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OncoSurge: A Strategy for Improving Resectability With Curative Intent in Metastatic Colorectal Cancer

From the Royal Liverpool University Hospital, Liverpool; University of Southampton, Southampton, UK; Hopital Ambroise Pare, Boulogne; Hopital Paul Brousse, Villejuif; Evidis, Paris, France; Mayo Clinic, Rochester, MN; The University of Texas M.D. Anderson Cancer Center, Houston, TX; L'Hospitalet de Llobregat, Barcelona, Spain; University of Pennsylvania Cancer Center, Philadelphia PA; Hopital Cantonal, Geneva, Switzerland; Marlene and Stewart Greenebaum Cancer Center, Baltimore MD; Allegheny General Hospital, Pittsburgh PA; University Medical Center, Nijmegen; RAND Europe, Leiden, the Netherlands; and Martin Luther University, Halle, Germany

Address reprint requests to Graeme J. Poston, Department of Surgery, Royal Liverpool University Hospital, Prescot St, Liverpool L7 8XP, UK. e-mail: GRAEME.POSTON{at}aht.nwest.nhs.uk

PURPOSE: Most patients with colorectal liver metastases present to general surgeons and oncologists without a specialist interest in their management. Since treatment strategy is frequently dependent on the response to earlier treatments, our aim was to create a therapeutic decision model identifying appropriate procedure sequences.

METHODS: We used the RAND Corporation/University of California, Los Angeles Appropriateness Method (RAM) assessing strategies of resection, local ablation and chemotherapy. After a comprehensive literature review, an expert panel rated appropriateness of each treatment option for a total of 1,872 ratings decisions in 252 cases. A decision model was constructed, consensus measured and results validated using 48 virtual cases, and 34 real cases with known outcomes.

RESULTS: Consensus was achieved with overall agreement rates of 93.4 to 99.1%. Absolute resection contraindications included unresectable extrahepatic disease, more than 70% liver involvement, liver failure, and being surgically unfit. Factors not influencing treatment strategy were age, primary tumor stage, timing of metastases detection, past blood transfusion, liver resection type, pre-resection carcinoembryonic antigen (CEA), and previous hepatectomy. Immediate resection was appropriate with adequate radiologically-defined resection margins and no portal adenopathy; other factors included presence of 4 or > 4 metastases and unilobar or bilobar involvement. Resection was appropriate postchemotherapy, independent of tumor response in the case of 4 metastases and unilobar liver involvement. Resection was appropriate only for > 4 metastases or bilobar liver involvement, after tumor shrinkage with chemotherapy. When possible, resection was preferred to local ablation.

CONCLUSION: The results were incorporated into a decision matrix, creating a computer program (OncoSurge). This model identifies individual patient resectability, recommending optimal treatment strategies. It may also be used for medical education.

Supported by an unrestricted educational grant from the Sanofi-Synthelabo Group.

Presented previously at the 40th Annual Meeting of the American Society of Clinical Oncology, New Orleans, LA, June 5-8, 2004; the 29th Annual Meeting of the Euproean Society of Medical Oncology, Vienna, Austria, October 29-November 2, 2004; and the American Society of Clinical Oncology Gastrointestinal Cancers Symposium, Hollywood, FL, January 27-29, 2005.

The results of this study have not been subject to approval by the Sanofi-Synthelabo Group. The recommendations given in this study are solely the responsibility of the authors and do not represent the views of the Sanofi-Synthelabo Group.

Authors' disclosures of potential conflicts of interest are found at the end of this article.

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