Resection of synchronous liver metastases between radiotherapy and definitive surgery for locally advanced rectal cancer: short-term surgical outcomes, overall survival and recurrence-free survival.
OBJECTIVE
There is debate as to the correct treatment algorithm sequence for patients with locally advanced rectal cancer with liver metastases. The aim of the study was to assess safety, resectability and survival after a modified 'liver-first' approach.


METHODS
This was a retrospective study of patients undergoing preoperative radiotherapy for the primary rectal tumour, followed by liver resection and, finally, resection of the primary tumour. Short-term surgical outcome, overall survival and recurrence-free survival are reported.


RESULTS
Between 2009 and 2013, 45 patients underwent liver resection after preoperative radiotherapy. Thirty-four patients (76%) received neoadjuvant chemotherapy, 24 (53%) concomitant chemotherapy during radiotherapy and 17 (43%) adjuvant chemotherapy. The median time interval from the last fraction of radiotherapy to liver resection and rectal surgery was 21 (range 7-116) and 60 (range 31-156) days, respectively. Rectal resection was performed in 42 patients but was not performed in one patient with complete response and two with progressive metastatic disease. After rectal surgery three patients did not proceed to a planned second stage liver (n = 2) or lung (n = 1) resection due to progressive disease. Clavien-Dindo ≥Grade III complications developed in 6.7% after liver resection and 19% after rectal resection. The median overall survival and recurrence-free survival in the patients who completed the treatment sequence (n = 40) were 49.7 and 13.0 months, respectively. Twenty of the 30 patients who developed recurrence underwent further treatment with curative intent.


CONCLUSIONS
The modified liver-first approach is safe and efficient in patients with locally advanced rectal cancer and allows initial control of both the primary tumour and the liver metastases.
Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway.
K J
KJ
Labori
Department of Oncology, Oslo University Hospital, Oslo, Norway.|K. G. Jebsen Colorectal Cancer Research Centre, Oslo University Hospital, Oslo, Norway.
M G
MG
Guren
Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway.
K W
KW
Brudvik
Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway.
B I
BI
Røsok
Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway.
A
A
Waage
K. G. Jebsen Colorectal Cancer Research Centre, Oslo University Hospital, Oslo, Norway.|Department of Gastrointestinal Surgery, Oslo University Hospital, Ullevål, Oslo, Norway.|Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
A
A
Nesbakken
Department of Gastroenterological Surgery, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway.
S
S
Larsen
Department of Oncology, Oslo University Hospital, Oslo, Norway.
S
S
Dueland
Institute of Clinical Medicine, University of Oslo, Oslo, Norway.|Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway.
B
B
Edwin
Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway.
B A
BA
Bjørnbeth
D000328:Adult; D000368:Aged; D000465:Algorithms; D059248:Chemoradiotherapy / Q000379:methods / Q000401:mortality; D003131:Combined Modality Therapy; D018572:Disease-Free Survival; D005260:Female; D006498:Hepatectomy / Q000379:methods / Q000401:mortality*; D006801:Humans; D008099:Liver / Q000601:surgery; D008113:Liver Neoplasms / Q000401:mortality / Q000556:secondary* / Q000601:surgery* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000379:methods / Q000401:mortality; D009364:Neoplasm Recurrence, Local / Q000401:mortality / Q000473:pathology / Q000601:surgery; D012004:Rectal Neoplasms / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery*; D012007:Rectum / Q000601:surgery*; D012189:Retrospective Studies; D016896:Treatment Outcome
Locally advanced rectal cancer; liver-first approach; synchronus colorectal liver metastases