World Journal of Surgery

, Volume 42, Issue 12, pp 4046–4053 | Cite as

Primary Tumor Versus Liver-First Approach for Synchronous Colorectal Liver Metastases: An Association Française de Chirurgie (AFC) Multicenter-Based Study with Propensity Score Analysis

  • Francesco Esposito
  • Chetana Lim
  • Antonio Sa Cunha
  • Patrick Pessaux
  • Francis Navarro
  • Daniel AzoulayEmail author
  • On behalf of the French Colorectal Liver Metastases Working Group, Association Française de Chirurgie (AFC)
Original Scientific Report



Multicenter studies comparing the reverse strategy (RS) with the classical strategy (CS) for the management of stage IVA liver-only colorectal cancer (CCR) are scarce. The aim of this study was to compare long-term survival and recurrence patterns following use of the CS and RS.


This retrospective multicenter review collected data from all consecutive patients with stage IVA liver-only CCR who underwent staged resection of CCR and liver metastases (LM) at 24 French hospitals between 2006 and 2013 and were retrospectively analyzed. Patients who underwent simultaneous liver and CCR resection, those with synchronous extrahepatic metastasis, and those who underwent emergent CCR resection were excluded. Overall survival (OS) and recurrence-free survival (RFS) rates and recurrence patterns were investigated before and after propensity score matching (PSM).


A total of 653 patients were included: 587 (89.9%) in the CS group and 66 (10.1%) in the RS group. Compared with the CS patients, RS patients were more likely to have rectal cancer (43.9 vs. 24.9%; p = 0.006), larger liver tumor size (52.5 ± 38.6 vs. 39.6 ± 30 mm; p = 0.01), and more positive lymph nodes (62.1 vs. 44.8%; p = 0.009). OS was not different between the two groups (75 vs. 72% at 5 years; p = 0.77), while RFS was worse in the RS group (24 vs. 33% at 5 years; p = 0.01). Time to recurrence at any site (1.8 vs. 2.4 years, p = 0.024) and intrahepatic recurrence (1.7 vs. 2.2 years, p = 0.014) were significantly shorter in the RS group than in the CS group. After PSM (63 patients in each group), no significant difference was found between the two groups in OS (p = 0.35), RFS (p = 0.62), time to recurrence at any site (p = 0.19), or intrahepatic recurrence (p = 0.13).


In this study, approximately 10% of patients with CCR and synchronous LM were offered surgery with the RS. Both strategies ensured similar oncological outcomes.



The authors would like to thank all participating centers for their contribution to this study.

