‘Liver first’ approach first choice for metastatic rectal cancer

Using the "liver first" approach to treat locally advanced rectal cancer and synchronous liver metastases allows nearly three-quarters of patients to receive optimal neoadjuvant therapy and resection for both their primary tumor and metastases, researchers report.

The first long-term study of the strategy indicates that it could also prevent patients with unresectable liver metastases from undergoing unnecessary rectal surgery for their primary tumor.

The study, reported in Diseases of the Colon and Rectum, included 42 patients treated between May 2003 and March 2009.

Overall, 31 (74%) patients completed the "liver first" treatment protocol of neoadjuvant chemotherapy and liver metastases resection. This was followed by neoadjuvant (chemo)radiotherapy and surgery for the rectal cancer.

Cornelis Verhoef (Erasmus Medical Centre, Rotterdam, the Netherlands) and colleagues report that over a median follow-up of 39 months among patients who completed "liver first" treatment, the 1-, 3-, and 5-year progression-free survival was 74%, 45%, and 40%, respectively, while overall survival was 100%, 79%, and 67%, respectively.

Eleven patients had unresectable liver metastases, of whom one underwent surgery for the primary tumor for symptom relief; the remaining 10 patients were therefore spared rectal surgery. The authors add that the approach could also hasten the time to palliative chemotherapy in patients for whom curative surgery is not an option.

Delaying treatment of the primary rectal tumor did not allow it to progress beyond resection in any patient, the authors note.

Postponing the treatment of liver metastases until after that of the primary rectal tumor often leads to suboptimal therapy due to the long course of chemoradiotherapy required and can be further delayed by complications following surgery, the authors explain. However, performing surgery of the primary tumor and metastases simultaneously is hindered by increased morbidity and mortality.

Conversely, "the 'liver first' approach facilitates optimal treatment of the liver metastases and adequate neoadjuvant treatment for the primary tumor," say Verhoef and colleagues.

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