Liver first approach as a therapeutic option for stage IV colorectal cancer: A 6-year single-centre experience

Aims: Initial treatment of liver metastases (LM) from colorectal cancer followed by the resection of the colorectal primary is known as the «liver-first approach». This therapeutic option is especially beneficial in patients with rectal tumors that require preoperative chemo-radiotherapy and/or complex pelvic surgery, since the treatment of the colorectal primary can delay the surgery of LM, facilitating their progression beyond resectability. The aim of our study was to investigate the outcome of the liver-first approach in patients with synchronous liver metastases treated in our centre. Methods: Patients managed under the liver-first approach between May 2008 and May 2014 were retrospectively analysed. Results: Eighty-one patients were operated on for synchronous colorectal cancer liver metastases (CRLM) in our centre, of whom 16 (19,8%) were managed under the liver-first approach. Fifteen patients (93,7%) completed both stages (initial hepatectomy and resection of the primary), 1 of them died in the postoperative period of a 2-stage hepatectomy (Associating Liver Partition and Portal vein Ligation for Staged hepatectomy, ALPPS). The location of the primary tumor was: rectum in 12 patients and sigmoid colon in 4. All patients received neoadjuvant chemotherapy. Eleven of the 16 patients had bilateral hepatic involvement. A mayor hepatectomy was performed in thirteen (81,3%) patients, and radiofrequency ablation was used in 6 patients. Based on the Clavien-Dindo classification, there were 3 grade II complications, 4 grade III and 1 grade IV complication. The recurrence rate was 56,2%. The 3-year survival was 71,3%, with a median follow-up of 23 months. Conclusions: The liver-first approach has emerged as a viable therapeutic strategy for CRLM, being especially beneficial in patients in which LM can be a limiting factor for treatment with curative intent. In our centre, the liver-first approach is used in selected patients, always in a multidisciplinary context, with comparable results to those previously reported.