Contributors: Amiens, CHU Amiens Picardie: Cyril Cosse, Delphine Lignier, Jean Marc Regimbeau; Angers, CHU Angers: Julien Barbieux, Emilie Lermite, Antoine Hamy; Beauvais, CH Beauvais: François Mauvais; Bordeaux, Groupe Hospitalier Saint André: Christophe Laurent; Chambery, CH Chambery: Irchid Al Naasan; Créteil, CHU Henri Mondor: Daniel Azoulay, Chady Salloum, Philippe Compagnon, Chetana Lim; Eaubonne, Hôpital Simone Veil: Mohammed Sbai Idrissi; Epinal, Polyclinique de la Ligne Bleue: Fréderic Martin; Gap, CH des Alpes du Sud: Jerôme Atger; Lyon, Hôpital de la Croix Rousse: Jacques Baulieux, Benjamin Darnis, Jean Yves; Mabrut; Lyon, Hôpital Edouart-Herriot: Vahan Kepenekian, Julie Perinel, Mustapha Adham; Lyon, CH Lyon Sud: Olivier Glehen; Lyon, Centre Léon Bérard: Michel Rivoire; Marseille, Hôpital de la Conception: Jean Hardwigsen, Anais Palen, Emilie Grégoire, Yves Patrice LeTreut; Marseille, Institut Paoli-Calmettes: Jean Robert Delpero, Olivier Turrini; Montpellier, Hôpital Saint Eloi: Astrid Herrero, Francis Navarro, Fabrizio Panaro; Nancy, CHU Brabois: Ahmet Ayav, Laurent Bresler; Nancy, Institut de Cancérologie de Lorraine Alexis-Vautrin: Philippe Rauch, François; Guillemin, Fréderic Marchal; Nice, Hôpital de l’Archet: Jean Gugenheim, Antonio Iannelli; Kremlin Bicêtre, CHU Kremlin Bicêtre: Stephane Benoist, Antoine Brouquet; Paris, Hôpital Lariboisière: Marc Pocard, Réa Lo Dico; Paris, Institut Mutualiste Montsouris: Brice Gayet, David Fuks; Paris, Hôpital Saint Antoine: Olivier. Scatton, Olivier Soubrane; Paris, Hôpital de la Pitié Salpetrière: Jean-Christophe Vaillant; Reims, Hôpital Robert Debré: Tullio Piardi, Daniel Sommacale, Reza Kianmanesh; La Roche-sur-Yon, Centre départemental de Vendée: Michel Comy; Strasbourg, Hôpital Hautepierre: Philippe Bachellier, Elie Oussoultzoglou, Pietro Addeo; Strasbourg, Nouvel Hôpital Civil: Dimitrios Ntourakis, Patrick Pessaux, Didier Mutter, Jacques Marescaux; Toulouse, Hôpital Rangueil: Loïc Raoux, Bertrand Suc, Fabrice Muscari; Troyes, Hôpital des Hauts-Clos: Georges Elhomsy; Villejuif, Hôpital Paul Brousse: Maximiliano Gelli, Antonio Sa Cunha, René Adam, Denis Castaing, Daniel Cherqui; Gabriella Pittau, Oriana Ciacio, Eric Vibert; and Villejuif, Gustave Roussy: Dominique Elias, Diane Goére, Fabrizio Vittadello.

Author contributions

Esposito, Lim, and Azoulay contributed to the study concept and design and statistical analysis. All authors involved in acquisition, analysis, and interpretation of data. Esposito, Lim, and Azoulay drafted the manuscript. Lim, Azoulay, Sa Cunha, Navarro, and Pessaux critically revised the manuscript for important intellectual content. Navarro, Sa Cunha, and Pessaux provided administrative, technical, and material support. Lim and Azoulay supervised the study.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

268_2018_4711_MOESM1_ESM.docx (21 kb)
Supplementary material 1 (DOCX 21 kb)
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Supplementary material 2 (DOCX 16 kb)
268_2018_4711_MOESM3_ESM.docx (14 kb)
Supplementary material 3 (DOCX 14 kb)
268_2018_4711_MOESM4_ESM.docx (17 kb)
Supplementary material 4 (DOCX 17 kb)


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Copyright information

© Société Internationale de Chirurgie 2018

Authors and Affiliations

  • Francesco Esposito
    • 1
  • Chetana Lim
    • 1
  • Antonio Sa Cunha
    • 2
  • Patrick Pessaux
    • 3
    • 4
  • Francis Navarro
    • 5
  • Daniel Azoulay
    • 1
    • 6
    Email author
  • On behalf of the French Colorectal Liver Metastases Working Group, Association Française de Chirurgie (AFC)
  1. 1.Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor HospitalUniversité Paris-Est (UPEC)CréteilFrance
  2. 2.Department of Hepatobiliary and Pancreatic Surgery and Liver TransplantationPaul Brousse HospitalVillejuifFrance
  3. 3.Institut Hospitalo-Universitaire, Institute for Minimally Hybrid Invasive Image-Guided SurgeryUniversité de StrasbourgStrasbourgFrance
  4. 4.Institut de Recherche sur les Cancers de l’Appareil Digestif (IRCAD)StrasbourgFrance
  5. 5.Department of Surgery, Saint-Eloi HospitalUniversité de MontpellierMontpellierFrance
  6. 6.INSERM, U955CréteilFrance

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