Managing synchronous liver metastases from colorectal cancer: a multidisciplinary international consensus

Patterns of disease dissemination and survival in patients with synchronous and metachronous metastatic pancreatic adenocarcinoma: Nationwide population-based study

AIM

Despite advances in understanding pancreatic adenocarcinoma, evidence on its metastatic patterns and impact on patient survival remains limited. This study aims to identify patterns of disease dissemination in synchronous versus metachronous metastatic pancreatic adenocarcinoma (mPAC) and their association with overall survival (OS).

METHODS

Patients diagnosed with synchronous- or metachronous-mPAC were selected from the Netherlands Cancer Registry (2015-2021). Patient, tumor, and treatment characteristics were compared using Chi-squared tests. Survival data, calculated from detection of metastatic disease (OS-M), were analyzed using Kaplan-Meier and Log-rank tests.

RESULTS

Overall, 10,788 patients with synchronous- and 508 with metachronous-mPAC were included. Median time to first metastasis in metachronous-mPAC was 13.2 months (IQR 9-23), varying significantly by metastatic site (liver-only 11.5; lung-only 28.0 months). Compared to synchronous-mPAC, patients with metachronous-mPAC had less liver metastases (48 % versus 75 %, p < 0.001), but more lung (29 % versus 21 %, p < 0.001) and peritoneal (35 % versus 25 %, p < 0.001) metastases. Synchronous metastases to liver-only, lung-only, lymph node-only, or multiple sites at first diagnosis had a median OS-M that was (nearly) half compared to metachronous metastases to the same sites. Bone-only or peritoneum-only metastases in synchronous-mPAC showed a median OS-M comparable to metachronous-mPAC.

CONCLUSION

This nationwide population-based study reveals that metachronous-mPAC less commonly presents with liver metastases and more often metastasizes to lung, peritoneum or other atypical sites compared to synchronous-mPAC. These distinct metastatic patterns and their differences in survival may help enhance the prognostic estimation for individual patients from the detection of metastatic disease and warrants further research into the biology underlying metastasis development.

Prediction of metachronous liver metastasis in mid-low rectal cancer using quantitative perirectal fat content from high-resolution MRI

PURPOSE

To investigate the relationship between perirectal fat content and metachronous liver metastasis (MLM) in patients with Mid-low rectal cancer (MLRC).

MATERIALS AND METHODS

A retrospective analysis was conducted on 254 patients who underwent curative surgery for MLRC between December 2016 and December 2021. Preoperative MRI measurements of the rectal mesenteric fat area (MFA), rectal posterior mesorectal thickness (PMT), and rectal mesenteric fascia envelopment volume (MFEV) were performed, along with collection of relevant clinical, pathological, and imaging data. Patients were categorized into the MLM group (Group A), other recurrence or metastasis group (Group B), and no recurrence and metastasis group (Group C). Analyze the differences between Group A and the other groups, and independent risk factors for MLM were explored. Kaplan-Meier analysis and log-rank test were used to validate independent predictive biomarkers for MLM.

RESULTS

Patients with MLM from MLRC had later pathological and imaging T stages and lower perirectal fat content (all P < 0.05). Compared to patients with other types of recurrent metastasis, male gender, poorly differentiated tumors, and advanced tumor N stage were more likely to develop MLM (all P < 0.05). In Cox univariate and multivariate regression analysis, smaller rectal PMT (hazard ratio (HR) 0.361 [0.154-0.846], P = 0.019) and MFEV (HR 0.983 [0.968-0.998], P = 0.022) were independently associated with MLM in MLRC (HR 0.361;0.983). Kaplan-Meier analysis showed that patients with rectal PMT <1.43 cm and rectal MFEV <137.46 cm3 had a significantly higher risk of MLM compared to patients with rectal PMT ≥1.43 cm and rectal MFEV ≥137.46 cm3 (all P < 0.05).

CONCLUSION

Rectal PMT and rectal MFEV can serve as novel parameters for predicting MLM in patients with MLRC.

EORTC consensus recommendations on the optimal management of colorectal cancer liver metastases

Patients with colorectal cancer liver metastases have long represented a unique and thoroughly investigated population. Nevertheless, the optimal management of these is still controversial with a number of open questions which are only partially addressed by available studies and existing guidelines. The European Organisation for Research and Treatment of Cancer (EORTC) Gastrointestinal Tract Cancer Group (GITCG) sought to fill this knowledge gap and promoted the development of a European consensus on this subject. By using the Delphi methodology and leveraging a multidisciplinary team of 43 international experts, including gastrointestinal oncologists, hepatobiliary surgeons, interventional radiologists, radiation oncologists, radiologists, nuclear medicine physicians and pathologists from 12 European countries, 34 practical recommendations and two consensus statements were proposed. These cover varying aspects of the optimal management of colorectal cancer liver metastases such as baseline imaging, selection criteria for liver-directed therapies, treatment strategies, assessment of treatment response, follow-up, care delivery, clinical research and future perspectives. This roadmap document is intended to complement national and international guidelines, and to provide practical guidance for clinicians and multidisciplinary teams, ultimately promoting practice standardisation, optimal management and better patient outcomes across Europe. Also, it provides a unique opportunity to highlight grey areas and unmet needs, and to give a strategic direction to future research in the field by identifying topics where there is no consensus among experts.

Prognostic assessment of T-cells in primary colorectal cancer and paired synchronous or metachronous liver metastasis

Prognostic value of T-cells between primary colorectal cancer (pCRC) and its paired synchronous and metachronous liver metastasis (LM) is underinvestigated and is the subject of the present study. We enrolled into this retrospective cohort study patients, who underwent resection of both pCRC and synchronous LM (N = 55) or metachronous LM (N = 44). After immunohistochemical staining for CD3+, CD8+, and CD45R0+ whole slides were scanned and T-cell densities were quantified using QuPath software in tumor center (TC), inner margin (IM), outer margin (OM), and peritumor zone (PT) of pCRC and LM. High densities of CD8+ T-cells in TC, OM and PT of synchronous LM were associated with longer disease-free survival (DFS). Greater densities of CD3+ T-cells in IM and PT and CD8+ T-cells in IM, OM and PT in synchronous LM over pCRC were associated with longer DFS. Greater densities of CD8+ T-cells in the TC and IM and CD3+ T-cells in the IM of pCRC were found in the metachronous over synchronous group. The first novel finding demonstrated that high density of CD8+ T cells in synchronous LM were associated with favorable outcome. The second finding of high CD8+ cell density in pCRC in metachronous over synchronous CRC may provide a mechanistic basis for the delay of metastatic spread. Both findings could be applied clinically with own reference values.

The Role of Chemotherapy in Patients with Synchronous Colorectal Liver Metastases: A Nationwide Study

BACKGROUND/OBJECTIVES

There is still no consensus as to whether patients with upfront resectable synchronous colorectal liver metastases (sCRLM) should receive neoadjuvant treatment prior to liver surgery. Two randomized controlled trials have assessed the role of peri-operative chemotherapy in sCRLM; neither have shown a survival benefit in the neoadjuvant group. The aim of this population-based study was to examine overall survival in patients treated with neoadjuvant chemotherapy and hepatectomy compared to patients who had upfront surgery.

METHODS

This is a retrospective observational study between 2009 and 2017 containing data extracted from two Swedish national registries. Descriptive statistics and Cox regression analyses were employed.

RESULTS

In total, 2072 patients with sCRLM were treated with liver surgery between 2009 and 2017. A majority (n = 1238, 60%) were treated with neoadjuvant chemotherapy, and 834 patients (40%) had upfront surgery. Patients in the upfront surgery group were older (median age 70 compared to 65 years, p ≤ 0.001). Median overall survival in the upfront surgery group was 26 months (95% CI 23-29 months) compared to 57 months (95% CI 42-48 months) in the neoadjuvant group, log rank p ≤ 0.001. In the multivariable Cox regression analysis, age ≥ 70 years (HR 1.46, 95% CI 1.25-1.70), T category of primary cancer (HR 1.41, 95% CI 1.09-1.84), lymphatic spread of primary cancer (HR 1.68, 95% CI 1.41-1.99), and number of liver metastases (six or more metastases resulted in HR 2.05, 95% CI 1.38-3.01) negatively influenced overall survival. By contrast, adjuvant therapy was protective (HR 0.80, 95% CI 0-69-0.94), whereas neoadjuvant treatment compared to upfront surgery did not influence overall survival (HR 1.04, 95% CI 0.86-1.26).

CONCLUSIONS

Neoadjuvant treatment in sCRLM did not confer a survival benefit compared to upfront surgery.

Proposal of "borderline resectable" colorectal liver metastases based on analysis of risk factors for early surgical failure

PURPOSE

We aimed to define borderline resectable colorectal liver metastases (CRLM) based on the analysis of risk factors for early surgical failure and investigate the efficacy of neoadjuvant chemotherapy in these patients.

METHODS

This was a retrospective analysis of a multi-institutional cohort of patients diagnosed with technically resectable CRLM. Early surgical failure within 6 months of liver surgery was defined as ESF6. We classified CRLM into three grades (A, B, and C) according to the definition of the Japanese Society for Cancer of the Colon and Rectum.

RESULTS

Among the 249 patients with technically resectable CRLM, 46 (18.5%) developed ESF6. The survival rate of these patients was significantly lower than that of the patients without ESF6. In the multivariate analysis of synchronous CRLM patients, no neoadjuvant chemotherapy, Grade B/C, and Charlson comorbidity index ≥ 3 were independent predictors of ESF6. Among patients with synchronous and Grade B/C CRLM, ESF6 rates, surgical failure-free survival, and overall survival in the neoadjuvant chemotherapy group were significantly better relative to the upfront surgery group.

