Surgery or chemotherapy first? Unveiling the best approach for colorectal cancer with resectable liver metastasis.

Background: Although neoadjuvant chemotherapy is foundational in treating stage IV colorectal cancer, its effectiveness for patients with resectable colorectal cancer liver metastasis is still under debate. This study evaluates the oncologic outcomes of operation-first compared with chemotherapy-first strategies in patients with initially resectable synchronous colorectal cancer liver metastasis, including the effects of targeted therapy and the survival outcomes after recurrence based on treatment strategy.

Methods: We conducted a retrospective analysis of 336 patients with resectable synchronous colorectal cancer liver metastasis who underwent complete radical resection and perioperative chemotherapy between 2007 and 2022. Patients were divided into operation-first (n = 244) and chemotherapy-first (n = 92) groups. The primary end points were disease-free survival and overall survival. We also explored the impact of targeted therapy and outcomes after recurrence.

Results: The operation-first group achieved significantly better disease-free survival and overall survival than the chemotherapy-first group. Targeted therapy was linked with lower disease-free survival and progression-free survival. Patients experiencing oligorecurrence who received local therapy had greater overall survival than those who underwent chemotherapy alone or those with polyrecurrence treated with local therapy plus chemotherapy or chemotherapy alone.

Conclusion: The operation-first strategy led to improved disease-free and overall survival in comparison with neoadjuvant chemotherapy for patients with resectable synchronous colorectal cancer liver metastasis. Local treatment of oligorecurrence improved oncologic outcomes, whereas perioperative targeted therapies were associated with poorer survival outcomes. These findings indicate the potential advantages of an operation-first approach; however, prospective randomized trials are necessary to verify these findings and to refine patient selection criteria.