New paradigm in the treatment of hepatic colorectal metastases: A surgeon's perspective

Curative resection of liver metastases from colorectal cancer is associated with high 5-year overall survival rates, making complete resection and conversion of unresectable disease to resectable disease goals of therapy for liver metastases. With advances in technology and surgical approaches, the definition of "resectable" has undergone a paradigmatic shift from focusing on "what comes out" to "what stays in." The current objective is to remove all known disease while leaving adequate remnant liver. This latter approach requires multidisciplinary efforts and extensive preoperative planning. When disease is not thought to be initially resectable, methods for converting initially unresectable to resectable disease include tumor downsizing (eg, via neoadjuvant chemotherapy), increasing remnant hepatic reserve (eg, via staged resection or portal vein embolization), and ablative techniques. Systemic chemotherapy for metastatic disease has improved in recent years, and there is accumulating evidence that adjuvant therapy improves outcome. However, considerable work remains in defining the optimal use of chemotherapy for resectable disease.