Treatment Approach for Locally Advanced Colorectal Cancer with Synchronous Hepatic Metastasis

Introduction to Treatment Guidelines

The American Society of Clinical Oncology recommends that patients with locally advanced colorectal cancer and synchronous hepatic metastasis receive intensive neoadjuvant chemotherapy with FOLFOX or FOLFIRI plus bevacizumab for 2-3 months, followed by complete surgical resection of the primary tumor and hepatic metastasis if disease control is achieved, completing a total of 6 months of perioperative chemotherapy 1, 2.

The European Society for Medical Oncology states that a hepatic lesion with a hypervascular enhancement pattern is highly suggestive of metastasis, and the diagnosis should be confirmed by biopsy or other diagnostic methods 3, 4.
The American Joint Committee on Cancer recommends that the tumor be staged as T4b due to direct invasion of adjacent organs or structures, and the metastasis be staged as M1a 3.

The National Comprehensive Cancer Network suggests that patients with locally advanced colorectal cancer and synchronous hepatic metastasis undergo urgent multidisciplinary evaluation to determine technical and oncological resectability 3, 4.
The evaluation should include assessment of the possibility of R0 resection of the primary tumor and hepatic metastasis, remnant liver function, and absence of unresectable extrahepatic disease 3, 1.

The European Society for Medical Oncology recommends that patients with locally advanced colorectal cancer and synchronous hepatic metastasis receive neoadjuvant chemotherapy with FOLFOX or FOLFIRI plus bevacizumab for 2-3 months before surgery 2, 5, 1.
The goals of neoadjuvant chemotherapy are to evaluate tumor biology and chemosensitivity, treat occult micrometastases, reduce the size of the hepatic metastasis, and obtain a "test of time" for disease control 1, 2.

The American Society of Clinical Oncology recommends that patients with locally advanced colorectal cancer and synchronous hepatic metastasis undergo simultaneous resection of the primary tumor and hepatic metastasis if both are technically resectable after neoadjuvant chemotherapy 7, 2.
The surgical procedure should include complete resection of the primary tumor and hepatic metastasis with margins, and the goal is to achieve R0 resection of all lesions 3, 1.

The National Comprehensive Cancer Network suggests that patients with locally advanced colorectal cancer and synchronous hepatic metastasis receive adjuvant chemotherapy with the same regimen used for neoadjuvant chemotherapy for a total of 6 months 2, 5, 1.

The European Society for Medical Oncology states that the 5-year survival rate for patients with locally advanced colorectal cancer and synchronous hepatic metastasis who undergo complete R0 resection of the primary tumor and hepatic metastasis is 20-45% 3, 1.
The prognosis is improved by response to neoadjuvant chemotherapy, R0 resection of all lesions, metachronous versus synchronous metastasis, and RAS/BRAF wild-type status 2, 3, 1.