Treating rectal cancer that has spread to the liver: liver or rectum first?

This study assessed the outcome of a reverse treatment strategy for rectal cancer patients with cancer that has spread to the liver (liver metastases).

The best treatment approach for patients with rectal cancer that has spread to the liver is not clear. In some cases the rectal cancer is treated first, followed by treatment for the liver cancer. In other cases the liver and rectal cancer can be surgically removed as the same time. It is also possible to treat the liver cancer first and then treat the rectal cancer (liver-first strategy or reverse strategy).

The liver-first strategy is effective and safe, however, the outcome of the rectal surgery has not been fully assessed after this reverse strategy.

This study included 33 patients with rectal cancer that had spread to the liver. All patients were treated with the liver-first strategy. The liver-first strategy involved an average of 3 chemotherapy cycles before liver surgery. After the liver surgery patients received chemotherapy and radiotherapy if needed (5.5 weeks), and underwent rectal surgery 6-8 weeks later. The outcome of the rectal surgery and patient survival was assessed in this study.

Patients spent an average of 11 days in hospital after the rectal surgery (5 to 23 days). 27.3% of patients developed complications after surgery, 6.1% of patients had severe complications. Severe complications included anastomotic leakage (leakage of fluid at the point where the intestines are reconnected during surgery) and severe whole-body inflammation requiring hospitalization. No patients died due to the rectal surgery.

After 1 year 81.6% of patients were still alive and after 5 years 52.5% were still alive. The cancer relapsed in the pelvis (pelvic recurrence) for 15.2% of patients. Pelvic recurrence happened after an average of 12.2 months.

The authors concluded that the liver-first strategy was safe and effective. They observed low levels of complications and good long-term outcomes. 

This was a relatively small study, future trials are needed to make sure the results are widely generalizable.