Letter to Editor Regarding “Simultaneous Resection Is Associated With Long‐Term Survival in Patients With High‐Risk Synchronous Rectal Cancer Liver Metastases”

We read with great interest the recent article by Labadie et al., titled “Simultaneous Resection Is Associated With Long-Term Survival in Patients With High-Risk Synchronous Rectal Cancer Liver Metastases” [1]. The authors present a single-center retrospective analysis of 92 patients undergoing simultaneous total mesorectal excision (TME) and hepatectomy for rectal cancer liver metastases (RCLM), demonstrating a median overall survival (OS) of 70 months and acceptable safety profiles despite high tumor burden. This study adds valuable real-world evidence supporting simultaneous resection in selected patients. However, it also underscores persistent challenges in standardizing patient selection, perioperative management, and addressing unmet needs in multimodal integration. The study's findings align with emerging evidence that simultaneous resection, when performed in high-volume centers, can achieve outcomes comparable to staged approaches. For instance, Tsilimigras et al. reported comparable long-term survival between simultaneous and staged resections for synchronous colorectal liver metastases (CRLM), though simultaneous resection was associated with higher morbidity in propensity-matched cohorts [2]. Labadie et al. extend this paradigm to RCLM, a subgroup often excluded from prior analyses due to concerns about pelvic dissection complexity and anastomotic healing. Their 5-year OS of 54% in patients with high Clinical Risk Scores (median 4) challenges traditional reluctance toward simultaneous resection for high-burden disease. While the authors highlight safety (0% 90-day mortality, 15% major complications), key questions remain unresolved. First, the criteria for “appropriate setting” are not explicitly defined. Tumor Burden Score (TBS) and CRS were used descriptively, but their predictive value for postoperative outcomes was not quantified. Earlier work by Abdalla et al. emphasized extent-based tailored strategies, where surgical sequencing was individualized based on rectal tumor locally advanced features and hepatic metastatic volume [3]. In Labadie's cohort, 21% underwent major hepatectomy, yet the impact of resection extent on complications (e.g., biliary leaks vs. pelvic sepsis) is not detailed. This gap mirrors broader literature calls for standardized risk stratification tools integrating tumor biology (e.g., RAS mutation), functional reserve, and procedural complexity. Second, the role of neoadjuvant therapy remains ambiguous. Although 99% of patients received systemic therapy (median 6 cycles), the study does not correlate chemotherapy duration or response with survival. Conversely, > 6 cycles were linked to reduced recurrence-free survival (RFS), possibly reflecting tumor aggressiveness or chemotherapy-induced liver injury. This aligns with Tsilimigras et al. observation that severe morbidity after simultaneous resection decreased over time with improved patient optimization [2]. A tailored approach—using liver-first strategies for poor responders or simultaneous resection for chemosensitive disease—may maximize outcomes. The study's single-center design limits generalizability. For example, the high rate of hepatic arterial infusion pump (HAIP) use (23%) is uncommon in many institutions, potentially confounding survival benefits. Future research should prioritize multicenter randomized trials comparing simultaneous versus staged resection within enhanced recovery pathways. Additionally, the low pelvic recurrence rate (12%) is commendable but raises questions about optimal TME quality and radiation timing—only 48% received neoadjuvant chemoradiation. Rectal cancer-specific considerations (e.g., sphincter preservation, radiation-related toxicity) warrant deeper exploration in synchronous RCLM management. Prospective studies should integrate biomarkers (e.g., ctDNA) and functional imaging to dynamically assess tumor response and guide sequencing. Moreover, patient-reported outcomes (e.g., stoma-related quality of life) are critical yet unaddressed in this surgical outcomes-focused analysis. Collaborative databases, like those used in Tsilimigras's multi-institutional study, could validate risk-prediction models to identify ideal candidates for simultaneous resection. In conclusion, Labadie et al. provide robust evidence supporting simultaneous resection in selected RCLM patients [1]. However, advancing the field requires precision patient selection, standardized perioperative pathways, and integration of multimodal therapies to optimize both survival and quality of life. Conceptualization: Xuexiang Shi. Study design: Xuexiang Shi. Manuscript draft: Jinlin Zang. Draft review and editing: Jinlin Zang and Xuexiang Shi. The authors have nothing to report. The authors received no specific funding for this work. The authors have nothing to report. The authors have seen and approved the final manuscript. The authors declare no conflicts of interest. The authors have nothing to report.