CONCLUSIONS

Patients with synchronous and Grade B/C CRLM are at a high risk of early surgical failure, have a poor long-term prognosis, and can be defined as borderline resectable and good candidates for neoadjuvant chemotherapy.

Advancement in the Management of Synchronous Colorectal Liver Metastasis: A Comprehensive Review of Surgical, Systemic, and Local Treatment Modalities

Synchronous colorectal liver metastases (sCRLMs) present a complex therapeutic challenge requiring multimodal management strategies due to their complex tumor biology, variable disease progression, and the need to balance oncologic control with liver function preservation. This systematic review evaluates recent advancements in surgical approaches, systemic therapies, and local treatment modalities. A comprehensive literature search was conducted across major databases (PubMed, EMBASE, and Cochrane) for studies published between 2013 and 2024. Studies evaluating surgical techniques, perioperative outcomes, systemic therapy integration, and local treatments for sCRLM were included. Quality assessment was performed using the Newcastle-Ottawa Scale for observational studies and the Cochrane risk-of-bias tool for randomized controlled trials (RCTs). Analysis of nine primary studies encompassing 3,856 patients revealed evolving treatment paradigms. This review includes English-language studies (2013-2024) on adult patients (≥18 years) with sCRLM, covering RCTs, cohort, and case-control studies reporting survival, perioperative outcomes, or quality of life (≥12 months follow-up). Exclusions include case reports (<10 patients), metachronous metastases, conference abstracts, reviews without data, unclear methodology, duplicates, and animal/in-vitro studies. Staged resection demonstrated superiority over the simultaneous approach in recent analyses (win ratio 1.59, 95%CI 1.47-1.71). This indicates that patients undergoing staged resection had a 59% higher likelihood of achieving better outcomes (such as survival or fewer complications) compared to those undergoing simultaneous resection. The narrow confidence interval suggests strong statistical reliability of this finding. Minimally invasive techniques showed comparable outcomes to open surgery, with acceptable morbidity rates (21.7%) even in simultaneous resections. Neoadjuvant chemotherapy with targeted agents achieved high resectability rates (97%) and significant response rates (66%). The presence of liver metastases negatively impacted immunotherapy efficacy, suggesting the need for tailored approaches. Management of sCRLM has evolved toward a more personalized approach incorporating advanced surgical techniques, targeted therapies, and novel treatment sequencing. While staged resection may offer advantages in selected cases, treatment decisions should be individualized based on patient and disease characteristics. Future research should focus on optimizing patient selection and treatment sequencing through prospective trials.

Assessment and treatment considerations for patients with colorectal liver metastases: AHPBA consensus guideline and update for surgeons

BACKGROUND

Colorectal cancer most commonly metastasizes to the liver. While various treatment strategies have been developed, surgical management of these patients has vital implications on the prognosis and survival of this group of patients. There remains a need for a consensus guideline regarding the surgical evaluation and management of patients with colorectal liver metastases (CRLM).

METHODS

This review article is a consensus guideline established by the members of the AHPBA Professional Standards Committee, as an amalgamation of existent literature and a guide to surgeons managing this complex disease.

RESULTS

These guidelines reports the benefits and shortcomings of various diagnostic modalities including imaging and next-generation sequencing in the management of patients with CRLM. While surgery has established survival benefits in patients with resectable disease, this report notes the importance of treatment sequencing with non-surgical modalities as well as between colon and liver resection. Finally, the guidelines address the various treatment modalities for patients with unresectable disease, that may have significant impact on survival.

CONCLUSION

CRLM is a complex diagnosis which warrants multidisciplinary approach with early surgical involvement in both assessment and management of the disease, to optimize patient outcomes and survival.

Pathogenetic development, diagnosis and clinical therapeutic approaches for liver metastasis from colorectal cancer (Review)

Colorectal cancer (CRC) is a prevalent malignancy and a significant proportion of patients with CRC develop liver metastasis (CRLM), which is a major contributor to CRC‑related mortality. The present review aimed to comprehensively examine the pathogenetic development and diagnosis of CRLM and the clinical therapeutic approaches for treatment of this disease. The molecular mechanisms underlying CRLM were discussed, including the role of the tumour microenvironment and epithelial‑mesenchymal transition. The present review also highlighted the importance of early detection and the current challenges in predicting the development of CRLM. Various treatment strategies were reviewed, including surgical resection, chemotherapy and immunotherapy, and the potential of novel therapies, such as selective internal radiation therapy and Traditional Chinese Medicine. Despite recent advancements in treatment options, the treatment of CRLM remains a therapeutic challenge due to the complexity of the liver microenvironment and the heterogeneity of CRC. The present review emphasized the need for a multidisciplinary approach and the integration of emerging therapies to improve patient outcomes.

Impact of sleep deprivation on colon cancer: Unraveling the KynA-P4HA2-HIF-1α axis in tumor lipid metabolism and metastasis

OBJECTIVE

There is growing evidence that sleep deprivation promotes cancer progression. In addition, colon cancer patients often experience sleep deprivation due to factors such as cancer pain and side effects of treatment. The occurrence of liver metastases is an important factor in the mortality of colon cancer patients. However, the relationship between sleep deprivation and liver metastases from colon cancer has not been elucidated.

METHODS

A sleep deprivation liver metastasis model was constructed to evaluate the effect of sleep deprivation on liver metastasis of colon cancer. Subsequently, mice feces were collected for untargeted metabolomics to screen and identify the key mediator, Kynurenic acid (KynA). Furthermore, HILPDA was screened by transcriptomics, and its potential mechanism was explored through ChIP, co-IP, ubiquitination experiments, phenotyping experiments, etc. RESULTS: Sleep deprivation promotes liver metastases in colon cancer. Functionally, sleep deprivation aggravates lipid accumulation and decreases the production of the microbiota metabolite KynA. In contrast, KynA inhibited colon cancer progression in vitro. In vivo, KynA supplementation reversed the promoting effects of sleep deprivation on liver metastases from colon cancer. Mechanistically, KynA downregulates the expression of P4HA2 to promote the ubiquitination and degradation of HIF-1α, which leads to a decrease in the transcription of HILPDA, and ultimately leads to an increase in lipolysis of colon cancer cells.

CONCLUSIONS

Our findings reveal that sleep deprivation impairs intracellular lipolysis by KynA, leading to lipid droplets accumulation in colon cancer cells. This process ultimately promotes colon cancer liver metastasis. This suggests a promising strategy for colon cancer treatment.

Liver metastases from colorectal cancer: A joint ESSO-EAHPBA-UEMS core curriculum collaboration

Colorectal liver metastases (CRLM) are a major indication for liver surgery in Europe, highlighting the need for standardized knowledge and training in surgical oncology. The European Society of Surgical Oncology (ESSO) has updated its core curriculum to provide a structured framework for education. Previous publications have addressed pancreatic, hepatocellular, and biliary tract cancers to support candidates preparing for the European Board of Surgery Qualification (EBSQ) exams in Surgical Oncology and Hepato-Pancreato-Biliary Surgery. However, a dedicated guide for CRLM remains absent. This article aims to fill that gap by offering a structured reference on CRLM, covering epidemiology, staging, genetics, and diagnosis of metastatic colorectal cancer. It also outlines multidisciplinary treatment strategies, including systemic, surgical, interventional, and palliative approaches. A structured literature review was conducted using PubMed to identify the most updated (inter)national management guidelines, prioritizing recent multicentre studies, systematic reviews, and meta-analyses published from January 2020 to January 2025. By bridging the gap between the ESSO core curriculum and detailed subspecialty training, this guide provides an essential resource for hepatobiliary surgeons and surgical oncologists. It serves as a valuable tool for those preparing for board examinations while promoting a standardized approach to CRLM education and management across Europe.

The Prostaglandin EP4 Antagonist Vorbipiprant Combined with PD-1 Blockade for Refractory Microsatellite-Stable Metastatic Colorectal Cancer: A Phase Ib/IIa Trial

PURPOSE

Novel combinations are required to overcome resistance to immune checkpoint inhibitors in proficient mismatch repair (pMMR) or microsatellite-stable (MSS) metastatic colorectal cancer (mCRC). We aimed to determine whether vorbipiprant, a prostaglandin E2 receptor EP4 subtype antagonist, can convert immune-resistant mCRC into a tumor responsive to anti-PD-1 inhibition.

PATIENTS AND METHODS

This phase Ib/IIa prospective, open-label, single-arm trial followed a 3 + 3 dose-escalation and dose-optimization design. A total of 28 patients with chemorefractory pMMR/MSS mCRC were given dose-escalated oral vorbipiprant (30, 90, or 180 mg twice daily), along with biweekly intravenous balstilimab (3 mg/kg), an anti-PD-1 antibody. The primary endpoints included safety and the disease control rate (DCR). Secondary endpoints were the overall response rate, duration of response, progression-free survival, and overall survival.

RESULTS

No dose-limiting toxicities were observed. Of the 28 patients, seven (25%) experienced serious adverse events, but only one was attributed to vorbipiprant and one to balstilimab. The trial achieved a DCR of 50% observed across the entire cohort. In the subgroup of patients with liver metastases (n = 12), the DCR was 25%. The overall response rate was 11%, with three patients showing a partial response (median duration of response, 7.4 months). The median progression-free survival was 2.6 months, and the median overall survival was 14.2 months. Translational exploratory analyses suggested that vorbipiprant may boost response to anti-PD-1 in patients with immunogenic tumors.

