Leading article Colorectal cancer with synchronous liver metastases R. Adam Centre H´ epato-Biliaire, Paul Brousse Hospital, Assistance Publique –H ˆ opitaux de Paris, Universit´ e Paris-Sud 11, Villejuif, Paris, France (e-mail: rene.adam@pbr.aphp.fr) Published online in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.5764 At the time of diagnosis, 15–20 per cent of patients with colorec- tal cancer have synchronous liver metastases. Synchronous metastases may confer a poorer prognosis than metachronous metastases but this is uncertain 1 . In any event, effective treatment requires an overall strategy that addresses both the primary and the metastatic disease, paying atten- tion to optimal timing between surgi- cal and medical interventions. Mod- ern chemotherapy and stents for sub- occlusive tumours add further com- plexity. Strategy is generally influ- enced by two criteria: the symptom pattern of the primary tumour and the potential resectability of the liver metastases. Certain clinical presenta- tions are clear indications for immedi- ate surgical treatment of the primary tumour – notably occlusion, perfora- tion, bleeding and locally advanced disease. Patients are usually elderly and ill, and the increased operative risks render a major one-stage proce- dure (resection of both primary and hepatic lesions) unwise. This con- trasts with an asymptomatic primary tumour when management depends on the resectability of the liver metas- tases. In the asymptomatic setting, resec- tion of synchronous liver metastases along with the primary lesion is war- ranted simply because this is the sole strategy with curative potential – a 5- year survival of 25 to 38 per cent 2–4 . But should patients be treated ini- tially by operation or by neoadjuvant chemotherapy? No randomized trial is yet available to answer this ques- tion directly, but a retrospective study examining outcomes in patients with more than four liver metastases sug- gests that neoadjuvant chemotherapy plus surgery offers a better survival than immediate operation 5 . A similar trend occurs in the LiverMetSurvey analysis of an international registry of patients operated for hepatic colorec- tal metastases. This shows that, while neoadjuvant chemotherapy does not improve outcome after resection of a single liver metastasis, it is associated with improved survival when more than four metastases are removed. While it seems logical that multin- odular disease is likely to respond well to neoadjuvant chemotherapy because of a greater probability of unde- tected small metastases, this hypoth- esis deserves further scrutiny. In cur- rent practice, immediate surgery is the standard treatment for patients with few metastases, but neoadjuvant chemotherapy followed by surgery may be appropriate for those with multinodular disease. Combining hepatic with colorectal resection has the appeal of a sin- gle operation, which may be bene- ficial in terms of quality of life and cost. Contraindications are based on the risk of morbidity and mortal- ity, and include emergency indica- tion for operation on the primary tumour, a locally advanced colorec- tal tumour, and the need for a major hepatectomy (involving three or more segments). Otherwise, com- bined resections seem appropriate 2–4 . An alternative is colorectal resec- tion with hepatic resection delayed for 2–3 months, with chemotherapy in between. It has been argued that combined resection may decrease the risk of metastatic spread by avoiding the repetitive immunosuppression of major surgery and by facilitating the efficacy of chemotherapy 6 . Delayed hepatic resection, however, is the pre- ferred approach of those who believe that a period of observation allows better selection of those likely to ben- efit from liver surgery 7 . The choice may depend on the experience of the surgical team. Any decision must also consider the extent of the hepatectomy. Although there is no increase in operative mortality for one-stage procedures involving limited hepatectomies (one or two segments), a large study suggests this may not be so when a hepatectomy of three or more segments is required 1 . Consistent with these data, most initial work with one-stage procedures has restricted this strategy to patients with right colon cancer and a limited number of liver metastases 2–4 . Unfortunately, such restriction allows less than half of the eligible patients with synchronous metastases to be treated with a single operation. Such a narrow policy has recently been challenged – experienced groups are now reporting similar mortalities with one-stage and two-stage strategies that include major hepatectomies 8 . These reports also indicate that the one-stage approach has the benefit of a shorter hospital stay 9 . Long-term survival must also be considered. Most advocates of a one- stage approach report survival results similar to those obtained with delayed hepatectomy 2,3 . However, as one- stage procedures have usually been offered only to patients with limited metastatic disease, true equivalency Copyright  2007 British Journal of Surgery Society Ltd British Journal of Surgery 2007; 94: 129–131 Published by John Wiley & Sons Ltd Downloaded from https://academic.oup.com/bjs/article/94/2/129/6142705 by guest on 12 August 2022