If you apply Fong’s score (or some other externally validated prognostic/risk scoring system) to your mean data you will probably see that they are representing group with points ≥3. The reccurence and survival in these patients does not differ significantly from your group. Some published data suggests that no patient with CRCLM with a score >3 survive more than 24 months. It is still not evidence that ALPPS is the problem especially looking at the extent of disease in patients treated with this approach.

I aggree. We still not know wether the high recurrence rate is caused by the ALPPS procedure or is just due to the extend the underlying malignant disease.

It is the typical life cycle of a new method in surgery/medicine. If you start, you have highly selected patients - and perhaps good results (or bad ones). But then, the method is used not in these highly selected group of patients and the results will be worse.

3 early relapses in 8 cases after ALPPS

It is possible that CRLM are not the best indication for ALPPS, but other liver tumors would benefit of such a challenging approach. Anyway even if preliminar data on early relapse seem to be descouraging, we are still at the beginning of this history. More data are needed to achieve clear indications and limits of the method.

We compared the Fung scores of 141 patients with CRLM treated ith ALPPS in 41 centers worldwide with the Fung score of 65 patietns with CRLM treated with two-stage hepatectomy by the MD Anderson group and publishhd in their famous JCO paper (Brouquet et al. JCO 2011) and found that ALPPS patients were generally older, had more lesions and a larger tumor diameter of the largest lesion, CEA was similar and the % of rectal cases was similar.  However the survival and disease -free survival was identical, if not better for ALPPS (59% DFS at 1 year and 41% at 2 years). The paper will be pubished in ANNALS in november.

I bet you that what you and many obersever in terms of high recurrence with ALPPS is a selsection bias, because the worst and most extensive CRLM cases are treated with ALPPS. Indeed we recently submitted a paper of 12 cases in which I argue that they could anatomically not be done without ALPPS.

Many people are calling for more data, but they easiest way to get to more data is to join efforts. I initiated a world-wide registry www.alpps.net and we now ahve 355 cases of ALPPS in the registry. 10 groups are currently analyzing these data worldwide, from Sao Paolp to Bejing and you can follow their porjects on www.alpps.net. I encourage you and others to join the regisitry and ask for the database of the 355 patients, which we can hand out to you 14 days after we ask for permission form the scientific commitee of the registry. Let us please work together.