CONCLUSIONS

The combination of vorbipiprant and a PD-1 inhibitor (balstilimab) yielded sufficient activity in refractory pMMR/MSS mCRC, which is worthy of confirmation in future clinical trials in biomarker-enriched populations.

Resectability assessment of colorectal liver metastases by an expert panel: Potential impact on hospitals referring patients for local treatment

BACKGROUND

Patients with colorectal liver-only metastases (CRLM) eligible for local treatment (resection/ablation) do not always receive this potentially curative treatment due to the lack of clear resectability criteria and expertise in centres not performing liver surgery. We evaluated the potential value of a liver expert panel in daily practice.

METHODS

All patients with CRLM starting with systemic treatment in centres not performing liver surgery between 2016 and 2020 were identified in the Netherlands Cancer Registry. A panel of liver surgeons retrospectively re-evaluated patients' imaging for resectability before and two-monthly during systemic treatment.

RESULTS

Sixty-three patients were included from 24 hospitals requiring a total of 544 resectability assessments by individual panel surgeons. The panel considered 18 (29 %) patients to have resectable CRLM before starting systemic treatment, which increased to 43 (68 %) after up to three evaluations. Eighteen (29 %) patients considered resectable by the panel at any time received no local treatment of whom 9 (50 %) were not referred to a liver surgeon.

CONCLUSION

In non-liver-surgery centres, over a quarter of patients technically eligible for local treatment of initially unresectable CRLM, sometimes mistakenly categorised as such, did not receive this. This stresses the need for liver expert panels in daily practice to increase local treatment rates.

A Systematic Review of Disappearing Colorectal Liver Metastases: Resection or No Resection?

Background: Colorectal cancer is the second most common type of cancer and a leading cause of cancer-related deaths worldwide. Approximately 15% of the patients with colorectal cancer will already have liver metastases (CRLMs) at diagnosis. Luckily, the advances in chemotherapy regimens during the past few decades have led to increased rates of disease regression that could even render an originally unresectable disease resectable. In certain patients with CRLMs, the hepatic lesions are missing on preoperative imaging after neoadjuvant chemotherapy. These patients can undergo surgery with or without resection of the sites of the disappearing liver metastases (DLMs). In this systematic review, we assess the recurrence rate of the DLMs that were left unresected as well as the complete pathologic response of those resected. Methods: A literature search was conducted in PubMed for studies including patients with CRLMs who received neoadjuvant chemotherapy and had DLMs in preoperative imaging. Two independent reviewers completed the search according to the PRISMA checklist. Results: Three hundred and twenty-six patients with 1134 DLMs were included in our review. A total of 47 out of 480 DLMs (72.29%) that were removed had viable tumor cells in postoperative histology. One hundred and forty-five tumors could not be identified intraoperatively and were removed based on previous imaging, with thirty (20.69%) of them presenting viable cancer cells. Four hundred and sixty-five lesions could not be identified and were left in place. Of them, 152 (32.69%) developed local recurrence within 5 years. Of note, 34 DLMs could not be categorized as viable or non-viable tumors. Finally, DLMs that were identifiable intraoperatively had a higher possibility of viable tumors compared to non-identifiable ones (72.29% vs. 20.69%, respectively). Conclusions: Disappearing liver metastases that are left unresected have an increased possibility of recurrence. Patients receiving neoadjuvant treatment for CRLMs may have better survival chances after resecting all the DLM sites, either identifiable intraoperatively or not.

Surgical Management of Colorectal Cancer Liver Metastases

Approximately 50% of colorectal cancer patients develop liver metastases. Hepatic metastases represent the most common cause of colorectal cancer-related mortality. Metastasectomy, if possible, represents the most effective treatment strategy; 20% of patients will be cured and more than 50% survive at least 5 years. Nuances to treatment planning hinge on whether patients present with resectable disease upfront, whether the future liver remnant is adequate, and whether the primary tumor, if present, is colon versus rectal in origin. This article discusses considerations impacting our approach to patients with colorectal liver metastases and the role for various multimodal treatment options.

Perioperative safety and oncological efficacy of simultaneous versus colorectal and liver first two-staged resections in patients with synchronous colorectal liver metastases: a systematic review and network meta-analysis

BACKGROUND

Previous meta-analyses have yielded conflicting results on the optimal surgical treatment strategy in patients with synchronous colorectal liver metastases (sCRLM). This network meta-analysis aims to provide an overview on colorectal-, liver first and simultaneous resections to treat sCRLM.

METHODS

A search was conducted in MEDLINE, Embase and Cochrane CENTRAL (inception-July 11,2023). Pairwise and network meta-analyses were conducted to compare the three strategies, using colorectal-first resections as reference group.

RESULTS

Overall, 46 studies with a total of 20,991 patients were included, a significant portion at a high risk of bias. Simultaneous resections were associated with less blood loss (MD -145.44 ml, 95%CI -239.40 to -51.48) and shorter hospital stays (MD -6.39 days, 95%CI -7.78 to -4.99). Liver-first resections were associated with more transfusions (OR 1.89, 95%CI 1.04 to 3.42) and shorter hospital stays (MD -4.53 days, 95%CI -7.99 to -1.06). Simultaneous resections were associated with less incomplete macroscopic disease clearances (OR 0.33, 95%CI 0.12 to 0.92), while liver-first resections were associated with more incomplete macroscopic disease clearances (OR 2.80, 95%CI 1.16 to 6.73) and less microscopically radical (R0) resections (OR 0.64, 95%CI 0.45 to 0.90). There were no significant differences in morbidity, mortality, disease-free or overall survival.

CONCLUSION

Based on meta-analysis of mainly observational studies, simultaneous resections were associated with less blood loss, shorter length of stay and more complete macroscopic disease clearances.

On-site recurrence risk after parenchymal R1 liver resection for colorectal metastases

BACKGROUND

Histologic microscopic positive resection margin is a debated prognostic factor in patients resected for colorectal liver metastases. This study aimed to assess whether patients with R1 resection experience recurrence at the site of the resection (on-site recurrence) and to identify predictive factors for recurrence profiles in patients with R1 margins after resection of colorectal liver metastases.

METHODS

All surgical colorectal liver metastasis resection cases with R1 parenchymal margin from September 2014 to March 2020 in our center were retrospectively included. Imaging was reviewed for each metastasis. All the analyses were performed per metastasis. Recurrence location was examined for each metastasis according to the site of the R1 margin and defined as on-site when recurrence was at the same place of the resected lesion. Prognostic factors for recurrence type were assessed using logistic regression.

RESULTS

Of 700 patients who underwent liver resection for colorectal liver metastases, 105 (15%) had at least 1 metastasis with R1 resection margin, representing 6.8% per metastasis. The median follow-up was 34 months. Overall recurrence occurred in 130 metastases (83.3%) with intrahepatic recurrence in 106 metastases (80.9%). On-site recurrence was observed for 49 metastases (31.4%) and isolated (without an additional recurrence site) for 20 metastases (12.8%). The on-site recurrence did not impact overall survival. Three predictive factors for on-site recurrence were found in the multivariate logistic regression: synchronous metastases, nonanatomic resection, and pathologic response tumor regression grade 4-5.

CONCLUSION

Intrahepatic localization of recurrence is more frequent than on-site recurrence after R1 parenchymal resection. Synchronous metastases, nonanatomic resection, and tumor regression grade 4-5 may impact the risk of on-site recurrence.

Multiparameter magnetic resonance imaging-based radiomics model for the prediction of rectal cancer metachronous liver metastasis

BACKGROUND

The liver, as the main target organ for hematogenous metastasis of colorectal cancer, early and accurate prediction of liver metastasis is crucial for the diagnosis and treatment of patients. Herein, this study aims to investigate the application value of a combined machine learning (ML) based model based on the multiparameter magnetic resonance imaging for prediction of rectal metachronous liver metastasis (MLM).

AIM

To investigate the efficacy of radiomics based on multiparametric magnetic resonance imaging images of preoperative first diagnosed rectal cancer in predicting MLM from rectal cancer.

METHODS

We retrospectively analyzed 301 patients with rectal cancer confirmed by surgical pathology at Jingzhou Central Hospital from January 2017 to December 2023. All participants were randomly assigned to the training or validation queue in a 7:3 ratio. We first apply generalized linear regression model (GLRM) and random forest model (RFM) algorithm to construct an MLM prediction model in the training queue, and evaluate the discriminative power of the MLM prediction model using area under curve (AUC) and decision curve analysis (DCA). Then, the robustness and generalizability of the MLM prediction model were evaluated based on the internal validation set between the validation queue groups.

RESULTS

Among the 301 patients included in the study, 16.28% were ultimately diagnosed with MLM through pathological examination. Multivariate analysis showed that carcinoembryonic antigen, and magnetic resonance imaging radiomics were independent predictors of MLM. Then, the GLRM prediction model was developed with a comprehensive nomogram to achieve satisfactory differentiation. The prediction performance of GLRM in the training and validation queue was 0.765 [95% confidence interval (CI): 0.710-0.820] and 0.767 (95%CI: 0.712-0.822), respectively. Compared with GLRM, RFM achieved superior performance with AUC of 0.919 (95%CI: 0.868-0.970) and 0.901 (95%CI: 0.850-0.952) in the training and validation queue, respectively. The DCA indicated that the predictive ability and net profit of clinical RFM were improved.

