HEPATECTOMY BEFORE PRIMARY TUMOR RESECTION AS PREFERRED APPROACH FOR SYNCHRONOUS LIVER METASTASES FROM RECTAL CANCER
Harufumi Maki*, Reed I. Ayabe, Yujiro Nishioka, Tsuyoshi Konishi, Timothy E. Newhook, Hop S. Tran Cao, Yun Shin Chun, Ching-Wei D. Tzeng, Y. Nancy You, Jean-Nicolas Vauthey
Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
Background: For patients with synchronous liver metastases (LM) from rectal cancer, consensus on surgical sequencing is lacking. We compared outcomes between the reverse (hepatectomy first), classic (primary tumor resection first), and combined (simultaneous hepatectomy and primary tumor resection) approaches.
Methods: A prospectively maintained database was queried for patients with rectal cancer LM diagnosed before primary tumor resection who underwent hepatectomy for LM from January 2004 to April 2021. Clinicopathological factors and survival were compared between the three approaches.
Results: Among 274 patients, 141 (51%) underwent the reverse approach; 73 (27%), the classic approach; and 60 (22%), the combined approach. Higher carcinoembryonic antigen level at LM diagnosis and higher number of LM were associated with the reverse approach. Combined-approach patients had smaller tumors and underwent less complex hepatectomies. Larger LM, BRAF mutation, and TP53 mutation were independently associated with worse overall survival (OS) (p = 0.001, 0.001 and 0.048, respectively). Although 35% of reverse-approach patients did not undergo primary tumor resection, OS did not differ between groups (Figure 1), and 82% of reverse-approach patients did not require diversion during follow-up. RAS/TP53 co-mutation was independently associated with lack of primary resection with the reverse approach (odds ratio: 0.16, 95% CI: 0.038–0.64, p = 0.010).
Conclusion: The reverse approach results in survival similar to that with the combined and classic approaches and may obviate primary rectal tumor resections and diversions that do not improve oncologic outcome but affect quality of life. RAS/TP53 co-mutation is associated with lower rate of completion of the reverse approach.
Overall survival of patients with synchronous liver metastases from rectal cancer by treatment approach (A) and by treatment approach with the reverse approach subdivided according to whether or not it was completed (B). * p < .001
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