Issue: 2006 > May > original article

Imaging and treatment of patients with colorectal liver metastases in the Netherlands: a survey

S. Bipat, M.S. van Leeuwen, J.N.M. IJzermans, P.M.M. Bossuyt, J-W. Greve, J. Stoker


Background: Clinical experience has highlighted the absence of a uniform approach to the management of patients with colorectal liver metastases in the Netherlands.
Methods: A written survey on the diagnosis and treatment of patients with colorectal liver metastases was sent to all 107 chairmen of oncology committees in each hospital. Questions were asked concerning: specialists involved in decision-making, availability and existence of guidelines and meetings, factors that needed to be improved, information regarding the diagnostic work-up of liver metastases, detailed techniques of ultrasonography (US ), computed tomography (CT), magnetic resonance imaging (MRI ) and positron emission tomography (PET), factors influencing resectability, types of surgery performed, the use of (neo)adjuvant chemotherapy, portal vein embolisation performance, considering isolated hepatic perfusion (IH P) or local ablation as treatment options, actual performance of local ablation and the use of systemic as well as regional chemotherapy.
Results: Response rate was 68% (73/107). Specialists
involved in the management were mostly surgeons (70),
medical oncologists (66) and radiologists (42). Factors that needed to be improved, as indicated by responders, were the absence of 1) guidelines; 2) registration of patients and 3) guidelines for radiofrequency ablation (RF A). Diagnostic work-up of synchronous liver metastases occurred in 71 hospitals, (by US in 69 and by CT in 2). For the work-up of metachronous liver metastases, US was used as initial modality in 14, CT in 2 hospitals, and 57 hospitals used one or the other (mainly US ). As additional modality, CT was performed (71) and to a lesser extent MRI (38) or PET (22). Diagnostic laparoscopy and biopsy were performed incidentally. The choice for an imaging modality was mostly influenced by the literature, and to a lesser
extent by the availability and by costs, personnel and
waiting lists. Substantial variation exists in the US, CT,
MRI and PET techniques. The absence of extrahepatic
disease and the clinical condition were considered as the
most important factors influencing resectability. Surgery
was performed in 30 hospitals; hemihepatectomy in 25,
segment resection in 27, multisegment resection in 23,
wedge excision in 27 and combination of resection and
RF A in 18 institutions. In 52 hospitals (neo)adjuvant
chemotherapy was administrated to improve surgical
results, partly (35%) in trials. In nine hospitals portal
vein embolisation was performed, with the volume of
the remnant liver as the most important factor. Local
ablative techniques were considered as a treatment option in 48 hospitals and actually performed in 16 hospitals, without clearly defined indications. Experimental IHP was considered a treatment option by 45 (62%) responders, irrespective whether this treatment was available at their centre. Patients with extensive metastases received systemic chemotherapy in all 73 hospitals and regional chemotherapy
in ten hospitals.
Conclusion: This survey shows substantial variation in
the diagnostic and therapeutic work-up of patients with
colorectal liver metastases. This variation reflects either
under- or over-utilisation of diagnosis and treatment
options. Evidence-based guidelines taking into account the available evidence, experience and availability can solve this variation.