CONCLUSION

By combining multiparameter magnetic resonance imaging with the effectiveness and robustness of ML-based predictive models, the proposed clinical RFM can serve as an insight tool for preoperative assessment of MLM risk stratification and provide important information for individual diagnosis and treatment of rectal cancer patients.

Predictive value of preoperative circulating tumor cells combined with hematological indexes for liver metastasis after radical resection of colorectal cancer

Colorectal cancer is one of the most common malignant tumors in the world, and about 50% of its advanced patients will have liver metastasis. Preoperative assessment of the risk of liver metastasis in patients with colorectal cancer is of great significance for making individualized treatment plans. Traditional imaging examinations and tumor markers have some limitations in predicting the risk of liver metastasis. Therefore, it is of great clinical value to explore more sensitive and specific predictive indicators for improving early detection and treatment effect. In recent years, circulating tumor cells (CTCs), as a new biomarker, have attracted much attention because of their close relationship with tumor metastasis and prognosis. The purpose of this study is to collect and analyze the data of colorectal cancer patients treated in our hospital, so as to determine the predictive value of circulating tumor cells before operation and related hematological indexes for liver metastasis after radical resection of colorectal cancer, and to establish the corresponding prediction model to provide gastrointestinal surgeons with more accurate identification of high-risk patients and guidance for treatment. A total of 88 patients were included in this study, and 26 of whom developed liver metastasis after colorectal cancer surgery. The possible related factors are included in the single factor logistic regression, and the results are obtained after analysis. Body mass index, carcinoembryonic antigen (CEA), carbohydrate antigen 19-9, tumor marker CA72-4 (CA72-4), cytokeratin-7 (CK-7), CTC count, and neutrophil-to-lymphocyte ratio (P < .2) are risk factors for liver metastasis after radical resection of colorectal cancer. Furthermore, the data obtained were included in multivariate regression analysis, and CEA, CA72-4, CK-7, and CTC counts were independent risk factors for liver metastasis after radical resection of colorectal cancer (P < .05). This study confirmed that CEA, CA72-4, CK-7, and CTC counts are independent risk factors for liver metastasis after radical resection of colorectal cancer. In addition, the prediction model of this study can help gastrointestinal surgeons accurately identify patients who are prone to liver metastasis after colorectal cancer surgery.

A prospective study of methylated ctDNA in patients undergoing treatment for liver metastases from colorectal cancer

BACKGROUND

Decision regarding local treatment of colorectal liver metastases (CRLM) is a multidisciplinary assessment, and liver intervention should be performed when the metastases are deemed resectable. There is no standard biomarker to aid neither this decision nor the postoperative treatment decisions. The present prospective, observational study aimed to investigate the potential clinical utility of a combined tumor-specific and organ-specific methylated circulating DNA assay in the perioperative setting of CRLM.

MATERIAL AND METHODS

The study included 56 cases with CRLM. Blood samples were drawn preoperatively and postoperatively. Multiplex methylation analysis of the markers NPY, KANK1, and GAL3ST3 (meth-ctDNA) was performed using droplet digital PCR.

RESULTS

The assay detected preoperative and postoperative meth-ctDNA in 37 % and 46 % of patients, respectively. Patients with negative preoperative meth-ctDNA had a longer median PFS compared to those with positive preoperative meth-ctDNA (HR = 2.2, 95 % CI 1.2-3.9, p < 0.01). In a multivariate analysis, preoperative negative meth-ctDNA was identified as a strong independent predictor of PFS (HR = 3.3, 95 % CI 1.5-7.2, p < 0.01). Similarly, patients with negative postoperative meth-ctDNA had longer median PFS (HR = 3.0, 95 % CI = 1.6-5.6, p < 0.001) and OS (HR = 4.1, 95 % CI 1.9-9.1, p < 0.001) compared to those with positive postoperative meth-ctDNA.

CONCLUSION

Preoperative meth-ctDNA may serve as an important biomarker to inform the multidisciplinary assessment and treatment planning of CRLM. Negative meth-ctDNA may indicate the optimal timing for liver intervention, whereas positive meth-ctDNA may indicate initiation or re-orientation of chemotherapy, or immediate local intervention. Our results confirm postoperative negative meth-ctDNA as a strong prognostic marker of survival.

Impact of Changes in Psoas Muscle Index on Prognosis in Patients With Colorectal Liver Metastases

Background/Aim

Reduction in skeletal muscle mass during chemotherapy is associated with poor outcomes. This study investigated the impact of changes in the psoas muscle index (PMI) on the prognosis of patients with unresectable colorectal liver metastases (CRLM) undergoing chemotherapy, including subgroup analyses based on the initial treatment response assessment.

Patients and Methods

We evaluated 47 patients with unresectable CRLM who underwent systematic chemotherapy and assessed changes in PMI to determine their prognosis.

Results

Changes in PMI were significantly associated with the presence or absence of primary tumor resection and the chemotherapeutic responses to first-line chemotherapy. The PMI reduction group was significantly associated with poor prognosis in both overall survival (OS) and progression-free survival (PFS) in patients with CRLM, and in both OS and PFS in the partial response (PR) group at the initial chemotherapy response assessment.

Conclusion

Skeletal muscle loss at chemotherapy initiation was significantly associated with poorer survival in patients with unresectable CRLM. Maintaining muscle mass could serve as a new indicator for identifying patients with a PR at the initial chemotherapy response assessment for prognosis. Personalized interventions should be investigated to determine whether they can improve muscle mass and lead to better clinical outcomes.

Pushing boundaries: simultaneous minimal-invasive resection of complex colorectal liver metastases and its primary tumor

INTRODUCTION

Synchronous liver metastases occur in approximately 15-20% of patients with colorectal cancer. Optimal oncological treatment of oligometastatic disease combines surgical resection and systemic therapy. Open simultaneous resection of the primary and liver metastases is well described, but there is not much evidence for the increasing use of the minimally invasive approach. We here report the results of our experience of simultaneous minimally invasive resections.

METHODS

A prospective database of patients with resection of colorectal liver metastases (CRLM) at the Charité - Universitätsmedizin Berlin was used for retrospective data analysis. We report all patients undergoing simultaneous minimal invasive resection of colorectal cancer and its synchronous liver metastases between May 2015 and December 2021.

RESULTS

Out of 281 patients undergoing resection of CRLM, 33 (11.7%) patients had simultaneous minimal invasive resection of the colorectal primary. The primary tumor was located mostly within the rectum (n = 17; 48.6%), followed by the descending colon (n = 6; 17.1%). CRLM were localized in both liver lobes in 69.7% (n = 23) of cases. Following resection of the colorectal tumor, an anastomosis was performed in 31 of 33 patients (93.9%), with no anastomotic leakage observed in the follow up. Simultaneous liver resections were performed mostly as subsegment (n = 20) or bisegment resections (n = 11). Mean IWATE-Score of all hepatic resections was 5.5 (± 2.4). Complication rates (Clavien-Dindo ≥ 3) were similar compared between low/intermediate and advanced/expert difficulty for liver resection (n = 4, 17.4% vs. n = 2, 20.0%; p = 1.0). In one case conversion to open resection was required.

CONCLUSION

Our data indicate that simultaneous minimal invasive resection of CRLM and the primary tumor is a safe and feasible procedure. Complication rates were consistent across different levels of difficulty (low to expert) in liver resections. Therefore, indications for simultaneous resection may be expanded.

Liver-First Resection in Patients With Synchronous Colorectal Liver Metastases Is Associated With Inferior Recurrence-Free Survival: Reconsidering the Importance of the Primary Cancer

BACKGROUND

Synchronous colorectal liver metastases may be managed with primary-first, simultaneous, or liver-first resection. Relative oncologic outcomes based on treatment sequencing are understudied.

OBJECTIVE

This study aimed to assess oncologic survival outcomes in patients with synchronous colorectal liver metastases managed with each of the 3 treatment strategies, with respect to early or delayed removal of the primary tumor.

DESIGN

Retrospective analysis of the prospectively maintained database, with 1:1 propensity score matching of relevant clinicopathologic variables comparing liver-first to primary-first/simultaneous approaches.

SETTINGS

Single-institution, tertiary cancer center.

PATIENTS

Patients undergoing curative-intent hepatectomy for synchronous colorectal liver metastases from 2003 to 2019.

MAIN OUTCOME MEASURES

Overall and recurrence-free survival.

RESULTS

Of 151 patients, 23% (n = 35) had liver-first and 77% (n = 116; primary-first = 93 and simultaneous = 23) had primary-first/simultaneous approaches. The median follow-up was 45 months. Recurrence-free survival was worse for liver-first versus primary-first/simultaneous groups (median 12 versus 16 months, p = 0.02), driven by 3-year extrahepatic recurrence-free survival of 19%, 58%, and 50% for liver-first, primary-first, and simultaneous groups, respectively. Three-year overall survival was not significantly different at 86%, 79%, and 86%, respectively. Oncologic outcomes did not differ significantly between primary-first and simultaneous groups (all p > 0.4). Matching yielded 34 clinicopathologically similar patients per group (liver-first = 34, primary-first = 28, simultaneous = 6). The liver-first approach was associated with shorter recurrence-free survival (median 12 versus 23 months, p = 0.004), driven by extrahepatic recurrence-free survival (3 years: 20% versus 55%, p = 0.04). Overall survival was not significantly different at 3 years (79% versus 80%, p = 0.95) or 5 years (59% versus 59%, p > 0.99).

LIMITATIONS

This study has a retrospective design and a limited sample size.

