Metastatic liver disease at diagnosis affects about 1/5 of the patients. Optimal treatment for synchronous colorectal cancer (CRC) and liver metastases is a matter of debate. Who is suitable for synchronous surgery?
In the presence of an acute presentation of the primary CRC, treatment must focus on solving the acute complication (e.g., bleeding, perforation, occlusion). A different approach is mandatory in CRC patients with synchronous metastases but without an acute presentation of the primary tumor. If the metastatic disease affects more than one organ, systemic therapy is the first-line treatment. On the contrary, if metastases are limited to the liver, synchronous surgery for primary cancer resection plus liver resection is a possibility. However, how can we decide which patients are to be offered synchronous surgery rather than staged surgery?
Comparing staged surgery with synchronous surgery, the METASYNC study and the CoSMIC prospective study, found that complications and in-hospital length of stay are similar between the two approaches. Both overall and disease-free survival were better for synchronous in the METASYNC study. The problem is the low number of patients for taking these conclusions, and the unethical it is to perform two operations if with synchronous the outcomes are similar. In that setting, the scientific community must focus on finding valid criteria for deciding which patients are better suitable for synchronous resection. According to Siriwardena from Manchester, UK, there are some factors to be taken into consideration:
Patient co-morbidities
The extent of the primary tumor
The volume of liver metastatic disease
Location of lesions
Extent of hepatic resection required
Additionally, synchronous major hepatectomy with major left colonic or rectal resection should be avoided because of increased complications (2015 Consensus). The optimal and safe extent of liver resection in the setting of synchronous surgery is also a matter of debate. According to the author the IWATE score, designed to define the difficulty of the laparoscopic hepatic resection, can eventually be useful.
IWATE difficulty score:
Low level – 0 to 3
Intermediate level – 4 to 6
Advanced level – 6 to 9
Expert level – 10 to 12
In the end, according to Dr. Siriwardena, the small group of patients with liver-limited metastatic disease resectable without major hepatectomy and with a CRC without the need for a high-risk primary tumor resection are candidates for synchronous surgery.
In sum, is suitable for synchronous surgery who has:
1. ECOG < 2
2. Metastatic disease limited to the liver:
Unilobular
Resectable with minor hepatectomy
Away from major vessels
3. Non-cirrhotic parenchyma
4. Colonic cancer:
Resectable
≤ T3
≤ N1
Not adherent to adjacent structures
Additionally, in the future, genetics can be a future helpful tool to help doctors to tailor the surgical approach to a specific tumor in a particular patient. This is tailored medicine. This is the future.
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Dr. Carlos Eduardo Costa Almeida
General Surgeon