title: Assessing the management of hepatic colorectal cancer metastases: is treatment consistent in Ontario?
abstract: OBJECTIVE
  Advances in surgical techniques and chemotherapeutic options have expanded indications for surgery in patients with metastatic colorectal cancer. This study aimed to examine how hepatopancreatobiliary (HPB) surgeons approach the management of patients with hepatic colorectal cancer metastases (HCCM).
  
  
  METHODS
  A web-based survey utilizing 10 clinical scenarios was distributed by e-mail to 37 HPB surgeons in Ontario, Canada. The study region has a population of approximately 13 million people and a universal, single-payer health care system. Descriptive analyses were used to tabulate results.
  
  
  RESULTS
  Twenty-two (59%) surgeons responded to the survey. The majority (19/22, 86%) of respondents favoured neoadjuvant chemotherapy for patients with multiple synchronous and unilobar metastases; only nine of 22 (41%) respondents favoured neoadjuvant chemotherapy for patients with a single synchronous metastasis. In the setting of residual resectable disease following downstaging chemotherapy, 77% (17/22) of surgeons advocated hepatic resection with either radiofrequency ablation (RFA) or wedge resection of the 'ghost' lesions. Over 80% of surgeons would perform a liver and pulmonary resection in a patient with hepatic and multiple unilobar lung metastases. None would offer liver resection to patients with multiple retroperitoneal node involvement, although 55% (12/22) would do so if a single retroperitoneal node was involved. Preoperative portal vein embolization was favoured over RFA in patients with a small metastasis and inadequate functional hepatic volume.
  
  
  CONCLUSIONS
  Notable heterogeneity was observed among Ontario's HPB surgeons in approaches to HCCM.
authors.affiliation: Department of Surgery, Division of General Surgery, University of Toronto Cancer Care Ontario, Toronto, ON, Canada. lakho.sandhu@utoronto.ca
authors.forename: Lakhbir
authors.initials: L
authors.lastname: Sandhu
authors.forename: Adrian
authors.initials: A
authors.lastname: Fox
authors.forename: Cindy
authors.initials: C
authors.lastname: Nhan
authors.forename: Heidi
authors.initials: H
authors.lastname: Barnett
authors.forename: Robin S
authors.initials: RS
authors.lastname: McLeod
authors.forename: Steven
authors.initials: S
authors.lastname: Gallinger
authors.forename: Carol-Anne
authors.initials: CA
authors.lastname: Moulton
mesh_terms: D017115:Catheter Ablation / Q000706:statistics & numerical data*; D017024:Chemotherapy, Adjuvant; D015179:Colorectal Neoplasms / Q000453:epidemiology / Q000473:pathology*; D004621:Embolization, Therapeutic / Q000706:statistics & numerical data; D019983:Guideline Adherence / Q000706:statistics & numerical data; D019538:Health Care Surveys; D006498:Hepatectomy / Q000706:statistics & numerical data*; D006801:Humans; D020407:Internet; D008113:Liver Neoplasms / Q000453:epidemiology / Q000556:secondary* / Q000628:therapy*; D008175:Lung Neoplasms / Q000556:secondary / Q000628:therapy; D020360:Neoadjuvant Therapy / Q000706:statistics & numerical data; D009864:Ontario / Q000453:epidemiology; D011013:Pneumonectomy / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires; D016896:Treatment Outcome