A patient with stage IV colorectal cancer has synchronous liver metastases (3 lesions in the right lobe, all resectable). The primary colon cancer is symptomatic (causing obstruction). What is the current surgical strategy?

• A Palliative chemotherapy only; surgery not indicated in stage IV
• B Colorectal resection first followed by liver-directed therapy
• C Liver resection first in all cases, followed by colectomy
• D Simultaneous resection of colon primary and liver metastases, or liver-first approach depending on tumor biology and symptoms ✓

Explanation

For synchronous colorectal liver metastases, several surgical strategies exist: (1) simultaneous resection of the primary and liver metastases in fit patients with limited hepatic disease; (2) primary-first approach — colectomy followed by chemotherapy then liver resection; (3) liver-first approach (reverse strategy) for right-sided colon primaries with large or borderline resectable liver disease, allowing systemic chemotherapy to treat the primary while addressing the dominant liver disease. The choice depends on patient fitness, primary tumor symptoms, extent of liver disease, and need for staged operations. In all cases, resection of both sites with curative intent can achieve 5-year survival of 25-40%.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.