Some patients diagnosed with colorectal (bowel) cancer, also present with liver metastases. The liver is the most common site in the body of patients with bowel cancer for metastasis to occur due to its anatomical location. Whilst this can be a very challenging diagnosis to be given, treatment can be possible, as well as cure. Mr Nicola de’ Liguori Carino, an experienced hepatobiliary and pancreatic surgeon, explains how liver metastases are identified and treated in patients with colorectal cancer.
What symptoms are tell-tale signs that colorectal cancer has spread to the liver?
Unfortunately, colorectal liver metastases (bowel cancer secondary to the liver) do not manifest themselves for an extremely long time, sometimes even years. In fact, when the metastases do start giving signs of their presence, the disease is very advanced and it might be too late to be able to treat them successfully.
If at all present, symptoms can be very vague, and most commonly will be abdominal pain, frequently located in the upper and right side of the abdomen. Colorectal cancer can also give patients a lack of appetite and/or indigestion. Occasionally, they can present with the onset of jaundice.
However, because up to 20% of patients with colorectal cancer have already developed liver metastases at the time of the diagnosis of the bowel primary cancer and another 50% will develop them during the course of the following years, the possible presence of liver metastases is usually carefully investigated with radiological scans. The most commonly used are CT scans, MRI scans, PET scans and ultrasound scans.
How likely is bowel cancer to spread to the liver? How is this monitored?
Following resection (surgical excision) of the primary bowel cancer, the likelihood of developing metastases declines progressively. After 5 years, it is extremely unlikely for metastases to appear and after 10 years, patients are considered cured.
Because of this, it is recommended that patients with newly diagnosed colorectal cancer be investigated with a chest, abdomen and pelvis CT scan. If deeper investigations are deemed necessary, an MRI liver and/or a PET CT scan are performed.
Following curative resection of the primary bowel cancer, and resection of the liver metastases if present, it is important that patients are followed-up with routine CT scans of their chest, abdomen and pelvis with or without measurement of a tumour marker level. Although there aren’t universally accepted guidelines on how often these investigations should be performed, most units suggest that they should be repeated every six or twelve months for the first 5 years.
In my unit, our patients with resected colorectal liver metastases are enrolled in a five-year follow-up plan with six monthly CT chest-abdomen-pelvis scans. If at the time of cancer the tumour marker CEA was elevated, this value will be measured as well at the same time of the scan. We also recommend a colonoscopy to be repeated every 2 to 3 years for the rest of the patient’s life.
How are hepatic liver metastases treated?
The main and most successful treatment to cure colorectal liver metastases is their complete excision from the liver. This is achieved by performing a complex surgical procedure called liver resection. The extension of the resection varies according to the characteristics of the metastases. Their size, number and location in the liver determine the feasibility and extension of the resection that is needed to remove them.
However, what has vastly improved the outcome of treatment of metastatic colorectal cancer is the so-called multimodality approach. In fact, although resection for colorectal metastatic disease alone can offer long-term survival and a consistent chance for cure, its success rate is further increased in many cases when systemic chemotherapy is given before and/or after surgery.
Why is metastatic colorectal cancer challenging to treat?
Metastatic colorectal cancer is a very heterogeneous disease that can present in many different ways, at different stages and with different behaviours amongst patients. Therefore, the strategy to treat it can vary significantly from one patient to another, using different treatments in different orders. To allow for the best possible decision regarding treatment strategy we, as most of the big hepatobiliary units, discuss each patient case individually by convening a multidisciplinary team meeting (MDT) exclusively dedicated to patients with metastatic disease to the liver. This team is made of a number of expert liver surgeons, oncologists dedicated to colorectal and liver cancer, dedicated radiologists, bowel surgeons, specialist nurses and, at times, lung surgeons.