Sequence of colorectal and liver resection in patients with surgically-treatable stage IV colorectal cancer

Abstract

Approximately 25-30% of patients with colorectal cancer develop hepatic metastases. For patients diagnosed with resectable colorectal hepatic metastases, variation exists regarding the timing of resection of the colorectal primary and the hepatic metastases including three approaches: (1) the “classical” colorectal-first staged approach, (2) the “combined” or simultaneous/synchronous approach, and (3) the “reverse” or liver-first staged approach. The purpose of this chapter is to review the current literature regarding the timing of colorectal and hepatic resection in patients with surgically treatable colorectal adenocarcinoma hepatic metastases. There are inadequate data at the current time to provide definitive recommendations as to the optimal timing and sequence of surgery. Our recommendations based on existing data favor delivery of neoadjuvant therapy followed by either: (1) the combined approach for low-risk resections, (2) the liver-first staged strategy for high-risk hepatic resections or mid- to distal rectal tumors that may benefit from total neoadjuvant therapy, or (3) the colorectal-first approach for symptomatic primary colon tumors.