title: OncoSurge: a strategy for improving resectability with curative intent in metastatic colorectal cancer.
abstract: OBJECTIVE
  Most patients with colorectal liver metastases present to general surgeons and oncologists without a specialist interest in their management. Since treatment strategy is frequently dependent on the response to earlier treatments, our aim was to create a therapeutic decision model identifying appropriate procedure sequences.
  
  
  METHODS
  We used the RAND Corporation/University of California, Los Angeles Appropriateness Method (RAM) assessing strategies of resection, local ablation and chemotherapy. After a comprehensive literature review, an expert panel rated appropriateness of each treatment option for a total of 1,872 ratings decisions in 252 cases. A decision model was constructed, consensus measured and results validated using 48 virtual cases, and 34 real cases with known outcomes.
  
  
  RESULTS
  Consensus was achieved with overall agreement rates of 93.4 to 99.1%. Absolute resection contraindications included unresectable extrahepatic disease, more than 70% liver involvement, liver failure, and being surgically unfit. Factors not influencing treatment strategy were age, primary tumor stage, timing of metastases detection, past blood transfusion, liver resection type, pre-resection carcinoembryonic antigen (CEA), and previous hepatectomy. Immediate resection was appropriate with adequate radiologically-defined resection margins and no portal adenopathy; other factors included presence of < or = 4 or > 4 metastases and unilobar or bilobar involvement. Resection was appropriate postchemotherapy, independent of tumor response in the case of < or = 4 metastases and unilobar liver involvement. Resection was appropriate only for > 4 metastases or bilobar liver involvement, after tumor shrinkage with chemotherapy. When possible, resection was preferred to local ablation.
  
  
  CONCLUSIONS
  The results were incorporated into a decision matrix, creating a computer program (OncoSurge). This model identifies individual patient resectability, recommending optimal treatment strategies. It may also be used for medical education.
authors.affiliation: Department of Surgery, Royal Liverpool University Hospital, Liverpool L7 8XP, UK. GRAEME.POSTON@aht.nwest.nhs.uk
authors.forename: Graeme J
authors.initials: GJ
authors.lastname: Poston
authors.forename: René
authors.initials: R
authors.lastname: Adam
authors.forename: Steven
authors.initials: S
authors.lastname: Alberts
authors.forename: Steven
authors.initials: S
authors.lastname: Curley
authors.forename: Juan
authors.initials: J
authors.lastname: Figueras
authors.forename: Daniel
authors.initials: D
authors.lastname: Haller
authors.forename: Francis
authors.initials: F
authors.lastname: Kunstlinger
authors.forename: Gilles
authors.initials: G
authors.lastname: Mentha
authors.forename: Bernard
authors.initials: B
authors.lastname: Nordlinger
authors.forename: Yehuda
authors.initials: Y
authors.lastname: Patt
authors.forename: John
authors.initials: J
authors.lastname: Primrose
authors.forename: Mark
authors.initials: M
authors.lastname: Roh
authors.forename: Philippe
authors.initials: P
authors.lastname: Rougier
authors.forename: Theo
authors.initials: T
authors.lastname: Ruers
authors.forename: Hans Joachim
authors.initials: HJ
authors.lastname: Schmoll
authors.forename: Carlos
authors.initials: C
authors.lastname: Valls
authors.forename: Nick Jean-Nicolas
authors.initials: NJ
authors.lastname: Vauthey
authors.forename: Marleen
authors.initials: M
authors.lastname: Cornelis
authors.forename: James P
authors.initials: JP
authors.lastname: Kahan
mesh_terms: D017024:Chemotherapy, Adjuvant; D015179:Colorectal Neoplasms / Q000532:radiotherapy* / Q000601:surgery*; D020000:Decision Support Systems, Clinical; D006801:Humans; D009361:Neoplasm Invasiveness; D009362:Neoplasm Metastasis; D015588:Observer Variation; D010347:Patient Care Planning