Real-world management of patients with simultaneously diagnosed synchronous liver and lung metastatic colorectal cancer – a national cohort study

Authors

  • Laia Faseh Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
  • Petter Fruhling Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
  • Helena Taflin Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden, Department of Transplantation, Sahlgrenska University Hospital Gothenburg, Region Västra Götaland Sweden https://orcid.org/0000-0002-8795-5250
  • Jenny Lundmark Rystedt Department of Clinical Sciences, Surgery, Lund University, Department of Surgery, Skåne University Hospital, Lund, Sweden. https://orcid.org/0000-0002-8865-9963
  • Caroline Williamsson Department of Clinical Sciences, Surgery, Lund University, Department of Surgery, Skåne University Hospital, Lund, Sweden. https://orcid.org/0000-0002-9743-3149
  • Oskar Hemmingsson Department of Diagnostics and Intervention, Surgery, Umeå University, Umeå, Sweden; Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden. https://orcid.org/0000-0003-1732-168X
  • Bergthor Björnsson Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden https://orcid.org/0000-0001-9704-1260
  • Marco Gerling Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden https://orcid.org/0000-0002-1810-0662
  • Ernesto Sparrelid Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden https://orcid.org/0000-0003-0259-8328
  • Per Sandström Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden https://orcid.org/0000-0002-8078-9528
  • Kristina Hasselgren Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden https://orcid.org/0000-0002-0792-1588
  • Jennie Engstrand Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden https://orcid.org/0000-0003-1123-7022

DOI:

https://doi.org/10.2340/1651-226X.2026.45045

Keywords:

Colorectal cancer, Liver metastases, Lung metastases, multidisciplinary team meeting, population-based study, Survival Analysis

Abstract

Background and purpose: Real-world data on management and outcomes of patients with simultaneously diagnosed synchronous colorectal liver and lung metastases are limited. This national study evaluated referral patterns, treatment strategies, and survival in a population-based cohort.
Patient/material and methods: This retrospective cohort study used Swedish national registries to identify patients with synchronous liver and lung metastatic colorectal cancer (CRC), defined as metastases detected within 6 months of CRC diagnosis between 2008 and 2016. Medical record review provided additional information on diagnosis confirmation, multidisciplinary team (MDT) referral, metastatic burden, and treatment. Logistic regression identified factors associated with MDT referral and curative treatment, and Cox regression with a time-varying covariate assessed survival.
Results: Among 2703 registry-identified patients, medical records were accessible for 855. After exclusion of extrahepatic, non-pulmonary metastases, 556 remained for analysis. A total of 189 patients (34%) were discussed at a liver MDT conference. Referred patients were younger, had lower metastatic burden, and better performance status than non-referred. Median survival was 24 months (95% CI [confidence interval] 21–28) for referred versus 10 months (95% CI 7–12) for non-referred patients. Curative local treatment of liver and/or lung metastases was performed in 101 patients (18%), and complete metastasectomy in 34 (6%), conferring superior survival compared with liver-only intervention (hazard ratio 0.34, 95% CI 0.18–0.61). The main reason for non-referral was presumed non-resectability.
Interpretation: Referral to an MDT and subsequent local treatment were associated with improved survival, although this may partly reflect favorable patient and tumor characteristics influencing referral and treatment decisions. Patients with adequate physiological reserve should routinely be evaluated in an organ-specific MDT for potential curative treatment.

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References

Adam R, de Gramont A, Figueras J, Kokudo N, Kunstlinger F, Loyer E, et al. Managing synchronous liver metastases from colorectal cancer: a multidisciplinary international consensus. Cancer Treat Rev. 2015;41(9):729–41.

https://doi.org/10.1016/j.ctrv.2015.06.006 DOI: https://doi.org/10.1016/j.ctrv.2015.06.006

Cervantes A, Adam R, Roselló S, Arnold D, Normanno N, Taïeb J, et al. Metastatic colorectal cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol. 2023;34(1):10–32.

https://doi.org/10.1016/j.annonc.2022.10.003 DOI: https://doi.org/10.1016/j.annonc.2022.10.003

van der Geest LG, Lam-Boer J, Koopman M, Verhoef C, Elferink MA, de Wilt JH. Nationwide trends in incidence, treatment and survival of colorectal cancer patients with synchronous metastases. Clin Exp Metastasis. 2015;32(5):457–65.

