Defining Early Multidisciplinary Goals: NEXTO Trial in High-Risk Colorectal Cancer with Liver Metastases
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EDITORIAL – HEPATOBILIARY TUMORS
Defining Early Multidisciplinary Goals: NEXTO Trial in High-Risk Colorectal Cancer with Liver Metastases Jeremy D. Kratz, MD1, and Noelle K. LoConte, MD1,2 1 2
Division of Hematology and Oncology, Department of Medicine, University of Wisconsin–Madison, Madison, WI; University of Wisconsin Carbone Cancer Center, University of Wisconsin–Madison, Madison, WI
The current issue of Annals of Surgical Oncology includes a report by Mise et al. reporting results of the NEXTO trial.1 Controlling distant micrometastatic disease remains a critical challenge in the management of advanced colorectal cancer (CRC). For locally advanced CRC, the rates of locoregional recurrence remain quite low at 4.4% for colon and 11.2–12.1% for rectal cancer.2,3 Metastatic disease by definition requires hematogenous dissemination with loss of systemic disease control. Prior management by primary resection and adjuvant chemotherapy resulted in a 40% rate of disease recurrence, yet a relatively modest risk of approximately 4% for marginal recurrence.4 FOLFOX chemotherapy (5-fluorouracil and oxaliplatin with leucovorin rescue) has remained a standard-of-care treatment regimen in metastatic CRC. This study examined FOLFOX and the addition of anti-epidermal growth factor receptor (EGFR) inhibition with cetuximab prior to surgical consideration in advanced CRC with hepatic metastases to evaluate conversion to R0 resection. A major strength of this study is the emphasis placed on multidisciplinary evaluation and care, specific in the early management of patients under consideration for metastasectomy.1 It has been consistently shown that multidisciplinary care in colorectal cancer including surgery, medical oncology, radiation oncology, radiology, and pathology can reduce time to initiation of therapy and expedite preoperative surgical evaluation.5 Patients who
Ó Society of Surgical Oncology 2020 First Received: 8 May 2020 J. D. Kratz, MD e-mail: [email protected]
undergo metastasectomy have shown significant differences in outcomes from registry reports with 5-year overall survival of 37% (vs. 2% for those deemed ineligible).6 The NEXTO study incorporated molecular profiling with KRAS wildtype status, necessitating expedited molecular profiling in alignment with standardized guideline-based practice.7 The expertise of surgeons who specialize in hepatectomy is of great value to a treating medical oncologist in defining the goals of systemic therapy and optimizing the timing of operative management. The ability to convert high-risk metastatic CRC to achieve successful R0 resection reflects optimized delivery of team-based cancer care. The NEXTO trial leveraged broad inclusion criteria with extrahepatic disease burden. This population was of particular high risk as the number of metastatic sites has been predictive of overall survival in CRC.8 Surgical margin status (R0 versus R1) in the liver is predictive of survival after hepatic resection.4 For patients with concurrent hepatic and pulmonary metastases, an incr
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