CONCLUSIONS

A liver-first approach is associated with worse recurrence-free survival compared to primary-first or simultaneous resection, driven by extrahepatic recurrence. A prospective study of whether oncologic risk is associated with leaving the primary in situ is needed. Multidisciplinary treatment sequencing and enhanced postoperative surveillance for patients receiving liver-first resection are recommended. See Video Abstract .

LA RESECCIN DEL HGADO PRIMERO EN PACIENTES CON METSTASIS HEPTICAS COLORRECTALES SINCRNICAS SE ASOCIA CON UNA SUPERVIVENCIA INFERIOR SIN RECURRENCIA RECONSIDERACIN DE LA IMPORTANCIA DEL CNCER PRIMARIO

ANTECEDENTES:Las metástasis hepáticas colorrectales sincrónicas se pueden tratar con resección primaria, simultánea o hepática. Los resultados oncológicos relativos basados en la secuenciación del tratamiento están poco estudiados.OBJETIVO:Este estudio tuvo como objetivo evaluar los resultados de supervivencia oncológica en pacientes con metástasis hepáticas colorrectales sincrónicas tratadas con cada una de las tres estrategias de tratamiento, con respecto a la extirpación temprana o tardía del tumor primario.DISEÑO:Análisis retrospectivo de una base de datos mantenida prospectivamente, con coincidencia de propensión 1:1 de variables clínico-patológicas relevantes que comparan enfoques de hígado primero con enfoques primarios primero/simultáneos.AJUSTES:Centro oncológico terciario de una sola institución.PACIENTES:Pacientes sometidos a hepatectomía con intención curativa por metástasis hepáticas colorrectales sincrónicas entre 2003 y 2019.MEDIDAS PRINCIPALES DE RESULTADOS:Supervivencia general y libre de recurrencia.RESULTADOS:De 151 pacientes, el 23% (n=35) tuvo un abordaje hepático primero y el 77% (n=116; primario primero=93 y simultáneo=23) tuvo un abordaje primario primero/simultáneo. La mediana de seguimiento fue de 45 meses. La supervivencia libre de recurrencia fue peor para los grupos de hígado primero versus primario primero/simultáneo (mediana 12 versus 16 meses, p = 0,02), impulsada por la supervivencia libre de recurrencia extrahepática a tres años del 19%, 58% y 50% para grupos de hígado primero, primario primero y simultáneo, respectivamente. La supervivencia general a tres años no fue significativamente diferente: 86%, 79% y 86%, respectivamente. Los resultados oncológicos no difirieron significativamente entre los grupos primario-primero y simultáneo (todos p > 0,4). El emparejamiento produjo 34 pacientes clínico-patológicamente similares por grupo (hígado primero = 34, primario primero = 28/simultáneo = 6). El enfoque de hígado primero se asoció con una supervivencia libre de recurrencia más corta (mediana de 12 frente a 23 meses, p = 0,004), impulsada por la supervivencia libre de recurrencia extrahepática (3 años: 20 % frente a 55 %, p = 0,04). La supervivencia general no fue significativamente diferente a los 3 años (79% versus 80%, p = 0,95) o a los 5 años (59% versus 59%, p > 0,99).LIMITACIONES:Este estudio tiene un diseño retrospectivo y un tamaño de muestra limitado.CONCLUSIONES:Un enfoque de hígado primero se asocia con una peor supervivencia libre de recurrencia en comparación con la resección primaria o simultánea, impulsada por la recurrencia extrahepática. Es necesario un estudio prospectivo sobre si el riesgo oncológico se asocia con dejar el primario in situ . Se recomienda la secuenciación del tratamiento multidisciplinario y una vigilancia posoperatoria mejorada para los pacientes que reciben una primera resección del hígado. (Traducción-Yesenia Rojas-Khalil ).

Pelvic Radiotherapy in Rectal Cancer Patients With Synchronous Potentially Treatable Liver Metastases

BACKGROUND

The optimal management strategy for Stage IV rectal cancer with potentially treatable liver metastases remains controversial, particularly regarding the role of pelvic radiotherapy (RT).

AIMS

We intend to investigate the impact of pelvic RT on oncological outcomes of rectal cancer with potentially treatable liver metastasis.

METHODS AND RESULTS

This retrospective study included 83 patients diagnosed with rectal cancer and synchronous liver metastases from June 2012 to January 2022. All patients underwent radical surgery for rectal cancer and treatment of synchronous liver metastases, as determined by a multidisciplinary team (MDT). We divided the 83 patients into two treatment groups: chemoradiotherapy and surgery (CRT + S) and chemotherapy and surgery (C + S). The CRT + S group (n = 40) received pelvic RT, systemic therapy, and liver metastasis treatment. The C + S group (n = 43) received systemic therapy and liver metastasis treatment only. A total of 83 patients were analyzed with a median follow-up of 45 months (range 12-127 months). In the CRT + S group, 48.2% (40/83) of patients underwent chemoradiotherapy, while the C + S group comprised 51.8% (43/83) of patients who received chemotherapy only. The CRT + S group demonstrated significantly longer local recurrence-free survival compared to the C + S group (median 37.5 vs. 34 months; p = 0.011). In addition, patients in the CRT + S group had a longer median overall survival (OS) compared to the C + S group (46.50 vs. 44.0 months; p = 0.0497). Notably, achieving no evidence of disease (NED) status after definitive treatment for both primary and liver metastases was associated with improved OS (p = 0.008).

CONCLUSION

This study suggests that the addition of pelvic RT to multimodality therapy for patients with rectal cancer and potentially treatable liver metastases may improve local control and long-term survival. The findings support the consideration of RT in the clinical management of this patient population.

Optimal treatment strategies for borderline resectable liver metastases from colorectal cancer

BACKGROUND

Traditionally, colorectal liver metastases (CRLMs) are divided into "initially resectable" and "initially unresectable." The terminology "borderline resectable" continues to be elusive without any common consensus or definition. This narrative review aims to decode the conundrum of "borderline resectable CRLM (BR-CRLM)" and to discuss optimal treatment strategies.

METHODS

A comprehensive review was performed using Medline/PubMed and Web of Science databases with a search period ending on January 1, 2024. Using PubMed, the terms "CRLM," "BR-CRLM," and "management of BR-CRLM" were searched.

RESULTS

The 2016 European Society for Medical Oncology guidelines defined the term "resectability" in CRLM using the "technical (surgical) criteria" and the "oncologically criteria." These 2 criteria form the basis of defining BR-CRLM. Thus, BR-CRLM can be either technically easy but with unfavorable oncologically criteria or technically difficult with favorable oncologically criteria. Although defining BR-CRLM by incorporating both these criteria seems to be the most logical way forward, there is currently a lot of heterogeneity in the literature. It is generally agreed upon that some form of chemotherapy needs to be administered in BR-CRLM before embarking on surgery. Conversion chemotherapy is used in patients with BR-CRLM in which there is a possibility of resection after effective downsizing. Along with improved effective chemotherapy, great strides have been made in pushing the limits of surgery to achieve resectability in this subset of patients.

CONCLUSION

Advanced surgical techniques and locoregional liver-directed therapies coupled with perioperative chemotherapy with or without targeted therapy have made long-term survival benefit, a reality in patients with BR-CRLM. Thus, the time has come to recognize "BR-CRLM" as a distinct entity.

Impact of pure desmoplastic histological growth patterns in colorectal liver metastasis

BACKGROUND

Colorectal cancer (CRC) has increasingly come into worldwide cancer and almost half of patients have liver metastasis (CRLM) during the progression. Therefore, treatment of colorectal cancer liver metastasis (CRLM) is important to improve the prognosis of CRC patients. Histopathological growth patterns (HGPs) of CRLM have emerged as a reliable prognostic marker. In this study, we investigated the role of prognostic impact of pure desmoplastic HGPs (dHGPs), 100% desmoplastic, in CRLM.

METHODS

The present study evaluated the HGPs in 71 patients with CRLM who underwent surgery (R0) between 1995 and 2012. HGPs were classified by international consensus guidelines with H&E stained slides. The pure dHGPs was defined as a complete peripheral fibrotic rim around the tumor.

RESULTS

The dHGP was present in 36.6% (n = 26) and the pure-dHGPs was present in 73% (n = 19) among dHGPs patients. Pure-dHGPs were significantly associated with sex (male), metachronous metastatic period, normal CEA level, shallow tumor invasion and less lymph node metastasis. Patients with dHGPs had longer overall survival (OS) compared to other HGPs (p < 0.05). Furthermore, pure dHGPs patients had longer OS than non-pure dHGPs (90.9% vs. 51.4%, p < 0.05). Multivariate analysis identified pure dHGPs (p = 0.04) and better primary tumor differentiation (p < 0.001) were identified as independent prognostic indicators for OS. Patients with pure dHGPs also had longer disease-free survival (DFS) compared to other HGPs (p < 0.05). Pure-dHGPs patients had longer DFS than non-pure dHGPs (63.4% vs. 28.8%, p < 0.05). Multivariate analysis identified pure dHGPs (p = 0.04) and better primary tumor differentiation (p = 0.03) as independent prognostic indicators.

CONCLUSIONS

Pure desmoplastic HGP might be a good prognostic marker in CRLM.

Liver-first approach to the treatment of patients with synchronous colorectal liver metastases: a systematic review and meta-analysis

OBJECTIVE

The optimal approach to the treatment of colorectal carcinoma and synchronous liver metastases remains controversial. The objective of this review was to analyze the outcomes of adopting the liver-first approach for the treatment of patients with colorectal cancer with synchronous hepatic metastases who initially underwent systemic chemotherapy and/or resection of the metastatic lesions and primary colorectal carcinoma.