https://doi.org/10.1007/s10585-015-9719-0 DOI: https://doi.org/10.1007/s10585-015-9719-0

Engstrand J, Taflin H, Rystedt JL, Hemmingsson O, Urdzik J, Sandström P, et al. The resection rate of synchronously detected liver and lung metastasis from colorectal cancer is low – a national registry-based study. Cancers (Basel). 2023;15(5):1434.

https://doi.org/10.3390/cancers15051434 DOI: https://doi.org/10.3390/cancers15051434

Väyrynen V, Wirta EV, Seppälä T, Sihvo E, Mecklin JP, Vasala K, et al. Incidence and management of patients with colorectal cancer and synchronous and metachronous colorectal metastases: a population-based study. BJS Open. 2020;4(4):685–92.

https://doi.org/10.1002/bjs5.50299 DOI: https://doi.org/10.1002/bjs5.50299

Storli PE, Dille-Amdam RG, Skjerseth GH, Gran MV, Myklebust TA, Gronbech JE, et al. Synchronous metastases from colorectal cancer. Treatment and long-term survival compared to patients with metachronous metastases: a population-based study from Central Norway 2001–2015. Acta Oncol. 2025;64:797–806.

https://doi.org/10.2340/1651-226X.2025.42985 DOI: https://doi.org/10.2340/1651-226X.2025.42985

Dave RV, Pathak S, White AD, Hidalgo E, Prasad KR, Lodge JP, et al. Outcome after liver resection in patients presenting with simultaneous hepatopulmonary colorectal metastases. Br J Surg. 2015;102(3):261–8.

https://doi.org/10.1002/bjs.9737 DOI: https://doi.org/10.1002/bjs.9737

Andres A, Mentha G, Adam R, Gerstel E, Skipenko OG, Barroso E, et al. Surgical management of patients with colorectal cancer and simultaneous liver and lung metastases. Br J Surg. 2015;102(6):691–9.

https://doi.org/10.1002/bjs.9783 DOI: https://doi.org/10.1002/bjs.9783

Matsumura M, Yamashita S, Ishizawa T, Akamatsu N, Kaneko J, Arita J, et al. Oncological benefit of complete metastasectomy for simultaneous colorectal liver and lung metastases. Am J Surg. 2020;219(1):80–7.

https://doi.org/10.1016/j.amjsurg.2019.06.007 DOI: https://doi.org/10.1016/j.amjsurg.2019.06.007

Engstrand J, Sterner J, Hasselgren K, Stromberg C, Sturesson C. Treatment intention and outcome in patients with simultaneously diagnosed liver and lung metastases from colorectal cancer. Eur J Surg Oncol. 2022;48(8):1799–806.

https://doi.org/10.1016/j.ejso.2022.03.006 DOI: https://doi.org/10.1016/j.ejso.2022.03.006

Siebenhüner AR, Güller U, Warschkow R. Population-based SEER analysis of survival in colorectal cancer patients with or without resection of lung and liver metastases. BMC Cancer. 2020;20(1):246.

https://doi.org/10.1186/s12885-020-6710-1 DOI: https://doi.org/10.1186/s12885-020-6710-1

Moberger P, Sköldberg F, Birgisson H. Evaluation of the Swedish Colorectal Cancer Registry: an overview of completeness, timeliness, comparability and validity. Acta Oncol. 2018;57(12):1611–21.

https://doi.org/10.1080/0284186X.2018.1529425 DOI: https://doi.org/10.1080/0284186X.2018.1529425

Täckningsgrader för nationella Kvalitetsregister 2020 .Available from: https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/statistik/2020-12-7049.pdf

von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg. 2014;12(12):1495–9.

https://doi.org/10.1016/j.ijsu.2014.07.013 DOI: https://doi.org/10.1016/j.ijsu.2014.07.013

Snapinn SM, Qi J, Iglewicz B. Illustrating the impact of a time-varying covariate with an extended Kaplan-Meier estimator. Am Stat. 2005;59(4):301–7.

https://doi.org/10.1198/000313005X70371 DOI: https://doi.org/10.1198/000313005X70371

Sjölander A. A cautionary note on extended Kaplan-Meier curves for time-varying covariates. Epidemiology. 2020;31(4):517–22.

https://doi.org/10.1097/EDE.0000000000001188 DOI: https://doi.org/10.1097/EDE.0000000000001188

