title: A systematic review of a liver-first approach in patients with colorectal cancer and synchronous colorectal liver metastases.
abstract: BACKGROUND
  Since the liver metastases rather than the colorectal cancer itself is the main determinant of patient's survival, the 'Liver-First Approach (LFA)' with upfront chemotherapy followed by a hepatic resection of colorectal liver metastases (CLM) and finally a colorectal cancer resection was proposed. The aim of this review was to analyse the evidence for LFA in patients with colorectal cancer and synchronous CLM.
  
  
  METHODS
  A literature search of databases (MEDLINE and EMBASE) to identify published studies of LFA in patients with colorectal cancer and synchronous CLM was undertaken focussing on the peri-operative regimens of LFA and survival outcomes.
  
  
  RESULTS
  Three observational studies and one retrospective cohort study were included for review. A total of 121 patients with colorectal cancer and synchronous CLM were selected for LFA. Pre-operative chemotherapy was used in 99% of patients. One hundred and twelve of the initial 121 patients (93%) underwent a hepatic resection of CLM. In total, 60% had a major liver resection and the R0 resection rate was 93%. Post-operative morbidity and mortality after the hepatic resection were 20% and 1%, respectively. Ultimately, 89 of the initial 121 (74%) patients underwent a colorectal cancer resection. Post-operative morbidity and mortality after a colorectal resection were 50% and 6%, respectively. The median overall survival was 40 months (range 19-50) with a recurrence rate of 52%.
  
  
  CONCLUSIONS
  Current evidence suggests that LFA is safe and feasible in selected patients with colorectal cancer and synchronous CLM. Future studies are required to further define patient selection criteria for LFA and the exact role of LFA in the management of synchronous CLM.
authors.affiliation: Department of Surgery, Westmead Hospital, University of Sydney, Sydney, NSW, Australia; Discipline of Surgery, Sydney Medical School, Sydney, NSW, Australia.
authors.forename: Vincent W T
authors.initials: VW
authors.lastname: Lam
authors.forename: Jerome M
authors.initials: JM
authors.lastname: Laurence
authors.forename: Tony
authors.initials: T
authors.lastname: Pang
authors.forename: Emma
authors.initials: E
authors.lastname: Johnston
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Hollands
authors.forename: Henry C C
authors.initials: HC
authors.lastname: Pleass
authors.forename: Arthur J
authors.initials: AJ
authors.lastname: Richardson
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D017024:Chemotherapy, Adjuvant; D003082:Colectomy; D015179:Colorectal Neoplasms / Q000401:mortality / Q000473:pathology* / Q000628:therapy*; D019317:Evidence-Based Medicine; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000556:secondary* / Q000628:therapy*; D009364:Neoplasm Recurrence, Local; D011300:Preoperative Care; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome; D006113:United Kingdom / Q000453:epidemiology