METHODS

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The MEDLINE, EMBASE, LILACS, and Cochrane Central Register of Controlled Trials databases were searched for the identification and retrieval of eligible studies. Studies that included details of using the liver-first approach for the treatment of synchronous liver metastases of colorectal cancer and its outcomes, including the patients' survival data, were included. Proportional meta-analysis was performed using the random-effects restricted maximum likelihood method to summarize the three- and five-year overall survival and recurrence rates of the patients.

RESULTS

Eight hundred and fifty-five articles describing the results of studies on the liver-first approach were identified. Three independent reviewers screened the titles and abstracts of the articles and excluded 750 articles. Thereafter, 29 retrospective and comparative studies that met the inclusion criteria were included. No randomized controlled trials were identified in the database search.

CONCLUSION

Neoadjuvant treatment with systemic chemotherapy for hepatic metastasis can prepare a patient for resection of liver metastases, offering the opportunity for potentially curative treatment of synchronous hepatic metastases initially considered unresectable. The decision regarding the resection of primary colorectal carcinoma and liver metastases should be based on individualized patient response. Prospero database registration ID: CRD42022337047 (www.crd.york.ac.uk/prospero).

Risk factors for residual liver recurrence of colorectal cancer after resection of liver metastases and significance of adjuvant chemotherapy

OBJECTIVE

The risk factors for residual liver recurrence after resection of colorectal cancer liver metastases were analyzed separately for synchronous and metachronous metastases.

METHODS

This retrospective study included 236 patients (139 with synchronous and 97 with metachronous lesions) who underwent initial surgery for colorectal cancer liver metastases from April 2010 to December 2021 at the Fujita Health University Hospital. We performed univariate and multivariate analyses of risk factors for recurrence based on clinical background.

RESULTS

Univariate analysis of synchronous liver metastases identified three risk factors: positive lymph nodes (p = 0.018, HR = 2.067), ≥3 liver metastases (p < 0.001, HR = 2.382), and use of adjuvant chemotherapy (p = 0.013, HR = 0.560). Multivariate analysis identified the same three factors. For metachronous liver metastases, univariate and multivariate analysis identified ≥3 liver metastases as a risk factor (p = 0.002, HR = 2.988); however, use of adjuvant chemotherapy after hepatic resection was not associated with a lower risk of recurrence for metachronous lesions. Inverse probability of treatment weighting analysis of patients with these lesions with or without adjuvant chemotherapy after primary resection showed that patients with metachronous liver metastases who did not receive this treatment had fewer recurrences when adjuvant therapy was administered after subsequent liver resection, although the difference was not significant. Patients who received adjuvant chemotherapy after hepatic resection had less recurrence but less benefit from this treatment.

CONCLUSION

Risk factors for liver recurrence after resection of synchronous liver metastases were positive lymph nodes, ≥3 liver metastases, and no postoperative adjuvant chemotherapy. Adjuvant chemotherapy is recommended after hepatic resection of synchronous liver metastases.

Management of Colorectal Cancer with Synchronous Liver Metastases: A systematic review of national and International Clinical Guidelines (CoSMIC-G)

Introduction

The contemporary management of patients with colorectal cancer and synchronous liver metastases is complex. This study appraises the recommendations made by national/international guidelines for the diagnosis and management of patients with synchronous liver metastases from colorectal cancer.

Methods

A systematic review of national and international guidelines published between 2011 and 2024 was carried out using PubMed, OvidSP and Guidelines International Network databases. The quality of guidelines was evaluated using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument. Guidelines were assessed for the quality of advice for specific scenarios. The protocol was registered with PROSPERO (CRD42021243744).

Results

The search strategy returned ninety unique articles with 11 guidelines eligible for inclusion. Of these, one (9 %) guideline defined 'synchronous disease' at outset, eight (73 %) recommended neoadjuvant chemotherapy as first intervention. Seven (64 %) guidelines supported synchronous hepatic resection with colectomy. One (9 %) recommended against synchronous surgery.

Conclusions

This study demonstrates important variations between international clinical guidelines on diagnostic workup and management of synchronous liver metastases in colorectal cancer. [167 words].

The Top Ten Annals of Surgical Oncology Original Articles on Twitter/X: 2020-2023

Social media has become omnipresent in society, especially given that it enables the rapid and widespread communication of news, events, and information. Social media platforms have become increasingly used by numerous surgical societies to promote meetings and surgical journals to increase the visibility of published content. In September 2020, Annals of Surgical Oncology (ASO) established its Social Media Committee (SMC), which has worked to steadily increase the visibility of published content on social media platforms, namely X (formerly known as Twitter). The purpose of this review is to highlight the 10 ASO original articles with the most engagement on X, based on total number of mentions, since the founding of the SMC. These articles encompass a wide variety of topics from various oncologic disciplines including hepatopancreatobiliary, breast, and gynecologic surgery.

The Prognostic Impact of Adipophilin Expression on Long-Term Survival Following Liver Resection in Patients with Colorectal Liver Metastases

Background/Objectives: Adipophilin (ADP) is a protein associated with lipid droplets, and its expression is related to poor prognosis in certain cancers. However, its impact on the survival of patients with colorectal liver metastases (CRLMs) remains unclear. This study investigated the impact of ADP expression on long-term survival following hepatectomy in patients with CRLM. Methods: We retrospectively analyzed 102 consecutive patients who underwent hepatectomy between 2006 and 2022. ADP expression was examined in resected specimens through immunohistochemical staining using tissue microarrays. Long-term outcomes for ADP-positive (n = 51) and ADP-negative (n = 51) groups were compared with Kaplan-Meier survival analysis. Results: We found significantly decreased 5-year recurrence-free survival (RFS) and overall survival (OS) rates for ADP-positive patients relative to ADP-negative patients (29.4% versus 52.1%, respectively; p = 0.001 and 43.7% versus 72.2%, respectively; p = 0.003). Moreover, multivariate Cox hazards analysis demonstrated that patients with ADP-positive CRLM had a worse prognosis after hepatectomy than those with ADP-negative CRLM, as reflected by both RFS (HR 2.46, 95% CI 1.39-4.36, p = 0.002) and OS (HR: 2.89, 95% CI 1.43-5.85, p = 0.003). Conclusions: ADP expression had a significant prognostic impact on the survival of patients with CRLM following liver resection and may aid in optimal treatment planning.

Survival benefit of adjuvant chemotherapy based on molecular residual disease detection in resected colorectal liver metastases: subgroup analysis from CIRCULATE-Japan GALAXY

BACKGROUND

The prognostic role of circulating tumor DNA (ctDNA)-based molecular residual disease (MRD) detection and its utility for postsurgical risk stratification has been reported in colorectal cancer. In this study, we explored the use of ctDNA-based MRD detection in patients with colorectal liver metastases (CLM), for whom the survival benefit of adjuvant chemotherapy (ACT) after surgical resection remains unclear.

METHODS

Patients with CLM without extrahepatic disease from the GALAXY study (UMIN000039205) were included. The disease-free survival (DFS) benefit of ACT was evaluated in MRD-positive and -negative groups after adjusting for age, gender, number, and size of liver metastases, RAS status, and previous history of oxaliplatin for primary cancer. ctDNA was detected using a personalized, tumor-informed 16-plex polymerase chain reaction-next-generation sequencing (mPCR-NGS) assay. ctDNA-based MRD status was evaluated 2-10 weeks after curative surgery, before the start of ACT.

RESULTS

Among 6061 patients registered in GALAXY, 190 surgically resected CLM patients without any preoperative chemotherapy were included with a median follow-up of 24 months (1-48 months). ctDNA positivity in the MRD window was 32.1% (61/190). ACT was administered to 25.1% (48/190) of patients. In the MRD-positive group, 24-month DFS was higher for patients treated with ACT [33.3% versus not reached, adjusted hazard ratio (HR): 0.07, P < 0.0001]; whereas no benefit of ACT was seen in the MRD-negative group (24-month DFS: 72.3% versus 62.2%, adjusted HR: 0.68, P = 0.371). Multivariate analysis showed that the size of liver metastases (HR: 3.94, P = 0.031) was prognostic of DFS in the MRD-positive group. In the MRD-negative group, however, none of the clinicopathological factors were prognostic of DFS.

CONCLUSIONS

Our data suggest that ACT may offer notable clinical benefits in MRD-positive patients with CLM. MRD status-based risk stratification could be potentially incorporated in future clinical trials for CLM.

Primary tumor sidedness is not prognostic factor in resectable colorectal cancer liver metastasis: a retrospective observational cohort study

Purpose

Right-sided tumors have been reported to have a poorer survival rate than left-sided tumors; however, there remains debate regarding whether sidedness is an independent prognostic factor in colorectal cancer liver metastasis (CRLM). This study aimed to assess the impact of sidedness on prognosis in resectable CRLM and to identify prognostic factors.

Methods

Patients who underwent liver resection for CRLM at Samsung Medical Center from January 2008 to December 2021 were included in the investigation. Overall survival (OS) and progression-free survival (PFS) were analyzed, and prognostic factors were identified.

Results

A total of 497 patients were included in the study, with 106 on the right side and 391 on the left side. The right-sided group had a higher percentage of synchronous tumors (90.6% vs. 80.3%, P = 0.020). In survival analysis, the right side showed lower 5-year OS (49.7% vs. 54.2, P = 0.305) and 5-year PFS (57.1% vs. 60.2%, P = 0.271), but the differences were not statistically significant. In the analysis of prognostic factors, synchronous tumor (odds ratio [OR], 5.01; P < 0.001), CEA (OR, 1.46; P = 0.016), and maximum tumor size of hepatic metastasis (OR, 1.09; P = 0.026) were associated with OS.

