[Treatment of nonresectable liver metastases]

A standardized procedure for dealing with nonresectable liver metastases does not currently exist. It is important that an interdisciplinary approach to treatment be taken, in order to look for the optimum solution for each individual patient. High response rates appear to be important, in order to make more patients with nonresectable liver metastases 'resectable' and thus provide a chance of cure. A series of randomized phase II-III trials found a clear increase in response rates and an improvement in the R0 resection rate as a result of more intensive therapy (triple chemotherapy or combination chemotherapy plus cetuximab or bevacizumab). In the NO16966 trial, too, under blinded conditions, more liver metastasis resections were carried out among patients who had received bevacizumab than among patients in the control arm without bevacizumab, although the response rates in the two arms were the same. A gap of 6-8 weeks between the last dose of bevacizumab and surgery is clinically optimal from the point of view of perioperative safety. If neoadjuvant treatment is given, then resection should be carried out as soon as the metastases are resectable. If the patient's response is not adequate, then consideration should be given to an adaptation or change of the treatment regimen. Regular evaluation for secondary resectability is important. Surgically, in addition to 2- or multi-stage surgery, other possible techniques include portal embolization and intraoperative ablation. The goal remains R0 resection. In order to minimize complications, clinicians must select patients carefully, take account of comorbidities, and know the critical resection volume.