Why the liver is special
Blood from the bowel drains to the liver, which is why it is the first place colorectal cancer spreads to: roughly 1 in 4 patients has liver metastases at diagnosis and others develop them later. Unlike most cancers, liver metastases from colon cancer can be cured with surgery in a meaningful proportion of cases, because the liver regenerates and because the disease is sometimes confined there.
What "resectable" means
The criteria have changed a great deal. What counts now is not so much the number or size of the lesions, but that:
- All of them can be removed (or any left treated with ablation) with clear margins.
- Enough healthy liver remains afterwards (at least 25-30 %, more if the liver has had a lot of chemotherapy).
- There is no disease outside the liver that cannot be controlled (an operable lung nodule is not an obstacle).
Three situations are distinguished: resectable from the outset, potentially resectable (too large or badly placed now, but could shrink with chemotherapy: so-called conversion treatment) and unresectable.
The tools
- Surgery (hepatectomy): from removing one segment to half the liver. Many are now done laparoscopically or robotically.
- Ablation (radiofrequency or microwave): a needle destroys small lesions (under 3 cm) with heat. It is combined with surgery or used alone when operating is not possible.
- Conversion chemotherapy: intensive regimens (FOLFOXIRI, FOLFOX/FOLFIRI with anti-EGFR if RAS wild-type, or with bevacizumab) to shrink the lesions and make them operable. Reassessed with CT every 2-3 months; if they become resectable, surgery goes ahead without waiting.
- Techniques to "gain liver": portal vein embolisation or two-stage surgery (ALPPS) so the part that will remain grows.
- High-precision radiotherapy (SBRT), radioembolisation or intra-arterial chemotherapy: in specific situations, in experienced centres.
- Liver transplantation: a highly selected option (disease only in the liver, controlled for a long time), already available in some European centres and under study in Spain.
The most important thing: the tumour board
The decision on whether your metastases are operable must be made by a multidisciplinary board that includes a hepatobiliary surgeon, not oncology alone. It has been shown that assessment by expert surgeons increases the number of patients considered operable. If your hospital has no liver surgery unit, you are entitled to be referred or to ask for a second opinion at a reference centre.
What to ask at your appointment
- Has my case been discussed at the tumour board? Was a liver surgeon present?
- Are my metastases resectable, potentially resectable or unresectable, and why?
- If they are not now, is the aim of chemotherapy to try to make them so? When is it reassessed?
- How much liver would remain after surgery?
- Are there clinical trials for my situation?
