NEW YORK (Reuters Health) – When colorectal metastases to the liver are resectable, preoperative chemo is not beneficial. For unresectable lesions, however, chemotherapy to downsize the lesions can be recommended.

Those conclusions come from a systematic review of the pros and cons of preoperative chemotherapy in patients with colorectal liver metastases, reported in the Annals of Surgery for November.

Dr. Pierre-Alain Clavien and colleagues at University Hospital Zurich, Switzerland explain that the use of chemotherapy before hepatic resection of colorectal metastases should be looked at in two distinct settings: as downsizing therapy aimed at reducing unresectable lesions to resectable status, and as neoadjuvant therapy in patients presenting with resectable tumors.

To assess the risks and benefits of preop chemo in these scenarios, the authors identified 805 clinical articles in English on the topic.

For downsizing, based on a selection of 20 relevant articles, the team concludes that chemotherapy can result in a resectability rate of about 30%, although many regimens are associated with numerous side effects.

In the case of clearly resectable lesions, the authors argue that the only justification for neoadjuvant chemotherapy should be a significant improvement in disease-free and overall survival. They failed to find that in their review of 14 studies.

For example, in the only randomized trial addressing the issue, an increase in progression-free survival at 3 years with neoadjuvant therapy did not lead to increased overall survival, and postop complications due to steatohepatitis or obstruction syndrome were higher in patients receiving neoadjuvant therapy.

Also, in retrospective studies analyzed, adjuvant therapy after surgery was associated with improved survival but neoadjuvant chemotherapy was not.

Summing up, Dr. Clavien and colleagues conclude: “Taken together, the data indicates that for unresectable liver metastases, downsizing chemotherapy may offer a chance for secondary resection in about a third of patients … In contrast, routine neoadjuvant chemotherapy cannot be recommended due to the increased risk of complications without clear benefit on survival.”

Reference:

Chemotherapy Before Liver Resection of Colorectal Metastases: Friend or Foe?

Ann Surg 2011;254.