Conclusion

In resectable CRLM, there was no difference in prognosis based on sidedness. CEA level, synchronous tumor, and maximum tumor size of hepatic metastasis were identified as prognostic factors.

Preoperative imaging of colorectal liver metastases: what the radiologist and the multidisciplinary team need to know

The management of patients with colorectal liver metastases (CRLM) has transformed over the past 2 decades. Advances in surgical techniques, systemic therapies, and local treatments have resulted in a paradigm shift. Disease that would once have been considered terminal is now frequently treated aggressively with both a disease-free and overall survival benefit. In line with the expanding range of treatment options, there has been an increase in the volume and complexity of imaging required in the management of these patients to ensure optimal patient selection and outcome. The radiologist plays a pivotal role in interpreting these studies, conveying the relevant information and informing the discussion at multidisciplinary team meetings. The purpose of this review is to provide an update for radiologists on the current surgical management of patients with CRLM highlighting specific imaging information that is required by the multidisciplinary team when assessing resectability and/or the need for additional liver-directed therapies.

Assessment by a multidisciplinary team conference affects treatment strategy and overall survival in patients with synchronous colorectal liver metastases

BACKGROUND

The aim of this retrospective observational study was to investigate the geographical or sex differences in patients with synchronous colorectal liver metastases (sCRLM) in terms of assessment by a multidisciplinary team conference (MDT), curative treatment, and overall survival.

METHOD

All sCRLM patients in the South-East Health Care Region of Sweden from 2009 to 2015 were included (n = 615). Data were derived from the Swedish Colorectal Cancer Registry, Swedish Registry of Liver and Bile Surgery and medical records.

RESULTS

Patients who had a hepatobiliary unit (HBU) at the nearest hospital were more likely to undergo liver surgery (HBU+, 37% (n = 106), compared to HBU-, 22% (n = 60); p = 0.001) and had a better median survival (p < 0.001). No sex differences were observed. In multivariate Cox regression analyses of overall survival, assessment by an MDT that included a liver surgeon was independently linked to better survival (HR 0.574, 0.433-0.760).

CONCLUSION

There were no sex differences in access to liver surgery or overall survival, however, there were geographical inequalities, where residency near a hospital with HBU was associated with increased overall survival and the possibility to receive liver surgery. Assessment at MDT with liver surgeon present was associated with greater survival, indicating its important role for treatment.

Predictive risk factors for resection surface-related complications after laparoscopic simultaneous resection of primary colorectal tumor and synchronous liver metastases: a single-center retrospective study

BACKGROUND

Laparoscopic simultaneous resection (LSR) of primary colorectal tumors and synchronous colorectal liver metastases (sCRLM) has been recently performed. This study aimed to evaluate the postoperative outcomes after LSR and determine the risk factors for resection surface-related complications (RSRC), such as postoperative biliary fistula and liver-transection surface abscess.

METHODS

Between 2009 and 2022, consecutive patients with sCRLM who underwent LSR were included. We retrospectively analyzed clinicopathological data, including intraoperative factors and postoperative outcomes. The difficulty level of all liver resections was classified according to the IWATE difficulty scoring system (DSS). We then performed univariate and multivariate analyses to identify the risk factors for RSRC.

RESULTS

Of the 112 patients, 94 (83.9%) underwent partial hepatectomy and colorectal surgery. The median DSS score was 5 points (1-11), with 12 (10.7%) patients scoring ≥ 7 points. Postoperative complications were observed in 41 (36.6%) patients, of whom 16 (14.3%) experienced severe complications classified as Clavien-Dindo grade IIIa or higher. There was no postoperative mortality. The most common complication was RSRC (19 patients, 17.0%). Multivariate analysis identified American Society of Anesthesiologists (ASA) classification ≥ 3 [odds ratio (OR) 10.3, 95% confidence interval (CI) 1.37-77.8; P = 0.023], DSS score ≥ 7 points (OR 5.08, 95% CI 1.17-20.0; P = 0.030), and right-sided colectomy (OR 4.67, 95% CI 1.46-15.0; P = 0.009) as independent risk factors for RSRC. Postoperative hospital stays were significantly longer for patients with RSRC than for those without RSRC (22 days vs. 11 days; P < 0.001).

CONCLUSION

Short-term outcomes of LSR for patients with sCRLM were acceptable in an experienced center. RSRC was the most common complication, and high-difficulty hepatectomy, right-sided colectomy, and ASA classification ≥ 3 were independent risk factors for RSRC.

Utility of circulating tumor DNA in secondary liver malignancies: What we know and what is to come

Secondary liver malignancies are a serious and challenging global health concern. Secondary metastasis to the liver is most commonly from colorectal cancer that has metastatically spread through splanchnic circulation. Metastatic diseases can portend poor prognosis due to the progressive nature typically found on detection. Improvements in detection of disease, monitoring therapy response, and monitoring for recurrence are crucial to the improvement in the management of secondary liver malignancies. Assessment of ctDNA in these patient populations poses an opportunity to impact the management of secondary liver malignancies. In this review, we aim to discuss ctDNA, the current literature, and future directions of this technology within secondary liver malignancies.

Baseline hepatobiliary MRI for predicting chemotherapeutic response and prognosis in initially unresectable colorectal cancer liver metastases

PURPOSE

To evaluate the performance of hepatobiliary MRI parameters as predictors of clinical response to chemotherapy in patients with initially unresectable colorectal cancer liver metastases (CRLM).

METHODS

Eighty-five patients with initially unresectable CRLM were retrospectively enrolled from two hospitals and scanned using gadobenate dimeglumine-enhanced MRI before treatment. Therapy response was evaluated based on the Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1. Conventional parameters (i.e., signal intensity [SI]) and radiomics features of portal venous phase (PVP) and hepatobiliary phase (HBP) images were analyzed between the responders and non-responders. Next, the combined model was constructed, and the area under the receiver operating characteristic (ROC) curve (AUC) was calculated. The relationship between the combined model and progression-free survival (PFS) was analyzed using Cox regression.

RESULTS

Of the 85 patients from two hospitals, 42 were in the response group, and 43 were in the non-response group. Upon conducting five-fold cross-validation, the normalized relative enhancement (NRE) of CRLM during the PVP yielded an AUC of 0.625. Additionally, a radiomics feature derived from the tumor area in the HBP achieved an AUC of 0.698, while a separate feature extracted from the peritumoral region in the HBP recorded an AUC of 0.709. The model that integrated these three features outperformed the individual features, achieving an AUC of 0.818. Furthermore, the combined model exhibited a significant correlation with PFS (P < 0.001).

CONCLUSION

The combined model, based on baseline hepatobiliary MRI, aids in predicting chemotherapeutic response and PFS in patients with initially unresectable CRLM.

Evolution and current trends in the management of colorectal cancer liver metastasis

Metastatic colorectal cancer (mCRC) is a major cause of cancer-related death, with a 5-year relative overall survival of up to 20%. The liver is the most common site of distant metastasis in colorectal cancer (CRC), with about 50% of CRC patients metastasizing to their liver over the course of their disease. Complete liver resection is the primary modality of treatment for resectable colorectal cancer liver metastasis (CRLM), with an overall 5-year survival rate of up to 58%. However, only 15% to 20% of patients with CRLM are deemed suitable for resection at presentation. For unresectable diseases, the median survival of patients remains low even with the best chemotherapy. In recent decades, the management of CRLM has continued to evolve with the expansion of resection criteria, novel targeted systemic therapies, and improved locoregional therapies. However, due to the heterogeneity of the CRC patient population, the optimal evaluation of treatment options for CRLM remains complex. Therefore, effective management requires a multidisciplinary team to help define resectability and devise a personalized treatment approach, from the initial diagnosis to the final treatment.

Colorectal cancer

Despite decreased incidence rates in average-age onset patients in high-income economies, colorectal cancer is the third most diagnosed cancer in the world, with increasing rates in emerging economies. Furthermore, early onset colorectal cancer (age ≤50 years) is of increasing concern globally. Over the past decade, research advances have increased biological knowledge, treatment options, and overall survival rates. The increase in life expectancy is attributed to an increase in effective systemic therapy, improved treatment selection, and expanded locoregional surgical options. Ongoing developments are focused on the role of sphincter preservation, precision oncology for molecular alterations, use of circulating tumour DNA, analysis of the gut microbiome, as well as the role of locoregional strategies for colorectal cancer liver metastases. This overview is to provide a general multidisciplinary perspective of clinical advances in colorectal cancer.

New trends in surgery for colorectal liver metastasis

By presenting the most up-to-date findings and incorporating the latest evidence, this article seeks to present a comprehensive guide for navigating the complexities inherent in the management of colorectal liver metastasis. It aims to serve as a valuable resource offering clinicians and healthcare professionals an understanding of the diverse modalities and approaches available for treating this challenging and multifaceted disease. In an era of rapidly evolving medical knowledge, this article examines the latest insights to make informed decisions in the realm of colorectal liver metastasis management. The article does not only highlight the up-to-date knowledge but also provides the evidence for existing therapeutic strategies. This practical tool provides evidence-based recommendations to clinicians, thereby contributing to the ongoing advancement of effective treatment strategies for this challenging disease.

