Comparing surgery options for patients with colorectal cancer that has spread to the liver

The aim of this study was to evaluate 2 treatment options for patients with colorectal cancer (CRC) that has spread to the liver. The study found that patients who underwent associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) had better outcomes compared to those who had 2-stage hepatectomy (TSH).

Liver metastasis (LM; cancer spread to the liver) is common in patients with CRC. Patients with CRC and LM can have surgery to remove the LM. Patients are often given chemotherapy (CT) before surgery to shrink the tumor.

In patients that have a high number of LM, it is not possible to remove all the tumors at once. In these patients, the resection can be done in two stages. First, the highest amount of tumor possible is removed. Then the liver has a chance to recover and regenerate for a few weeks. In the second stage, the patient has another surgery to try to remove all the remaining LM. This is a common treatment method for CRC with LM and is called a two-stage hepatectomy (TSH). Patients that have a bad liver recovery/regeneration between surgeries have a poor outcome.  Some of these patients may not be able to progress to the second surgery.

A newer strategy for LM resection is called ALPPS. ALPPS aims to increase liver recovery between stages 1 and 2 of surgery. The surgeon resects the tumor in a different way to TSH. This allows for faster and higher rates of liver recovery.

It is not currently known whether TSH or ALPPS gives patients with LM a better outcome.

This study included data from 100 patients. Patients were randomly assigned to receive ALPPS (group 1) or TSH (group 2). Patients were given CT after surgery if their oncologist decided they needed it. The average follow-up time was 38 months.

92% of patients in group 1 had an effective surgery. 80% of patients in group 2 had an effective surgery. 1 month after the surgery, 77% of group 1 and 57% of group 2 were free of liver tumors. 

Patients in group 1 had an estimated survival rate of 46 months. In group 2, the estimated survival rate was 26 months. ALPPS was associated with a 48% better chance of improved survival compared to TSH.

The study concluded that patients with LM that were treated with ALPPS had a better outcome than those treated with TSH.

The sample size was small. The improvement in ALPPS over TSH had a low statistical significance. Some patients in group 2 were given ALPPS after TSH which makes the results difficult to analyze. More randomized trials comparing ALPPS and TSH should be carried out to get more definite results.