Colorectal cancer hepatic metastases: the surgeons role

Liver metastases are not uniformly fatal. A group of patients exists that will benefit from therapy directed at the liver either with surgical resection, intra-arterial chemotherapy or a combination of both. (Fig 2) All patients should be evaluated for the possibility of surgical resection since it can provide a 5-year survival of 25 to 40%, or hepatic arterial infusion therapy since response rates are higher and toxicity lower than systemic chemotherapy. When metastases are discovered simultaneously with the primary tumor, consideration should be given to concomitant treatment of both the primary and the liver if the patient is a suitable operative candidate and the resection will not entail more than a wedge or a left lateral lobe resection. Metastases discovered on follow-up of the primary tumor may be immediately addressed with surgical resection or hepatic artery infusion pump placement if the disease-free interval has been greater than 1-2 years. When the disease free interval has been less than a year, systemic chemotherapy is probably more prudent to allow time for manifestation of extra hepatic disease. If no extra-hepatic metastases become manifested after 6 months of systemic chemotherapy, then regional chemotherapy or resection should be considered. Intrahepatic progression on systemic chemotherapy is not a contraindication to hepatic artery infusion chemotherapy since the metastases may still respond. This approach allows patients manifesting extrahepatic disease while on systemic chemotherapy to be spared an operative procedure.