Medical management of colorectal liver metastasis

Colorectal cancer is the third most common cancer in the United States, and about 145, 000 new cases are expected each year (1). Approximately 15% to 30% of all colorectal cancer patients have synchronous liver metastases at initial diagnosis, and up to 60% will develop hepatic metastases at some point during their disease course (2–4). Therefore, liver metastases from colorectal cancer are a common oncologic problem. Because management of patients with colorectal liver metastases frequently involves medical oncologists, surgical oncologists, interventional radiologists and other specialists, a multidisciplinary setting is optimal. Palliative chemotherapy remains the mainstay of treatment for patients with widely metastatic colorectal cancer, and survival has increased significantly with the introduction of novel agents. However, 5-year survival of such patients remains anecdotal. Advances in surgical and interventional techniques, however, have made cure a possibility for some colorectal cancer patients with liver-only metastases. Patients with initially resectable colorectal liver metastases have achieved impressive 5-year survival rates of 30% to 70% following metastatectomy (4–6). Unfortunately, only 20% to 30% of patients with colorectal liver metastases are candidates for resection at initial presentation (7, 8). Preoperative or neoadjuvant chemotherapy may improve the rate of successful metastatectomy, limit the extent of hepatectomy and improve postoperative recovery in this group of patients. In patients with unresectable liver metastases, neoadjuvant chemotherapy can potentially render previously unresectable liver metastases amenable to surgery. The 5-year survival rate of those who subsequently undergo hepatic metastatectomy has been reported to be 20% to 40% (9).