Mas L, Bachet JB, Jooste V, Lepage C, Bouvier AM. Chemotherapy of metastatic colon cancer in France: a population-based study. Dig Liver Dis. 2021;53(10):1334–42.

https://doi.org/10.1016/j.dld.2021.03.019 DOI: https://doi.org/10.1016/j.dld.2021.03.019

Noren A, Sandstrom P, Gunnarsdottir K, Ardnor B, Isaksson B, Lindell G, et al. Identification of inequalities in the selection of liver surgery for colorectal liver metastases in Sweden. Scand J Surg. 2018;107(4):294–301.

https://doi.org/10.1177/1457496918766706 DOI: https://doi.org/10.1177/1457496918766706

Almlov K, Arbman G, Bjornsson B, Elander NO, Hager J, Hamid S, et al. Assessment by a multidisciplinary team conference affects treatment strategy and overall survival in patients with synchronous colorectal liver metastases. HPB (Oxford). 2024;26(9):1131–40.

https://doi.org/10.1016/j.hpb.2024.05.008 DOI: https://doi.org/10.1016/j.hpb.2024.05.008

Isoniemi H, Uutela A, Nordin A, Lantto E, Kellokumpu I, Ovissi A, et al. Centralized repeated resectability assessment of patients with colorectal liver metastases during first-line treatment: prospective study. Br J Surg. 2021;108(7):817–25.

https://doi.org/10.1093/bjs/znaa145 DOI: https://doi.org/10.1093/bjs/znaa145

Thillai K, Repana D, Korantzis I, Prachalias A, Kane P, Ross PJ. Clinical outcomes for patients with liver-limited metastatic colorectal cancer: arguing the case for specialist hepatobiliary multidisciplinary assessment. Eur J Surg Oncol. 2016;42(9):1331–6.

https://doi.org/10.1016/j.ejso.2016.03.031 DOI: https://doi.org/10.1016/j.ejso.2016.03.031

t Lam-Boer J, van der Stok EP, Huiskens J, Verhoeven RH, Punt CJ, Elferink MA, et al. Regional and inter-hospital differences in the utilisation of liver surgery for patients with synchronous colorectal liver metastases in the Netherlands. Eur J Cancer. 2017;71:109–16.

https://doi.org/10.1016/j.ejca.2016.10.026 DOI: https://doi.org/10.1016/j.ejca.2016.10.026

Huiskens J, Bolhuis K, Engelbrecht MR, De Jong KP, Kazemier G, Liem MS, et al. Outcomes of resectability assessment of the Dutch Colorectal Cancer Group liver metastases expert panel. J Am Coll Surg. 2019;229(6):523–32.e2.

https://doi.org/10.1016/j.jamcollsurg.2019.08.1445 DOI: https://doi.org/10.1016/j.jamcollsurg.2019.08.1445

Engstrand J, Kartalis N, Stromberg C, Broberg M, Stillstrom A, Lekberg T, et al. The impact of a hepatobiliary multidisciplinary team assessment in patients with colorectal cancer liver metastases: a population-based study. Oncologist. 2017;22(9):1067–74.

https://doi.org/10.1634/theoncologist.2017-0028 DOI: https://doi.org/10.1634/theoncologist.2017-0028

Hellingman T, de Swart ME, Joosten JJA, Meijerink MR, de Vries JJJ, de Waard JWD, et al. The value of a dedicated multidisciplinary expert panel to assess treatment strategy in patients suffering from colorectal cancer liver metastases. Surg Oncol. 2020;35:412–17.

https://doi.org/10.1016/j.suronc.2020.09.024 DOI: https://doi.org/10.1016/j.suronc.2020.09.024

van der Ven R, Westra D, van Erning FN, de Hingh IH, Olde Damink SWM, Paulus A, et al. The impact of a multi-hospital network on the inequality in odds of receiving resection or ablation for synchronous colorectal liver metastases. Acta Oncol. 2023;62(8):842–52.

https://doi.org/10.1080/0284186X.2023.2238545 DOI: https://doi.org/10.1080/0284186X.2023.2238545

Torzilli G, McCormack L, Pawlik T. Parenchyma-sparing liver resections. Int J Surg. 2020;82S:192–7.

https://doi.org/10.1016/j.ijsu.2020.04.047 DOI: https://doi.org/10.1016/j.ijsu.2020.04.047

