Updated 10 April 2013

Note – non liver organ confined or oligo-metastatic (eg. Lung) disease should be reviewed in a multi-disciplinary setting.

Diagnostic and Staging Work-up

• Diagnostic and staging work-up is similar to the rectal and colon guidelines. When liver lesions are determined on the staging work-up, the following imaging work-up is recommended.
• Accurate staging is needed to determine the suitability of the patient for potential resection as well to determine the systemic management.
• Preoperative serum carcinoembryonic antigen (CEA) tumour marker is recommended to guide subsequent follow-up.
• Staging should incorporate contrast enhanced CT Chest/Abdomen/Pelvis preferably.
• PET/CT should be considered for surgical operable disease to rule out extrahepatic disease.
• If CT scan shows unresectable extrahepatic disease – should not proceed with PET/CT.
• Contrast enhanced MRI with Primavist for equivocal lesions less than 1 cm should be performed to characterize malignant lesions.
• Staging work-up should be performed prior to the start of systemic therapy.
• Imaging should be performed within 6-8 weeks of a surgical decision ideally.

Surgical Therapy

• In patients who have a symptomatic primary, it is reasonable to consider primary resection to alleviate the symptoms. This should be discussed with a Medical Oncologist and if possible reviewed in a multidisciplinary setting.
• At the time of diagnosis of operable metastatic disease – a referral to a HPB surgeon should be considered.
• If the choice of chemotherapy is influenced by the resectability of the lesion – then the surgical consult should be performed prior to treatment.
• The sequence of surgery should be discussed in a multidisciplinary role depending on extent of disease, symptoms and response to therapy.
• The minimal requirements for consideration of liver resections are:
  • Two adjacent hepatic segments (excluding caudate lobe) free of tumour
  • Biliary drainage
  • Arterial inflow
  • Non-thrombosed portal vein
  • 20% or more liver functional reserve
• Upfront liver resection followed by post-operative chemotherapy vs. perioperative chemotherapy with liver resection are both reasonable options to consider (see Systemic therapy).
• Adjunctive conversion procedures such as portal vein embolization (PVE) may be performed in the setting of complex resection or those resections that may require a disproportional percentage of the liver to be resected however should be reviewed and performed on a case by case basis, subject to multidisciplinary review involving medical oncology, surgical oncology and radiology.

Systemic Therapy

• Patients diagnosed with metastatic disease should be referred to a medical oncologist.
• For resectable liver limited mCRC, systemic therapy should be considered in either a perioperative or post-operative setting.
• Initially unresectable patients should still be considered for local regional strategies if there is a reasonable response and should be reviewed in a multidisciplinary setting.
• Patients should be assessed by HPB surgeon early in their course of chemotherapy or prior to commencement of chemotherapy.
• There is no single optimal choice of chemotherapy for perioperative/post-operative treatment.
• 5FU/Oxaliplatin or 5FU/Irinotecan or 5FU based chemotherapy can be considered.
• Steatohepatitis caused by irinotecan can interfere with surgery and therefore should be discussed with the surgeon if used – therefore, it is preferable to consider oxaliplatin based treatment.
• Irinotecan is NOT a contraindication for surgery and can be considered if the patient is felt to be oxaliplatin resistant or ineligible.
• Bevacizumab and EGFR monoclonal antibody therapy are still considered investigational in the setting of upfront resectable liver metastases.
• In borderline patients who are being considered for conversion – biologic therapy in combination with chemotherapy are an option to consider depending on the approval of the GI systemic therapy group.
• If bevacizumab is used – it should be discontinued at least 4-6 weeks prior to surgery due to wound healing concerns with this medication.
• Chemotherapy should be discontinued at least 4 weeks prior to surgery.
• Patients should be reviewed by their medical oncologist after surgery and depending on patient fitness and co-morbidities, chemotherapy should be consider 4-6 weeks after surgery to complete a total of 12 cycles of treatment (or 6 months).

Role of other local regional strategies:

Local Ablation Therapy

• Patients who are eligible for surgery should be considered for a surgical resection.
• If there are less than 3 target lesions and each lesion measures less than 3 cm, ablation can be considered in patients who are not optimal surgical candidates.

Stereotactic Body Radiotherapy (SBRT)

• Reserved for liver metastases that are not eligible for surgical resection or RFA.
• Patients who have had a cancer recurrence after either surgery or RFA and are medically or surgically ineligible or those that refuse surgery
• Eligible patients are those with tumours not to exceed 6 cm in diameter, with no more than 3 liver tumours, and Child’s Pugh Grade A (or very early CP Grade B) function.

Embolic therapy

• Radioembolization – ongoing data is pending with respect to this therapy and at present is not a funded option.
• Chemoembolization is an evolving therapy and not formally recommended.

Follow-up

• There are no standard guidelines for follow-up. The reason for follow-up is to detect liver limited recurrence that may be amenable for future local regional treatment.
• A contrast enhanced CT scan of the Chest/Abdo/pelvis should be performed within 3 months of the procedure.
• No standard guidelines currently exist for surveillance in Stage IV NED and are as determined by the treating oncologist. However, at the treating physician’s discretion, follow up per BC Cancer colorectal surveillance guidelines for stage II & III can be considered. This schedule can also be modified at the treating physician’s discretion.
• See also: Follow-up and Surveillance of Colon Cancer Patients Treated with Curative Intent
• Follow-up imaging – CT scan of the Chest/abdo/pelvis (contrast enhanced) should be considered every 3-6 months for the first 3 years and then annually for a further 2 years.
• A CEA can be considered every 3 months for the first 3 years then every 6 months for 2 further years.
• Colonoscopy should be performed as per adjuvant guidelines.