Oncological strategies for middle and low rectal cancer with synchronous liver metastases

In rectal cancer, the incidence of synchronous liver metastases (SLM) ranges from 14% to 30%. The treatment of SLM combines neo-adjuvant chemo- and/or radiotherapy with of one three surgical resection strategies (rectal resection first, liver resection first or simultaneous resection). The present study evaluated the success rate for each resection strategy.

From January 2005 to December 2013, we retrospectively included all patients with distal (middle and low) rectal cancer (MLRC) and SLM and who had been operated on with curative intent. The primary study endpoint was the proportion of complete resections at both tumour sites. The secondary endpoints were postoperative morbidity, the long-term outcome and risk factors for incomplete resection.

52 patients were included. There were no significant intergroup differences in the incidence of complete resection (respectively 74%, 66% and 50% in the rectum-first (n = 20), simultaneous (n = 10) and liver-first groups (n = 5); p = 0.3), the overall complication rate or mortality rate after rectal resection (p = 0.5) or liver resection (p = 0.8), overall survival (60, 47 and 38 months, respectively; p = 0.4) or disease-free survival (31, 32 and 7.8 months, respectively; p = 0.1). Emergency surgery was the only risk factor for treatment failure (p = 0.01).

There were no differences in short and long-term outcomes between the three strategies. No one oncological strategy should be favoured for all cases of MLRC with SLM. The strategy should be choosen, based on the oncological emergency (rectum-first or liver-first), predictive factors for morbidity in rectal surgery and MDT discussion.