Improving outcomes for patients with bowel cancer and liver metastases

Unfortunately, depending on the stage of colorectal cancer, it can metastasize to other parts of the body, which is commonly the liver. Despite the challenges seen in treating this difficult diagnosis, advancements in surgery and improvements in understanding how to target liver metastases have given patients a better outlook. Here we learn from a top hepatobiliary and pancreatic surgeon, Mr Nicola de’ Liguori Carino, how colorectal cancer and liver metastases are treated.

Are there new medical advancements in surgery for liver metastases?

The biggest advancement in the surgical treatment of liver metastases over the last 10 years is the development and diffusion of laparoscopic (keyhole) liver resections. The main advantage is that this treatment can offer reduced postoperative discomfort, a faster postoperative recovery and avoid a large scar on the abdomen. However, it is important to know that, when compared to the traditional open technique (access to the liver through an incision in the abdomen called laparotomy), the laparoscopic technique doesn’t offer any added advantage in terms of long-term survival or cure. In fact, the aim of curative surgery is that of completely removing the metastases from the liver while preserving as much of the liver as possible, exposing the patients to the smallest chance of developing complications. The surgical means by which this result is to be achieved (laparoscopic versus open approach) is of secondary importance.

At times, if one or more metastases can’t be resected, a possible alternative is ablation. There are three main types of ablation called radiofrequency ablation (RFA) , microwave ablation (MWA) and irreversible electroporation. Their desired effect is to destroy the cancer cells by introducing a needle into the middle of the tumour. Ablation is a second choice compared with resection, and in clinical practice, its role is limited to very few cases. However, for single very small metastases, some studies would suggest that ablation can perhaps be as good as resection.

Read more: Irreversible electroporation

In a healthy liver, up to 70% of its whole volume can be resected based on the liver’s peculiar ability to regenerate. If, in order to remove the whole tumour, the amount of the overall liver volume needed to be resected exceeds that of 70%, a few complex techniques can be employed to try to achieve a full tumour resection leaving at least 30% of the healthy liver behind. These techniques are portal vein embolisation, two-stage liver resection and the ALPSS procedure.

What is the outlook after surgery?

Most patients recover from liver surgery without long-term complications. According to the type of operation and patient overall health, a full recovery with return to daily activities is usually completed within three months. Some patients might need more treatment (most commonly chemotherapy), which might keep them away from their daily life for longer.

The aim of surgery is to cure the cancer. Depending on a combination of factors, cure within five years of living disease-free can be achieved in up to 60% of cases. Overall, surgery can significantly increase long-term survival even if the disease might recur after some years. Liver resections to remove recurrent metastases can be repeated several times.

How long does treatment last?

It varies according to the extension of the disease at the time of diagnosis and it is extremely difficult to give an exact forecast. At times, an isolated liver resection can be all a patient needs. In this case, treatment might last a maximum of four weeks counting the operation and postoperative recovery before going back to daily life. In other cases, if the primary tumour in the bowel and metastases in the liver are present at the same time, it can be as long as a whole year to complete radiotherapy, bowel surgery, liver surgery and systemic chemotherapy. Each patient case is different and treatment can vary significantly between individuals.