Surgical results after downstaging of initially marginal or non-resectable liver metastases

Surgery remains the best curative treatment for resectable patients with colorectal liver metastases. In patients initially considered unresectable, both refinements in surgical technique using portal vein occlusion or two-step resections and increased efficiency of chemotherapy regimen with the adjunction of antiangiogenics now allow secondary resection. Recent evidence suggests almost identical long-term survival in case of secondary downstaged lesions advocating an aggressive approach. However, these data lie on disparate and nonconsensual criteria for unresectability, which often do not gather technical and oncologic components together. Furthermore, both impaired general status and damaged underlying parenchyma as a consequence of prolonged chemotherapy to achieve resectability as well as the technical challenge required to perform adequate carcinologic resection could increase the operative risk in such patients. In our experience, a subgroup of slow chemo-responding initially unresectable patients who required preoperative liver volume modulation after ≥ 12 cycles of chemotherapy to achieve sufficient response experienced dramatically high operative risk which jeopardized postoperative chemotherapy and subsequently put these patients at increased risk of recurrence. Whether all patients preoperatively amenable to surgery using intensive chemotherapy and complex surgical strategy actually benefit from such an aggressive approach is a matter of ongoing debate, which needs a reappraisal.