All of the published data, as well as recently published international consensus stated that in SELECTED patients the liver-first approach offers as good an outcome as the conventional approach.

You can look at the consensus and reference papers.

http://theoncologist.alphamedpress.org/content/17/10/1225.full.pdf+html

I totally agree but, if the assumption is correct, the liver-first approach could even turn out to be superior than the conventional staged approach under the condition that it becomes as much as "tissue sparing" as possible, in orded to exactly avoid a systematic growth potential, that could boost tumor growth in the primary site and in distant subclinical lesions.

It is important to note that liver-first approach is generally proposed for patients with advanced RECTAL cancer and marginally resectable synchronous liver metastases. These patients needed neoadjuvant CRT for their primary tumor and six or more months usually passed before addressing the hepatic component of the disease. In the vast majority of the patients, disease in the liver progresses to unresectable state during that time, or the patients are still not fit for further major surgery. So to address liver-first seems logical in those patients, moreover the primary tumor is not left untreated during that time, as patients usually received neoadjuvant chemo- followed by CRT which controlled well the rectal primary. Surely in some cases the liver-first is preferable.

Dear Dr Julianov,

Thank you for your comment, which is clearly indicative of the complexity of the management of these patients. The achievement of the optimal clinical benefit for every patient depends significantly on the appropriate initial selection, critical interpretation of the current data and personal experience, fact that highlights the challenge of a tailored approach. The reason I posted this question was the lack of any research investigating if the variations in the amount of the resected liver in the "liver-first" approach may have a different impact on the primary tumor. Adding to that, I believe that the role of the different techniques of liver resection could have a different effect on the primary tumor - from my theoretical point of view (great liver resection leads to a systematic growth effect...?).

Personally, although my surgical experience is limited, my opinion is that we should never forget that the removal of as much of the cancer load as possible, as fast as possible, is a crucial factor that can give the immune system the time to try to adopt better and withstand cancer. I think this is of great importance, taking also into account that the conventional CRT has both favorable and unfavorable consequences concerning the function of the immune system, locally and systematically. The metastatic disease is what eventually kills, but cancer is disseminated far before the detection of the metastatic lesions, in the liver, for instance, fact which in our case is a main argument of the surgeons who favor the liver-first approach. However, little attention is paid to the fact that, at this point, the bone marrow will be infiltrated and the immune system's response will have been significantly compromised for a long time.

To put in a nutshell, my point is that whenever liver surgery comes first, it should be as much as tissue sparing as possible, for reasons far more than technical. The implementation of the "new" energy sources could significantly help on this issue and maybe enable the adoption of a standard sort of "damage control" surgery for the liver as a standard procedure, when the bowel-first approach is followed.

In very selected patients 'liver first' may be helpful to control the patients disease. But you should never forget, that major loss of functional hepatic parenchyma has the consequence of passager portal hypertension and the drugs used in neoadjuvant chemoradiotherapy (5-FU/Capecitabine etc.) need a well functioning liver to work! But is not the solution of all problems because in some patients the remaining metastases start to grow very fast or you can detect some metastases those were hidden at the beginning

Dear Dr Becker,

Thank you very much for your comment. It provides an important insight with respect to the overall treatment plan that is not infrequently overlooked.