In this review, standards of diagnosis and treatment of colorectal liver
metastases are described on the basis of a workshop discussion. Algorithms of care for patients with synchronous / metachronous colorectal liver
metastases or locoregional recurrent tumour are presented. Surgical resection is the procedure of choice in the curative treatment of liver
metastases. The decision about the resection of liver
metastases should consider the following parameters: 1. General operability of the patient (comorbidity); 2. Achievability of an R 0 situation: i. if necessary, in combination with ablative methods, ii. if necessary,
neoadjuvant chemotherapy, iii. the ability to eradicate extrahepatic tumour manifestations; 3. Sufficient volume of the liver remaining after resection ("future liver remnant = FLR): i. if necessary, in combination with portal vein embolisation or two-stage
hepatectomy; 4. The feasibility to preserve two contiguous hepatic segments with adequate vascular inflow and outflow as well as biliary drainage; 5. Tumour biological aspects ("prognostic variables"); 6. Experience of the surgeon and centre! Extrahepatic disease does not contraindicate
hepatectomy for colorectal liver
metastases provided a complete resection of both intra- and extrahepatic disease is feasible. Even in bilobar colorectal
metastases and 5 or more tumours in the liver, a complete tumour resection has been described. The type of resection (hepatic wedge resection or anatomic resection) does not influence the recurrence rate. Preoperative volumetry is indicated when major hepatic resection is planned. The FLR should be 25 % in patients with normal liver, 40 % in patients who have received intensive
chemotherapy or in cases of
fatty liver,
liver fibrosis or diabetes, and 50-60 % in patients with
cirrhosis. In patients with initially unresectable colorectal liver
metastases, preoperative
chemotherapy enables complete resection in 15-30 % of the cases, whereas the value of
neoadjuvant chemotherapy in patients with resectable liver
metastases has not been sufficiently supported. In situ ablative procedures (
radiofrequency ablation = RFA and
laser-induced interstitial
thermotherapy = LITT) are local
therapy options in selected patients who are not candidates for resection (central recurrent liver
metastases, bilobar multiple
metastases and high-risk resection or restricted patient operability). Patients with tumours larger than 3 cm have a high local recurrence rate after percutaneous RFA and are not optimal candidates for this procedure. The physician's experience influences the results significantly, both after
hepatectomy and after in situ ablation. Therefore, patients with colorectal liver
metastases should be treated in centres with experience in liver surgery.