Bond, Marinde J G

Punt, Cornelis J A

Swijnenburg, Rutger-Jan

Utrecht University Repository

Vol:.(1234567890)Ann Surg Oncol (2023) 30:5386–5387https://doi.org/10.1245/s10434-023-13513-4ASO AUTHOR REFLECTIONSASO Author Reflections: Towards Consensus on Resectability Assessments and Local Treatment Planning for Patients with Initially Unresectable Colorectal Cancer Liver MetastasesMarinde J. G. Bond, MD1, Cornelis J. A. Punt, MD, PhD1, and Rutger‑Jan Swijnenburg, MD, PhD2,31Department of Epidemiology, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands; 2Department of Surgery, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; 3Cancer Center Amsterdam, Amsterdam, The Netherlands PASTLocal treatment (e.g. surgery and ablation) is the only potentially curative treatment for patients with colorectal cancer liver metastases (CRLM). However, not all patients who may be eligible for local treatment are offered this option. This is due to the absence of transparent and vali-dated criteria for local treatment as well as the inability to keep up with local treatment possibilities by improving sur-gical techniques such as ablation and liver augmentation in non-liver expert centres. Previous studies have shown that the use of online liver expert panels may increase the number of patients who may benefit from local treatment.1,2 How-ever, disagreements in resectability assessments as well as in the type of local treatment have been demonstrated even among experienced liver surgeons.3–5 To improve the quality of care for patients with CRLM, more data are required to establish the optimal method of evaluation of these patients and to identify the main factors that contribute to the afore-mentioned disagreements.PRESENTThis study assessed the variability in resectability assess-ments and local treatment planning among 17 surgeons par-ticipating in the Dutch Colorectal Cancer Group (DCCG) liver expert panel from the randomised controlled phase III CAIRO5 study (NCT02162563).6 In this RCT, patients with initially unresectable colorectal cancer liver-only metastases were randomised between the currently most effective induc-tion regimens consisting of chemo- and targeted therapy. The analysis of 1149 evaluations of 496 patients showed disagreement between panel surgeons in 50% of resect-ability assessments, and surgeons proposing different local treatment plans in 77% of patients. The most pronounced inter-surgeon differences concerned the advice to proceed with a major hepatectomy versus parenchymal-preserving approaches involving local resection and ablation strategies.FUTURESeveral steps should be taken to reduce this unwarranted variability and to ensure that every patient who is eligible for local treatment is given the opportunity to undergo such treatment. First, all patients with CRLM should be evaluated by a multidisciplinary team involving at least one liver sur-geon, and preferably by a panel of multiple surgeons consid-ering the high rate of disagreement. The implementation of online liver expert panels within oncological networks can help to improve the consistency and quality of care. These panels allow multiple experts to review patients, reducing variability and ensuring that every patient, including those with multiple CRLM, is evaluated for local treatment before and after systemic therapy. This is particularly important given the success of induction therapy in CRLM. Second, consensus guidelines on resection criteria and technical approaches should be further developed to enhance the standardisation of local treatment. Current local treatment evaluation of initially unresectable CRLM remains primarily © The Author(s) 2023First Received: 20 March 2023 Accepted: 20 March 2023 Published online: 21 April 2023R.-J. Swijnenburg, MD, PhD e-mail: r.j.swijnenburg@amsterdamumc.nl5387ASO Author Reflections: Towards Consensus …               a technical anatomical decision. Existing clinically available tumour biomarkers fall short in predicting early recurrence after local treatment of CRLM, i.e., selecting patients who will and will not derive benefit from local treatment.7 Lastly, most studies in patients with initially unresectable CRLM only report on the percentage of patients in whom local treatment was achieved, and not on the long-term outcome of these patients.8 More efforts should be made to iden-tify patients in whom local treatments result in a clinically meaningful benefit. Therefore, further research is needed to explore whether resectability assessments can be supported by other biological resection criteria such as the consen-sus molecular subtypes and/or circulating tumour DNA. In addition, it is important to examine whether the different technical treatment plans as proposed by the panel surgeons are associated with differences in survival and postoperative morbidity.DISCLOSURE C.J.A.P. has an advisory role for Nordic Pharma. This funding is not related to the current research. M.J.G.B. and R.J.S. declare no potential conflicts of interest.OPEN ACCESS This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adap-tation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.REFERENCES 1. Jones RP, Vauthey JN, Adam R, et  al. Effect of specialist decision-making on treatment strategies for colorectal liver metastases. Br J Surg. 2012;99(9):1263–9. https:// doi. org/ 10. 1002/ bjs. 8835. 2. Hellingman T, de Swart ME, Joosten JJA, et al. The value of a dedicated multidisciplinary expert panel to assess treatment strat-egy in patients suffering from colorectal cancer liver metastases. Surg Oncol. 2020;35:412–7. https:// doi. org/ 10. 1016/j. suronc. 2020. 09. 024. 3. Folprecht G, Gruenberger T, Bechstein WO, et  al. Tumour response and secondary resectability of colorectal liver metas-tases following neoadjuvant chemotherapy with cetuximab: the CELIM randomised phase 2 trial. Lancet Oncol. 2010;11(1):38–47. https:// doi. org/ 10. 1016/ S1470- 2045(09) 70330-4. 4. Huiskens J, Bolhuis K, Engelbrecht MR, et al. Outcomes of resectability assessment of the Dutch Colorectal Cancer Group liver metastases expert panel. J Am Coll Surg. 2019;229(6):523–32. https:// doi. org/ 10. 1016/j. jamco llsurg. 2019. 08. 1445. 5. Ignatavicius P, Oberkofler CE, Chapman WC, et al. Choices of therapeutic strategies for colorectal liver metastases among expert liver surgeons: a throw of the dice? Ann Surg. 2020;272(5):715–22. https:// doi. org/ 10. 1097/ SLA. 00000 00000 004331. 6. Bond MJG, Kuiper BI, Bolhuis K, et al. Intersurgeon variability in local treatment planning for patients with initially unresectable colorectal cancer liver metastases: Analysis of the Liver Expert Panel of the Dutch Colorectal Cancer Group. Ann Surg Oncol. 2023. https:// doi. org/ 10. 1245/ s10434- 023- 13510-7. 7. Bolhuis K, Bond MJG, Amerongen MJV, et  al. The role of tumour biological factors in technical anatomical resectability assessment of colorectal liver metastases following induction systemic treatment: an analysis of the Dutch CAIRO5 trial. Eur J Cancer. 2023;183:49–59. https:// doi. org/ 10. 1016/j. ejca. 2023. 01. 013. 8. Bolhuis K, Kos M, van Oijen MGH, Swijnenburg RJ, Punt CJA. Conversion strategies with chemotherapy plus targeted agents for colorectal cancer liver-only metastases: A systematic review. Eur J Cancer Oxf Engl. 1990;2020(141):225–38. https:// doi. org/ 10. 1016/j. ejca. 2020. 09. 037.Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

ASO Author Reflections: Towards Consensus on Resectability Assessments and Local Treatment Planning for Patients with Initially Unresectable Colorectal Cancer Liver Metastases

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ASO Author Reflections: Towards Consensus on Resectability Assessments and Local Treatment Planning for Patients with Initially Unresectable Colorectal Cancer Liver Metastases

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