Table 1 Summarized highlights of controversies surrounding the management of colorectal cancer liver metastases
From: Unresolved issues and controversies surrounding the management of colorectal cancer liver metastasis
Treatment strategy | Arguments in support of | Arguments against |
|---|---|---|
The simultaneous approach | No increase of morbidity and/or mortality in carefully selected patients | Considerable increase of morbidity and/or mortality |
| Â | Removal of all cancer in a single procedure; thereby lowering the risk of disease dissemination | No time-test approach to evaluate the biological behavior of metastasis and this may result in unnecessary liver resection in rapidly progressing disease |
| Â | Similar PFS and OS compared to those with staged resection | Higher recurrence rate and a negative impact on long-term outcome |
Pre-HR chemotherapy | Decreases the magnitude of resection | Delays liver resection and may result in a unresectable state in nonresponders |
| Â | Eradicates micrometastases | May lead to liver parenchyma damage and increased postoperative morbidity |
| Â | Increases R0 resection rates | No impact on PFS and OS |
| Â | Assesses responsiveness to specific chemotherapy, thus, identifying and selecting patients with favorable tumor biology. It improves PFS | Â |
Extensive resection for DLM | Response on imaging does not necessarily signify clinical or pathological response ( in up to 83% evidence of residual disease); so resect all initial sites if possible, despite disappearance on imaging | Hence, durable clinical response is as high as 62%, resect only residual macroscopic disease leaving the disappeared lesions in situ or alternatively, continue systemic chemotherapy alone |
The liver-first approach | It is the liver metastasis, rather than the primary tumor, that gives rise to systematic metastatic disease, so it should be addressed first | No, it is the primary tumor that produces systemic effects promoting angiogenesis in the liver, thus favoring the spread of metastatic disease |
| Â | It avoids the risk for progression of CRLM while the patient is treated for the primary tumor, especially if complications are encountered; thereby improving median survival and 3-year survival rates | Despite apparently similar treatment protocols in those few studies, the variations in survival rates of the liver-first approach are wide; so its comparison with the bowel-first approach or the combined strategy is problematic |
| Â | Option to give systemic chemotherapy as a first step early in the treatment course that may lead to an effective response in the primary tumor and avoids resection | Â |