title: The liver-first approach to the management of colorectal cancer with synchronous hepatic metastases: a systematic review.
abstract: OBJECTIVE
  To our knowledge, this is the first systematic review of the liver-first approach to the management of patients with colorectal cancer with synchronous liver metastases.
  
  
  OBJECTIVE
  To review current evidence for the liver-first approach to the management of patients with colorectal cancer with synchronous liver metastases.
  
  
  METHODS
  PubMed, EMBASE, the Science Citation Index, the Social Sciences Citation Index, Conference Proceedings Citation Index, and the Derwent Innovations Index were searched for the period from January 2000 to May 2012 using terms describing colorectal cancer, liver metastases, and surgery. A predefined protocol for data extraction was used to retrieve data on the design of each study including demographic profile, distribution of primary and hepatic metastatic disease, management of chemotherapy, surgery, the sequence of intervention, disease progression, the numbers completing treatment algorithm, and outcome and survival.
  
  
  RESULTS
  The literature search identified 417 articles, of which 4 cohort study reports described the liver-first approach and reported survival data. There was good agreement between studies on the sequence of treatment using the liver-first approach. The preferred algorithm was systemic chemotherapy, followed by liver resection, then chemoradiotherapy for those patients with rectal lesions, and colorectal resection as the last operative step. Two protocols provided further adjuvant chemotherapy after colorectal resection. Of 121 patients starting treatment, 90 (74%) completed the specified treatment protocol. Disease progression during the protocol period occurred in 23 patients (19%). There was wide variation in survival despite apparently similar protocols.
  
  
  CONCLUSIONS
  The liver-first approach for patients with colorectal cancer with synchronous liver metastases is possible but is associated with a wide range of survival outcomes, despite protocol similarities between studies. There is a need for a well-designed clinical trial comparing this liver-first approach with the classic (bowel-first) approach.
authors.affiliation: Hepatobiliary Surgery Unit, Manchester Royal Infirmary, Manchester, England.
authors.forename: Santhalingam
authors.initials: S
authors.lastname: Jegatheeswaran
authors.forename: James M
authors.initials: JM
authors.lastname: Mason
authors.forename: Helen C
authors.initials: HC
authors.lastname: Hancock
authors.forename: Ajith K
authors.initials: AK
authors.lastname: Siriwardena
mesh_terms: D015179:Colorectal Neoplasms / Q000473:pathology* / Q000601:surgery; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000473:pathology* / Q000601:surgery*; D009378:Neoplasms, Multiple Primary / Q000473:pathology* / Q000601:surgery*