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Assessing Resectability of Colorectal Liver Metastases: Diagnostic Chaos!
Jean-Michel Aubin*1, Alexsander K. Bressan1, Sean C. Grondin1, Elijah Dixon1, Anthony R. MacLean1, Sean Gregg1, Patricia A. Tang1, Gilaad Kaplan1, Guillaume Martel2, Chad G. Ball1
1University of Calgary, Calgary, AB, Canada; 2University of Ottawa, Ottawa, ON, Canada

The definition of resectable colorectal liver metastases (CRLM) has evolved substantially over time. An increasing number of techniques available to liver surgeons have led to more extensive resections and increasing confusion regarding resectability amongst other care providers. The goal of this study was to assess the perception of resectability amongst patients with CRLM.
A survey was distributed to General and Colorectal Surgeons, as well as Surgical and Medical Oncologists. No liver surgeons were invited. Clinical scenarios (with CT images) from 6 patients with CRLM were presented to assess clinicians’ impression of resectability. Criteria for defining resectability were also obtained. Unknown to participants, all patients had undergone complete R0 resection of hepatic metastases.
Fifty-five clinician responses (62%=surgeons, 38%=non-surgeons) were obtained. Colorectal malignancies represented at least half of a clinician’s practice mix for 31% of surgeons and 50% of non-surgeons. For each of the 6 case scenarios, the patient was deemed resectable by 64%, 72%, 62%, 71%, 24% and 58% of respondents overall. The mean number of cases perceived to be resectable was variable (Colorectal Surgery: 3.0/6; Medical Oncology: 3.3/6; General Surgery: 3.7/6; Surgical Oncology: 4.5/6)(p<0.05). When deemed ‘unresectable’, only 61% of surgeons and 56% of non-surgeons would refer the patient to either HPB or a multidisciplinary conference for assessment. On average, 70% of clinicians would urgently refer patients from these 6 case scenarios to an HPB service. Factors cited in defining resectability varied dramatically: (1) the ability to clear all hepatic disease (98%), (2) the ability to obtain an R0 resection (77%), (3) the presence of disease limited to the liver (55%), (4) the absence of vascular invasion (40%), (5) the number of liver lesions (36%), (6) the size of liver lesions (19%), and (7) the time interval to metastases (19%). Distance to an HPB centre influenced referral patterns for both patients (42%) and clinicians (11%).
This study highlights the extensive discordance and dated nature that exists amongst non-liver surgeon evaluations of CRLM resectability. All clinician groups significantly underestimated the ability to achieve R0 clearance of these patients. Given that all patient scenarios had undergone complete resection of their CRLM, resectability is best assessed by HPB surgeons. When deemed unresectable by a non-liver surgeon, a worrisome, low number of patients are referred to an HPB service for detailed evaluation.

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