Key Points
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Up to a 20% of patients with colorectal cancer (CRC) present with synchronous hepatic metastases
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In patients who present without intestinal obstruction or perforation, comprehensive whole-body imaging is required to exclude extrahepatic disease
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Current evidence indicates a state of equipoise between several different management approaches for the treatment of CRC and synchronous liver metastatic disease, none of which has supportive randomized trial evidence
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Neoadjuvant systemic chemotherapy is supported by current guidelines and can result in tumour downsizing, enabling some 'unresectable' liver metastases to be surgically removed
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Surgery can take the form of the 'classic' approach (colorectal resection, then interval chemotherapy followed by liver resection), synchronous removal of liver and bowel tumours, or a liver-first approach
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Clear superiority has not been demonstrated for any of these surgical interventions for CRC with synchronous liver metastases, although the mode of presentation can determine the approach used
Abstract
Up to a fifth of patients with colorectal cancer (CRC) present with synchronous hepatic metastases. In patients with CRC who present without intestinal obstruction or perforation and in whom comprehensive whole-body imaging confirms the absence of extrahepatic disease, evidence indicates a state of equipoise between several different management pathways, none of which has demonstrated superiority. Neoadjuvant systemic chemotherapy is advocated by current guidelines, but must be integrated with surgical management in order to remove the primary tumour and liver metastatic burden. Surgery for CRC with synchronous liver metastases can take a number of forms: the 'classic' approach, involving initial colorectal resection, interval chemotherapy and liver resection as the final step; simultaneous removal of the liver and bowel tumours with neoadjuvant or adjuvant chemotherapy; or a 'liver-first' approach (before or after systemic chemotherapy) with removal of the colorectal tumour as the final procedure. In patients with rectal primary tumours, the liver-first approach can potentially avoid rectal surgery in patients with a complete response to chemoradiotherapy. We overview the importance of precise nomenclature, the influence of clinical presentation on treatment options, and the need for accurate, up-to-date surgical terminology, staging tests and contemporary management options in CRC and synchronous hepatic metastatic disease, with an emphasis on multidisciplinary care.
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A.K.S. and S.J. researched the data for the article, and A.K.S., J.M.M., S.M. and S.J. substantially contributed to discussion of content. A.K.S., J.M.M., S.M. and H.C.H. wrote the article, and all authors reviewed/edited the manuscript before submission.
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Siriwardena, A., Mason, J., Mullamitha, S. et al. Management of colorectal cancer presenting with synchronous liver metastases. Nat Rev Clin Oncol 11, 446–459 (2014). https://doi.org/10.1038/nrclinonc.2014.90
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DOI: https://doi.org/10.1038/nrclinonc.2014.90
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