G C Y Carvalho, Department of Surgical Oncology, Hospital e Maternidade Brasil Rede D'Or São Luiz, Santo André 09030-590, São Paulo, Brazil
Author contributions: Araujo RLC contributed to the study conception, data preparation, data interpretation, and writing; Carvalho CGCY contributed to the data preparation, data interpretation, and writing; Maeda CT, Milani JM contributed to the data acquisition, data preparation, and writing; Bugano DG, de Moraes PHZ and Linhares MM contributed to the data interpretation, and critical writing of the paper.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (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: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Raphael L C Araujo, MD, PhD, Adjunct Professor, Surgical Oncologist, Department of Surgery, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 Second Floor Vila Clementino, São Paulo 04024-002, Brazil. raphael.l.c.araujo@gmail.com
Received: May 2, 2022
Peer-review started: May 2, 2022
First decision: July 14, 2022
Revised: July 27, 2022
Accepted: August 15, 2022
Article in press: August 15, 2022
Published online: September 27, 2022
Abstract

Colorectal cancer represents the third most diagnosed malignancy in the world. The liver is the main site of metastatic disease, affected in 30% of patients with newly diagnosed disease. Complete resection is considered the only potentially curative treatment for colorectal liver metastasis (CRLM), with a 5-year survival rate ranging from 35% to 58%. However, up to 80% of patients have initially unresectable disease, due to extrahepatic disease or bilobar multiple liver nodules. The availability of increasingly effective systemic chemotherapy has contributed to converting patients with initially unresectable liver metastases to resectable disease, improving long-term outcomes, and accessing tumor biology. In recent years, response to preoperative systemic chemotherapy before liver resection has been established as a major prognostic factor. Some studies have demonstrated that patients with regression of hepatic metastases while on chemotherapy have improved outcomes when compared to patients with stabilization or progression of the disease. Even if disease progression during chemotherapy represents an independent negative prognostic factor, some patients may still benefit from surgery, given the role of this modality as the main treatment with curative intent for patients with CRLM. In selected cases, based on size, the number of lesions, and tumor markers, surgery may be offered despite the less favorable prognosis and as an option for non-chemo responders.

Keywords: Colorectal liver metastases, Oncology, Disease progression, Surgery, Liver resection, Hepatectomy

Core Tip: The mainstream curative-intent treatment of colorectal liver metastasis (CRLM) is complete surgical resection. Increasingly effective systemic chemotherapy has helped to improve long-term outcomes, downstaging of CRLM, and patient selection for surgery. Disease progression during chemotherapy represents an independent negative prognostic factor. However, in selected cases, based on size, the number of lesions, and tumor markers, surgery may be offered as an option for non-chemo responders. This minireview article aims to explore this open question in the literature using both evidence and meaningful thoughts on this controversial and challenging topic.