Decision Making Around Optimal Management of Liver-Limited Metastatic Colorectal Cancer

Abstract

Since the early 1980s, selected patients with liver-limited colorectal metastases (CRLM) have increasingly been offered hepatic resection with the aim of improving longterm survival. Meta-analysis suggests approximately 40 % of patients undergoing surgery are alive 5 years later, with 25 % surviving for 10 years. 1 These impressive results have established hepatic resection as a key treatment modality for CRLM. Patients are now considered technically resectable if all disease can be removed with microscopically negative margins whilst maintaining a sufficient volume of liver parenchyma. However, it is also clear that not all patients with technically resectable liver metastases enjoy long-term survival after surgery; within 1 year approximately 30 % will develop recurrence and 15 % will succumb to their disease. 2 While there is broad agreement among liver surgeons over which patients clearly should and should not be offered resection, we have demonstrated that in the UK there is a lack of consensus between liver surgeons and oncologists. 3 For a patient with a small solitary liver metastasis presenting several years after primary resection, surgery is generally accepted to offer a clear and significant long-term survival benefit. For patients with synchronous extensive large-volume disseminated disease, surgery is generally considered inappropriate. Deciding on the optimal management strategy for patients who fall into the gray area between these two groups is one of the most challenging decisions in the management of CRLM and involves careful assessment of both technical and onco