Tinguely P, Ruiter SJS, Engstrand J, de Haas RJ, Nilsson H, Candinas D, et al. A prospective multicentre trial on survival after Microwave Ablation VErsus Resection for Resectable Colorectal liver metastases (MAVERRIC). Eur J Cancer. 2023;187:65–76.

https://doi.org/10.1016/j.ejca.2023.03.038 DOI: https://doi.org/10.1016/j.ejca.2023.03.038

van der Lei S, Puijk RS, Dijkstra M, Schulz HH, Vos DJW, De Vries JJJ, et al. Thermal ablation versus surgical resection of small-size colorectal liver metastases (COLLISION): an international, randomised, controlled, phase 3 non-inferiority trial. Lancet Oncol. 2025;26(2):187–99.

https://doi.org/10.1016/S1470-2045(24)00660-0 DOI: https://doi.org/10.1016/S1470-2045(24)00660-0

Dong T, Fan H, Lyu J, Shi Y, Hu P, Wu X, et al. A retrospective study comparing the efficacy of microwave ablation and stereotactic body radiotherapy in colorectal cancer lung metastases. Oncol Lett. 2024;28(1):322.

https://doi.org/10.3892/ol.2024.14455 DOI: https://doi.org/10.3892/ol.2024.14455

Ogawa H, Yajima T, Sohda M, Shirabe K, Saeki H. Role of surgical resection and its alternative local therapy for pulmonary metastasis of colorectal cancer. Ann Gastroenterol Surg. 2021;5(6):747–53.

https://doi.org/10.1002/ags3.12472 DOI: https://doi.org/10.1002/ags3.12472

Adam R, Piedvache C, Chiche L, Adam JP, Salame E, Bucur P, et al. Liver transplantation plus chemotherapy versus chemotherapy alone in patients with permanently unresectable colorectal liver metastases (TransMet): results from a multicentre, open-label, prospective, randomised controlled trial. Lancet. 2024;404(10458):1107–18. DOI: https://doi.org/10.2139/ssrn.4830489

https://doi.org/10.1016/S0140-6736(24)01595-2 DOI: https://doi.org/10.1016/S0140-6736(24)01595-2

Valdimarsson VT, Syk I, Lindell G, Sandström P, Isaksson B, Rizell M, et al. Outcomes of simultaneous resections and classical strategy for synchronous colorectal liver metastases in Sweden: a nationwide study with special reference to major liver resections. World J Surg. 2020;44(7):2409–17.

https://doi.org/10.1007/s00268-020-05475-5 DOI: https://doi.org/10.1007/s00268-020-05475-5

Frühling P, Strömberg C, Isaksson B, Urdzik J. A comparison of the simultaneous, liver-first, and colorectal-first strategies for surgical treatment of synchronous colorectal liver metastases at two major liver-surgery institutions in Sweden. HPB (Oxford). 2023;25(1):26–36.

https://doi.org/10.1016/j.hpb.2022.09.001 DOI: https://doi.org/10.1016/j.hpb.2022.09.001

Stewart CL, Warner S, Ito K, Raoof M, Wu GX, Kessler J, et al. Cytoreduction for colorectal metastases: liver, lung, peritoneum, lymph nodes, bone, brain. When does it palliate, prolong survival, and potentially cure? Curr Probl Surg. 2018;55(9):330–79.

https://doi.org/10.1067/j.cpsurg.2018.08.004 DOI: https://doi.org/10.1067/j.cpsurg.2018.08.004

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Published

2026-03-12

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Faseh, L., Fruhling, P., Taflin, H., Lundmark Rystedt, J., Williamsson, C., Hemmingsson, O., … Engstrand, J. (2026). Real-world management of patients with simultaneously diagnosed synchronous liver and lung metastatic colorectal cancer – a national cohort study. Acta Oncologica, 65, 201–212. https://doi.org/10.2340/1651-226X.2026.45045

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Vol. 65 (2026): Acta Oncologica

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Copyright (c) 2026 Laia Faseh, Petter Fruhling, Helena Taflin, Jenny Lundmark Rystedt, Caroline Williamsson, Oskar Hemmingsson, Bergthor Björnsson, Marco Gerling, Ernesto Sparrelid, Per Sandström, Kristina Hasselgren, Jennie Engstrand

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