title: Treatment strategies for colorectal carcinoma with synchronous liver metastases: Which way to go?
abstract: OBJECTIVE
  To offer an up-to-date review of all available treatment strategies for patients with synchronous colorectal liver metastases (CLM).
  
  
  METHODS
  A comprehensive literature search was performed to identify articles related to the management of patients with synchronous CLM. A search of the electronic databases PubMed, MEDLINE, and Google Scholar was conducted in September 2014. The following search terms were used: synchronous colorectal liver metastases, surgery, stage IV colorectal cancer, liver-first approach, and up-front hepatectomy. These terms were employed in various combinations to maximize the search. Only articles written in English were included. Particular attention was devoted to studies and review articles that were published within the last six years (2009-2014). Additional searches of the cited references from primary articles were performed to further improve the review. The full texts of all relevant articles were accessed by two independent reviewers.
  
  
  RESULTS
  Poor long-term outcomes of patients with synchronous CLM managed by a traditional treatment strategy have led to questions about the timing and sequence of possible therapeutic interventions. Thus, alternative paradigms called reverse strategies have been proposed. Presently, there are four treatment strategies available: (1) primary first approach (or traditional approach) comprises resection of the primary colorectal tumor followed by chemotherapy; subsequent liver resection is performed 3-6 mo after colorectal resection (provided that CLM are still resectable); (2) simultaneous resection of the primary colorectal tumor and CLM during a single operation presents intriguing options for a highly select group of patients, which can be associated with significant postoperative morbidity; (3) liver-first (or chemotherapy-first) approach comprises preoperative chemotherapy (3-6 cycles) followed by liver resection, adjuvant chemotherapy, and resection of the primary colorectal tumor (it is best suited for patients with asymptomatic primary tumors and initially unresectable or marginally resectable CLM); and (4) up-front hepatectomy (or "true" liver-first approach) includes liver resection followed by adjuvant chemotherapy, colorectal resection, and adjuvant chemotherapy (strategy can be offered to patients with asymptomatic primary tumors and initially resectable CLM).
  
  
  CONCLUSIONS
  None of the aforementioned strategies appears inferior. It is necessary to establish individual treatment plans in multidisciplinary team meetings through careful appraisal of all strategies.
authors.affiliation: Peter Ihnát, Petr Vávra, Pavel Zonča, Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Ostrava 70300, Czech Republic.
authors.forename: Peter
authors.initials: P
authors.lastname: Ihnát
authors.affiliation: Peter Ihnát, Petr Vávra, Pavel Zonča, Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Ostrava 70300, Czech Republic.
authors.forename: Petr
authors.initials: P
authors.lastname: Vávra
authors.affiliation: Peter Ihnát, Petr Vávra, Pavel Zonča, Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Ostrava 70300, Czech Republic.
authors.forename: Pavel
authors.initials: P
authors.lastname: Zonča
mesh_terms: D000970:Antineoplastic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D002277:Carcinoma / Q000401:mortality / Q000556:secondary* / Q000628:therapy*; D017024:Chemotherapy, Adjuvant; D003082:Colectomy / Q000009:adverse effects / Q000401:mortality; D015179:Colorectal Neoplasms / Q000401:mortality / Q000473:pathology* / Q000628:therapy*; D004334:Drug Administration Schedule; D006498:Hepatectomy / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000556:secondary* / Q000628:therapy*; D020360:Neoadjuvant Therapy; D009367:Neoplasm Staging; D018579:Patient Selection; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000970:Antineoplastic Agents
keywords: Colorectal cancer; Liver-first approach; Reverse strategy; Simultaneous resection; Up-front hepatectomy