Colorectal liver metastases: An update on multidisciplinary approach

Abstract

Liver metastasis is the commonest form of distant metastasis in colorectal cancer. Selection criteria for surgery and liver-directed therapies have recently been extended. However, resectability remains poorly defined. Tumour biology is increasingly recognized as an important prognostic factor; hence molecular profiling has a growing role in risk stratification and management planning. Surgical resection is the only treatment modality for curative intent. The most appropriate surgical approach is yet to be established. The primary cancer and the hepatic metastasis can be removed simultaneously or in a two-step approach; these two strategies have comparable long-term outcomes. For patients with a limited future liver remnant, portal vein embolization, combined ablation and resection, and associating liver partition and portal vein ligation for staged hepatectomy have been advocated, and each has their pros and cons. The role of neoadjuvant and adjuvant chemotherapy is still debated. Targeted biological agents and loco-regional therapies (thermal ablation, intra-arterial chemo- or radio-embolization, and stereotactic radiotherapy) further improve the already favourable results. The recent debate about offering liver transplantation to highly selected patients needs validation from large clinical trials. Evidence-based protocols are missing, and therefore optimal management of hepatic metastasis should be personalized and determined by a multi-disciplinary team.

Keywords: Colorectal cancer, Liver metastases, Hepatic resection, Neoadjuvant therapy, Adjuvant chemotherapy, Intra-arterial therapy, Precision medicine, Multidisciplinary approach

Core tip: Surgery offers the only hope of cure in colorectal liver metastasis. It can be performed if complete metastasectomy is attainable. There is no consensus on the ideal management strategy for synchronous disease. A subset of patients presenting with unresectable disease may become eligible for resection after liver remnant augmentation or conversion therapy (chemo-therapeutics +/- biological agents). Amid increasing application of loco-regional therapies to colorectal liver metastasis, their role in the treatment paradigm remains to be defined. Refined patient selection – with greater emphasis on tumour biology – is essential to improving treatment outcome. The multidisciplinary approach helps determine the optimal treatment strategy from an expanding armamentarium of therapeutic options for each patient.