Full Descriptions and Definitions of Treatment Options:

Approaches for Liver Only Disease (Resectable or Convertible)

Treatment Option Definitions That May Appear in Those Cases Presenting with Unilobar or Bilobar Hepatic Metastases in the Absence of a Synchronous Primary Lesion or Simultaneous Lung Metastases

1. No resection (systemic therapy only): You do not feel that this patient should undergo surgery but that he or she should be treated with systemic therapy only for Stage IV disease.
2. Immediate resection alone: You would recommend immediate resection (no preoperative treatment) without a plan for postoperative adjuvant systemic therapy.
3. Immediate resection followed by systemic therapy: You would recommend immediate resection (no preoperative treatment) and would plan to administer postoperative adjuvant systemic therapy, whether the resection is R0 or R1.
4. Preoperative systemic therapy and resection followed by systemic therapy: You would recommend the “Nordlinger” approach of perioperative systemic therapy, half administered prior to surgery and the other half postoperatively. The decision to use preoperative therapy is not predicated on a need to shrink or convert the liver lesion(s).
5. Preoperative systemic therapy, and resection if tumor response is adequate (conversion therapy): You would recommend neoadjuvant (preoperative) systemic therapy to shrink or convert the liver lesion(s) to facilitate resection, and you would plan to proceed with resection if this is successful, but you would NOT follow the procedure with additional postoperative adjuvant systemic therapy.
6. Preoperative systemic therapy and resection if tumor response is adequate (conversion therapy), followed by systemic therapy: You would recommend neoadjuvant (preoperative) systemic therapy to shrink or convert the liver lesion(s) to facilitate resection, and you would plan to proceed with resection if this is successful, but you would also follow the procedure with additional postoperative adjuvant systemic therapy, whether the resection is R0 or R1.
7. PVE (staged or prior to any resection) with or without preoperative systemic therapy and, with adequate segment hypertrophy (and tumor response, if necessary), resection with or without postoperative systemic therapy: For a patient with questionable hepatic reserve, you would like to bring him or her to surgery and recommend portal vein embolization (PVE) prior to resection (which may be staged if disease is bilobar). You may also recommend neoadjuvant (preoperative) systemic therapy to shrink or convert the liver lesion(s) to facilitate resection, and you would plan to proceed with resection if this is successful. Postoperative systemic therapy would be considered after completion of all surgery (single or staged procedure).

Approaches for Synchronous Primary Disease and Liver Metastases

Treatment Option Definitions That May Appear in Those Cases Presenting with Intact Primary Colon Cancer and Synchronous Hepatic Metastases

1. No resection (systemic therapy only): You do not feel that this patient should undergo surgery but that he or she should be treated with systemic therapy only for Stage IV disease.
2. Immediate resection of primary lesion only (with or without postoperative systemic therapy): You feel that the patient is not a candidate for resection of both the primary lesion and the hepatic metastases, and you believe that the primary lesion should be removed surgically and the liver treated by other means (eg, systemic therapy, local ablative or radiation therapy techniques). Postoperative systemic therapy would be considered after completion of surgery.
3. Immediate resection of liver metastases only (with or without postoperative systemic therapy): You believe the asymptomatic primary tumor may initially be left in place and that the patient would be best served by immediate resection of the liver metastases. Postoperative systemic therapy would be considered after completion of surgery.
4. Immediate resection of primary lesion and liver metastases (single or staged procedure but no systemic therapy between procedures if staged, with or without postoperative systemic therapy): You believe that both the primary lesion and the liver metastases are resectable at presentation and would proceed with surgery as a single or two-step staged procedure. Postoperative systemic therapy would be considered after completion of all surgery.
5. Preoperative systemic therapy followed by resection of primary lesion and liver metastases (single or staged procedure, with or without postoperative systemic therapy): You would remove both the primary lesion and the liver metastases but feel that neoadjuvant systemic therapy is necessary before surgery (single or staged procedure). Postoperative systemic therapy would be considered after completion of all surgery.
6. PVE (staged or prior to any resection) with or without preoperative systemic therapy and, with adequate segment hypertrophy (and tumor response, if necessary), resection of primary lesion and liver metastases (single or staged procedure, with or without postoperative systemic therapy): For a patient with questionable hepatic reserve, you would like to bring him or her to surgery and recommend portal vein embolization (PVE) prior to resection (which may be staged if disease is bilobar). You may also recommend neoadjuvant (preoperative) systemic therapy to shrink or convert the liver lesion(s) to facilitate resection, and you would plan to proceed with resection of the primary lesion and liver metastases if this is successful. Postoperative systemic therapy would be considered after completion of all surgery (single or staged procedure).

