title: 'Liver first' approach in the treatment of colorectal cancer with synchronous liver metastases.
abstract: BACKGROUND
  In patients with synchronous colorectal liver metastases, an approach reversing the traditional therapeutic order - i.e. starting with chemotherapy first, doing the liver surgery second, and performing the colorectal surgery last - is theoretically appealing as it avoids the risk of metastatic progression during treatment of the primary tumor. The present series updates on a previously reported pilot experience.
  
  
  METHODS
  35 patients with advanced synchronous colorectal metastases and nonobstructive colorectal tumors were treated with the reversed approach. Data were collected in a prospective database.
  
  
  RESULTS
  The median number of metastases was 6, the median size of the largest metastasis was 6 cm. Five patients could not complete the program (one death from sepsis during chemotherapy, 3 cases of progressive disease under treatment, and one case of vanishing liver metastases). The remaining 30 patients responded and underwent R0 liver resections with no major complications. One patient needed a Hartmann's procedure for obstruction after a first-step hepatectomy, and 1 patient had a rectal anastomotic leak. Median survival was 44 months. Overall survival rates of the 30 patients who completed the program at 1, 2, 3, 4 and 5 years were 100, 89, 60, 44 and 31%.
  
  
  CONCLUSIONS
  The reverse approach appeared feasible and safe, with operability and survival rates better than expected for patients with similar severity. Potential problems, in particular regrowth of vanishing metastases and primary tumors, chemotherapy-associated liver damage, and large bowel obstruction, can be minimized by careful multidisciplinary selection, planning and execution.
authors.affiliation: Department of Surgery, University Hospitals of Geneva, Geneva, Switzerland. gilles.mentha@hcuge.ch
authors.forename: Gilles
authors.initials: G
authors.lastname: Mentha
authors.forename: Arnaud D
authors.initials: AD
authors.lastname: Roth
authors.forename: Sylvain
authors.initials: S
authors.lastname: Terraz
authors.forename: Emiliano
authors.initials: E
authors.lastname: Giostra
authors.forename: Pascal
authors.initials: P
authors.lastname: Gervaz
authors.forename: Axel
authors.initials: A
authors.lastname: Andres
authors.forename: Philippe
authors.initials: P
authors.lastname: Morel
authors.forename: Laura
authors.initials: L
authors.lastname: Rubbia-Brandt
authors.forename: Pietro E
authors.initials: PE
authors.lastname: Majno
mesh_terms: D000328:Adult; D000368:Aged; D017024:Chemotherapy, Adjuvant; D003082:Colectomy / Q000379:methods; D015179:Colorectal Neoplasms / Q000401:mortality / Q000473:pathology* / Q000628:therapy*; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000556:secondary* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009367:Neoplasm Staging; D010865:Pilot Projects; D011446:Prospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome