Table 1.

Rationale for use of preoperative chemotherapy in patients with liver metastases

Rationale	Justification	Evidence against
As an attempt to downstage patients for resection
To increase number of patients eligible for resection	15–20% of disease is converted to resectable;3 long-term survival of patients documented after resection3
As neoadjuvant therapy for resectable disease
To perform in vivo chemosensitivity testing	Determines chemotherapy to use after resection	Less than 10% will progress on first-line cetuximab and FOLFOX;5 produces liver-related toxicities, and detrimentally changes outcome of liver resection10
To allow distant disease to manifest	Avoids liver resection in those who will not benefit	Fewer than 2% of patients progressed outside the liver in the waiting period;6 there is increasing evidence that resection of the liver may be beneficial even in patients with small-volume disease outside the liver
To allow treatments of and possible eradication of microscopic disease	The smaller the tumor volume, the more likely it is to be cured by chemotherapy	No trial has shown the use of preoperative chemotherapy to improve long-term outcome over postoperative chemotherapy alone
To allow patients to recover from colectomy/proctectomy before liver resection	Many patients have weight loss and debilitation post-surgery. In particular, patients with complications from the colectomy/proctectomy may fall into this category