title: Rectal outcomes after a liver-first treatment of patients with stage IV rectal cancer.
abstract: BACKGROUND
  The treatment of patients with metastatic rectal cancer remains controversial. We developed a reverse strategy, the liver-first approach, to optimize the chance of a curative resection. The aim of this study was to assess rectal outcomes after reverse treatment of patients with metastatic rectal cancer.
  
  
  METHODS
  From May 2000 to November 2013, a total of 34 consecutive selected patients with histology-proven adenocarcinoma of the rectum and liver metastases were prospectively entered into a dedicated computerized database. All patients were treated via our reverse strategy. Rectal and overall survival outcomes were analyzed.
  
  
  RESULTS
  Most patients presented with advanced disease (median Fong clinical risk score of 3; range 2-5). One patient failed to complete the whole treatment (3%). Rectal surgery was performed after a median of 3.9 months (range 0.4-17.8 months). A total of 73.3% patients received preoperative radiotherapy. Perioperative mortality and morbidity rates were 0 and 27.3% after rectal surgery. Severe complications were reported in two patients (6.1%): one anastomotic leak and one systemic inflammatory response syndrome. The median hospital stay was 11 days (range 5-23 days). Complete local pathological response was observed in three patients (9.1%). The median number of lymph nodes collected was 14. The R0 rate was 93.9%. There was no positive circumferential margin. After a mean follow-up of 36 months after rectal surgery, 5-year overall survival was 52.5%. Five patients experienced pelvic recurrence.
  
  
  CONCLUSIONS
  In our cohort of selected patients with stage IV rectal cancer, the reverse strategy was not only safe and effective, but also oncologically promising, with a low morbidity rate and high long-term survival.
authors.affiliation: Department of Surgery, Clinic for Visceral and Transplantation Surgery, University Hospital of Geneva, Geneva, Switzerland, nicolas.c.buchs@hcuge.ch.
authors.forename: Nicolas C
authors.initials: NC
authors.lastname: Buchs
authors.forename: Frédéric
authors.initials: F
authors.lastname: Ris
authors.forename: Pietro E
authors.initials: PE
authors.lastname: Majno
authors.forename: Axel
authors.initials: A
authors.lastname: Andres
authors.forename: Wulfran
authors.initials: W
authors.lastname: Cacheux
authors.forename: Pascal
authors.initials: P
authors.lastname: Gervaz
authors.forename: Arnaud D
authors.initials: AD
authors.lastname: Roth
authors.forename: Sylvain
authors.initials: S
authors.lastname: Terraz
authors.forename: Laura
authors.initials: L
authors.lastname: Rubbia-Brandt
authors.forename: Philippe
authors.initials: P
authors.lastname: Morel
authors.forename: Gilles
authors.initials: G
authors.lastname: Mentha
authors.forename: Christian
authors.initials: C
authors.lastname: Toso
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D000328:Adult; D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy / Q000401:mortality*; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D009367:Neoplasm Staging; D011379:Prognosis; D011446:Prospective Studies; D012004:Rectal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D015996:Survival Rate