Defining the optimal therapy sequence in synchronous resectable liver metastases from colorectal cancer: a decision analysis approach.
BACKGROUND
Approximately 5%-20% of colorectal cancer (CRC) patients present with synchronous potentially resectable liver metastatic disease. Preclinical and clinical studies suggest a benefit of the 'liver first' approach, i.e. resection of the liver metastasis followed by resection of the primary tumour. A formal decision analysis may support a rational choice between several therapy options.


METHODS
Survival and morbidity data were retrieved from relevant clinical studies identified by a Web of Science search. Data were entered into decision analysis software (TreeAge Pro 2009, Williamstown, MA, USA). Transition probabilities including the risk of death from complications or disease progression associated with individual therapy options were entered into the model. Sensitivity analysis was performed to evaluate the model's validity under a variety of assumptions.


RESULTS
The result of the decision analysis confirms the superiority of the 'liver first' approach. Sensitivity analysis demonstrated that this assumption is valid on condition that the mortality associated with the hepatectomy first is < 4.5%, and that the mortality of colectomy performed after hepatectomy is < 3.2%.


CONCLUSIONS
The results of this decision analysis suggest that, in patients with synchronous resectable colorectal liver metastases, the 'liver first' approach is to be preferred. Randomized trials will be needed to confirm the results of this simulation based outcome.
Van Dessel
E
E
UZ Gent, Department of Surgery, Belgium. Els.vandessel@ugent.be
Fierens
K
K
Pattyn
P
P
Van Nieuwenhove
Y
Y
Berrevoet
F
F
Troisi
R
R
Ceelen
W
W
D003082:Colectomy / Q000379:methods*; D015179:Colorectal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D003658:Decision Making, Computer-Assisted; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D015996:Survival Rate