Current Surgical Management Strategies for Colorectal Cancer Liver Metastases

Abstract

Colorectal cancer is the third most common cancer diagnosis in the world, and the second most common cause of cancer-related deaths. Despite significant progress in management strategies for colorectal cancer over the last several decades, metastatic disease remains difficult to treat and is often considered incurable. However, for patients with colorectal liver metastases (CRLM), surgical resection offers the best opportunity for survival, can be curative, and remains the gold standard. Unfortunately, surgical treatment options are underutilized. Misperceptions regarding resectable and unresectable CRLM likely play a role in this. The assessment of factors that impact resectability status like medical fitness, technical considerations, and disease biology can be difficult, necessitating careful multidisciplinary input and discussion. The identification of ideal operative time windows that align with the multimodal management of these patients can also be perplexing. For all patients with CRLM it may therefore be advantageous to obtain surgical evaluation at the time of discovering liver metastases to mitigate these challenges and minimize the risk of undertreatment. In this review we summarize current surgical management strategies for CRLM and discuss factors to be considered when determining resectability.

Keywords: associating liver partition and portal vein ligation for staged hepatectomy; colorectal liver metastases; hepatic arterial infusional chemotherapy; liver transplantation; minimally invasive liver resection; one- and two-stage hepatectomy; parenchymal-sparing hepatectomy.

Figure 1

Surgical strategies for colorectal liver metastases. (a) Parenchymal-sparing hepatectomy. (b) One-stage hepatectomy with or without PVE. (c) Two-stage hepatectomy with PVE. (d) Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). (e) Orthotopic liver transplantation (OLT). Dashed lines illustrate the future liver remnant prior to augmentation (i.e., PVE; portal vein ligation during ALPPS).

Figure 2

Hepatic arterial infusional pump.