Timing of the liver resection for patients with synchronous metastases: practical and outcome considerations.

Hepatic resections have become the standard treatment for metastatic colorectal cancer and represent a durable treatment and the only potential curative option for patientswith disease isolated to the liver.Over the last decade, one of the most important advances has been the development and use of chemotherapeutic agents such as oxaliplatin and irinotecan that have been shown to convert patients with initially unresectable disease to resectable. Such use of downstaging chemotherapy, which should be distinguished from neoadjuvant chemotherapy, has provided an additional 10% of patients with liver metastases a chance at a potentially curative resection. On the basis of data derived from unresectable patients, some have advocated preoperative use of chemotherapy for patients with resectable disease, although no direct data from trials support such a neoadjuvant approach. The article by Capussotti et al. represents a growing body of retrospective data that suggests that patients with adverse clinical characteristics, such asmore than three liver metastases or T4 primary tumors, might benefit from neoadjuvant chemotherapy. Although the report is far from conclusive because the article only reports 10 patients with more than three tumors, data from papers such as this one will help shape treatment of patients with synchronous disease until more definitive data become available. When considering timing of liver resection for patients with synchronous liver metastases, patients should be segregated into two groups: patients with liver tumors discovered before colorectal resection, and patients with tumors discovered during the resection of the colorectal primary. In the first group, surgical treatment has greatly changed over the last decade. Before the 1990s, it was thought that simultaneous resection of the liver metastases along with the colorectal primary was fraught with prohibitive risks. Over the last decade, data have been published that such simultaneous resections are not only safe but advantageous in terms of patient outcome. In a report comparing simultaneous and staged resections, patients with simultaneous resections have half the hospital stay and complications with no increase in mortality. For patients going to the operating room with known synchronous disease, therefore, simultaneous resections should be performed if the patient is medically suitable, tumors are technically resectable, and the operation is within the comfort level and technical expertise of the surgeons. Even low rectal resections with pouch reconstructions can be safely performed at the same time as major liver resections. Contraindications to simultaneous resections are usually due to medical comorbidities. When patients present to the hepatic surgeon immediately after resection of the colorectal primary with liver metastases still in place, far less data exist about choosing the timing of resection. There are many theoretical reasons for considering neoadjuvant chemotherapy. Neoadjuvant chemotherapy allows assessment of effectiveness of the regimen while liver tumors are still in situ. It allows immediate treatment of possible microscopic disease. It allows time for additional disease to declare itself before definitive liver resection. It also allows time for the patient to recover from the recent colorectal surgery before a return to the operating room. Data are also evolving Received December 12, 2006; accepted January 17, 2007; published online: June 12, 2007. Address correspondence and reprint requests to: Yuman Fong, MD; E-mail: fongy@mskcc.org