Treatment Option Definitions That May Appear in Those Cases Presenting with Intact Primary Rectal Cancer and Synchronous Hepatic Metastases

1. No resection — Systemic therapy only (with or without palliative radiation therapy for primary lesion): You feel that this patient is not a good surgical candidate and the risks of surgery outweigh the potential long-term benefits.
2. Immediate resection of primary lesion only (with or without postoperative systemic therapy): You feel that the patient is not a candidate for resection of both the primary lesion and the hepatic metastases, and you believe that the primary lesion should be removed surgically and the liver treated by other means (eg, systemic therapy, local ablative or radiation techniques). Postoperative systemic therapy would be considered after completion of surgery.
3. Immediate resection of liver metastases only (with or without postoperative systemic therapy): You believe the asymptomatic primary tumor may initially be left in place and that the patient would be best served by immediate resection of the liver metastases. Postoperative systemic therapy would be considered after completion of surgery.
4. Immediate resection of primary lesion and liver metastases (single or staged procedure but no systemic therapy between procedures if staged, with or without postoperative systemic therapy): You believe that both the primary lesion and the liver metastases are resectable at presentation and proceed with surgery as a single or two-step staged procedure. Postoperative systemic therapy would be considered after completion of all surgery.
5. Preoperative systemic therapy followed by resection of primary lesion and liver metastases (single or staged procedure, with or without postoperative systemic therapy): You would remove both the primary lesion and the liver metastases but feel that neoadjuvant systemic therapy is necessary before surgery (single or staged procedure). Postoperative systemic therapy would be considered after completion of all surgery.
6. Immediate chemoradiation therapy for primary lesion with the intent of proceeding to surgical resection of both primary lesion and liver metastases (single or staged procedure): You would administer neoadjuvant chemoradiation therapy for the primary rectal lesion and plan to proceed with surgical resection of both the primary lesion and the liver metastases (single or staged procedure). Postoperative systemic therapy would be considered if successful surgery is completed.
7. PVE (staged or prior to any resection) with or without preoperative systemic therapy and, with adequate segment hypertrophy (and tumor response, if necessary), resection of primary lesion and liver metastases (single or staged procedure, with or without postoperative systemic therapy): For a patient with questionable hepatic reserve, you would like to bring him or her to surgery and recommend portal vein embolization (PVE) prior to resection (which may be staged if disease is bilobar). You may also recommend neoadjuvant (preoperative) systemic therapy to shrink or convert the liver lesion(s) to facilitate resection, and you would plan to proceed with resection of the primary lesion and liver metastases if this is successful. Postoperative systemic therapy would be considered after completion of all surgery (single or staged procedure).

Approaches for Simultaneous Liver and Lung Metastases

Treatment Option Definitions That May Appear in Those Cases Presenting with Simultaneous Hepatic and Pulmonary Metastases

1. No resection (systemic therapy only): You do not feel that this patient should undergo surgery but that he or she should be treated with systemic therapy only for Stage IV disease.
2. Immediate resection of both liver and lung lesions (single or staged procedure, with or without postoperative systemic therapy): You would recommend immediate resection (no preoperative treatment) and would plan to administer postoperative adjuvant systemic therapy, whether the resection is R0 or R1.
3. Immediate resection of lung lesion(s), followed by systemic therapy and resection of liver lesion(s) (with or without additional postoperative systemic therapy): You would recommend immediate removal of the resectable pulmonary nodules but feel that preoperative systemic therapy should be administered before excision of the liver lesion(s). Postoperative systemic therapy would be considered after completion of all surgery.
4. Preoperative systemic therapy followed by resection of both liver and lung lesions (single or staged procedure, with or without additional postoperative systemic therapy): You would recommend resection of both the liver and lung lesions but feel that the patient would benefit from some preoperative systemic therapy before any surgery is attempted. Postoperative systemic therapy would be considered after completion of all surgery.