Challenges and Opportunities for Precision Surgery for Colorectal Liver Metastases

The incidence of colorectal cancer and colorectal liver metastases (CRLM) is increasing globally due to an interaction of environmental and genetic factors. A minority of patients with CRLM have surgically resectable disease, but for those who have resection as part of multimodal therapy for their disease, long-term survival has been shown. Precision surgery-the idea of careful patient selection and targeting of surgical intervention, such that treatments shown to be proven to benefit on a population level are the optimal treatment for each individual patient-is the new paradigm of care. Key to this is the understanding of tumour molecular biology and clinically relevant mutations, such as KRAS, BRAF, and microsatellite instability (MSI), which can predict poorer overall outcomes and a poorer response to systemic therapy. The emergence of immunotherapy and hepatic artery infusion (HAI) pumps show potential to convert previously unresectable disease to resectable disease, in addition to established systemic and locoregional therapies, but the surgeon must be wary of poor-quality livers and the spectre of post-hepatectomy liver failure (PHLF). Volume modulation, a cornerstone of hepatic surgery for a generation, has been given a shot in the arm with the advent of liver venous depletion (LVD) ensuring significantly more hypertrophy of the future liver remnant (FLR). The optimal timing of liver resection for those patients with synchronous disease is yet to be truly established, but evidence would suggest that those patients requiring complex colorectal surgery and major liver resection are best served with a staged approach. In the operating room, parenchyma-preserving minimally invasive surgery (MIS) can dramatically reduce the surgical insult to the patient and lead to better perioperative outcomes, with quicker return to function.

A systematic review of population-based studies on metachronous metastases of colorectal cancer

BACKGROUND

The occurrence of metachronous metastases (MM) of colorectal (CRC), colon (CC), and rectal (RC) cancer of population-based studies has not been compiled in a systematic review previously.

METHODS

MEDLINE, Embase, and Cochrane Library were searched for primary studies of any design from inception until January 2021 and updated in August 2023 (CRD42021261648). The PRISMA guidelines were adopted, and the Newcastle-Ottawa Quality Assessment Scale used for risk of bias assessment. Outcomes on overall and organ-specific MM were extracted. A narrative analysis followed.

RESULTS

Out of 2143 unique hits, 162 publications were read in full-text and 37 population-based cohort studies published in 1981-2022 were included. Ten studies adopted time-dependent analyses; eight were registry-based and seven had a low risk of bias. Three studies reported 5-year recurrence rate of MM overall of stages I-III; for CRC, it was 20.5%, for CC, it was 18% and 25.6%, and for RC, it was 23%. Four studies reported 5-year recurrence rate of organ-specific MM of stages I-III-for CRC, it was 2.2% and 5.5% for peritoneal metastases and 5.8% for lung metastases and for CC 4.5% for peritoneal metastases. Twenty-seven studies reported proportions of patients diagnosed with MM, but data on the length of follow-up was incomplete and varied widely. Proportions of patients with CRC stages I-III that developed MM overall was 14.4%-26.1% in 10 studies. In relation to the enrollment period, a downward trend may be discernible.

CONCLUSION

Studies adopting a more appropriate analysis were highly heterogeneous, whereas uncertain data of partly inadequate studies may indicate that MM are overall declining.

Robotic Stereotactic Body Radiation Therapy for Oligometastatic Liver Metastases: A Systematic Review of the Literature and Evidence Quality Assessment

INTRODUCTION

The role of stereotactic body radiation therapy (SBRT) as a locally effective therapeutic approach for liver oligometastases from tumors of various origin is well established. We investigated the role of robotic SBRT (rSBRT) treatment on oligometastatic patients with liver lesions.

MATERIAL AND METHODS

This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The PubMed and Scopus databases were accessed by two independent investigators concerning robotic rSBRT for liver metastases, up to 3 October 2023.

RESULTS

In total, 15 studies, including 646 patients with 847 lesions that underwent rSBRT, were included in our systematic review. Complete response (CR) after rSBRT was achieved in 40.5% (95% CI, 36.66-44.46%), partial response (PR) in 19.01% (95% CI, 16.07-22.33%), whereas stable disease (SD) was recorded in 14.38% (95% CI, 11.8-17.41%) and progressive disease (PD) in 13.22% (95% CI, 10.74-16.17%) of patients. Progression-free survival (PFS) rates at 12 and 24 months were estimated at 61.49% (95% CI, 57.01-65.78%) and 32.55% (95% CI, 28.47-36.92%), respectively, while the overall survival (OS) rates at 12 and 24 months were estimated at 58.59% (95% CI, 53.67-63.33%) and 44.19% (95% CI, 39.38-49.12%), respectively. Grade 1 toxicity was reported in 13.81% (95% CI, 11.01-17.18%), Grade 2 toxicity in 5.57% (95% CI, 3.82-8.01%), and Grade 3 toxicity in 2.27% (955 CI, 1.22-4.07%) of included patients.

CONCLUSIONS

rSBRT represents a promising method achieving local control with minimal toxicity in a significant proportion of patients. Further studies are needed to evaluate the role of rSBRT in the management of metastatic liver lesions.

Predicting early recurrence after resection of initially unresectable colorectal liver metastases: the role of baseline and pre-surgery clinical, radiological and molecular factors in a real-life multicentre experience

BACKGROUND

Advances in surgical techniques and systemic treatments have increased the likelihood of achieving radical surgery and long-term survival in metastatic colorectal cancer (mCRC) patients with initially unresectable colorectal liver metastases (CRLMs). Nonetheless, roughly half of the patients resected after an upfront systemic therapy experience disease relapse within 6 months from surgery, thus leading to the question whether surgery is actually beneficial for these patients.

MATERIALS AND METHODS

A real-world dataset of mCRC patients with initially unresectable liver-limited disease treated with conversion chemotherapy followed by radical resection of CRLMs at three high-volume Italian institutions was retrospectively assessed with the aim of investigating the association of baseline and pre-surgical clinical, radiological and molecular factors with the risk of relapse within 6 or 12 months from surgery.

RESULTS

Overall, 268 patients were included in the analysis and 207 (77%) experienced recurrence. Ninety-six (46%) of them had disease relapse within 6 months after CRLM resection and in spite of several variables associated with early recurrence at univariate analyses, only primary tumour resection at diagnosis [odds ratio (OR) 0.53, 95% confidence interval (CI) 0.32-0.89, P = 0.02] remained significant in the multivariable model. Among patients with resected primary tumours, pN+ stage was associated with higher risk of disease relapse within 6 months (OR 3.02, 95% CI 1.23-7.41, P = 0.02). One hundred and forty-nine patients (72%) had disease relapse within 12 months after CRLMs resection but none of the analysed variables was independently associated with outcome.

CONCLUSIONS

Clinical, radiological and molecular factors assessed before and after conversion chemotherapy do not reliably predict early recurrence after secondary resection of initially unresectable CRLMs. While novel markers are needed to optimize the cost/efficacy balance of surgical procedures, CRLM resection should be offered as soon as metastases become resectable during first-line chemotherapy to all patients eligible for surgery.

Evolving survival gains in patients with young-onset colorectal cancer and synchronous resectable liver metastases

We aimed to evaluate the practice and the associated outcomes of surgical treatment for young-onset colorectal cancer (YOCRC) patients presenting with synchronous liver metastases. The study cohort was divided into two groups according to surgery date: 131 patients in the early era (EE, 1998-2011) and 179 in the contemporary era (CE, 2012-2020). The CE had a higher rate of node-positive primary tumors, higher carcinoembryonic antigen level, and lower rate of RAS/BRAF mutations. The CE had higher rates of reverse or combined resection, multi-drug prehepatectomy chemotherapy, and two-stage hepatectomy. The median survival was 8.4 years in the CE and 4.3 years in the EE (p = 0.011). On multivariate analysis, hepatectomy in the CE was independently associated with improved overall survival (HR 0.48, p = 0.001). With a combination of perioperative systemic therapy, careful selection of treatment approach, and coordinated resections, durable cure can be achieved in YOCRC patients.

Locally advanced mid/low rectal cancer with synchronous resectable liver metastases: systematic review of the available strategies and outcome

The management of patients with locally advanced mid/low rectal cancer with resectable liver metastases is complex because of the need to combine the optimal treatment of both tumors. This study aims to review the available treatment strategies and compare their outcome, focusing on radiotherapy (RT) and liver-first approach (LFA). A systematic review was performed in PubMed, Embase, and web sources including articles published between 2000 and 02/2023 and reporting mid-/long-term outcomes. Overall, twenty studies were included (n = 1837 patients). Three- and 5-year overall survival (OS) rates were 51-88% and 36-59%. Although several strategies were reported, most patients received RT (1448/1837, 79%; > 85% neoadjuvant). RT reduced the pelvic recurrence risk (5.8 vs. 13.5%, P = 0.005) but did not impact OS. Six studies analyzed LFA (n = 307 patients). LFA had a completion rate similar to the rectum-first approach (RFA, 81% vs. 79%) but the interval strategy-an LFA variant with liver surgery in the interval between radiotherapy and rectal surgery-had a better completion rate than standard LFA (liver surgery/radiotherapy/rectal surgery, 92% vs. 75%, P = 0.011) and RFA (79%, P = 0.048). Across all series, LFA achieved the best survival rates, and in one paper it led to a survival advantage in patients with multiple metastases. In conclusion, different strategies can be adopted, but RT should be included to decrease the pelvic recurrence risk. LFA should be considered, especially in patients with high hepatic tumor burden, and RT before liver surgery (interval strategy) could maximize its completion rate.