What Are Liver Metastases?
Liver metastases are the most common malignant liver tumours, far outnumbering primary liver cancer (hepatocellular carcinoma). They occur when cancer cells spread from a primary tumour to the liver via the bloodstream or lymphatics. The most common primary sources are colorectal (50% of patients develop liver metastases), breast, lung, gastric and pancreatic cancers.
Symptoms
Small liver metastases are often asymptomatic and detected on surveillance imaging. Larger deposits may cause: right upper quadrant pain or heaviness, jaundice (if biliary compression), ascites, nausea and loss of appetite, weight loss, or signs of liver dysfunction in advanced disease.
Diagnosis
CT scan (triphasic): Most widely used for detection and characterisation. Liver MRI: More sensitive for small or indeterminate lesions. Superior for pre-surgical planning. PET-CT: Assesses overall disease extent. Tumour markers: CEA for colorectal, CA 19-9 for pancreatic/biliary, AFP for hepatocellular. Biopsy: May be required for diagnosis when primary is unknown.
Treatment of Colorectal Liver Metastases
Surgical resection: The only potentially curative treatment. 5-year survival of 30–50% in resected patients. Two-stage hepatectomy or ALPPS allow resection when the future liver remnant is inadequate. Ablative techniques: Radiofrequency ablation (RFA), microwave ablation for small, surgically inaccessible lesions. Chemotherapy: FOLFOX, FOLFIRI ± targeted agents as neoadjuvant or palliative. SIRT/TACE: Intra-arterial therapies for unresectable hepatic disease.
Conversion Surgery
Initially unresectable liver metastases may become resectable after response to systemic chemotherapy. This "conversion" strategy has expanded the pool of patients who can benefit from curative surgery.
The Question That Decides Everything: Are They Operable?
Of everything above, only one thing genuinely changes the prognosis: whether the metastases can be removed. Resection is the only potentially curative treatment, and yet many patients are told they are inoperable without ever being assessed by a specialist liver surgery team.
Resectability does not depend on the number of lesions, as was believed years ago. Today the criteria are different:
• Sufficient liver remnant after resection (typically 25 to 30% of functional volume, more if the liver has been damaged by chemotherapy).
• Preservable vascular and biliary inflow and outflow to the remaining liver.
• Extrahepatic disease that is controlled or itself resectable.
A patient with six bilobar metastases may be operable, while one with a single badly placed lesion may not be. That is why the assessment must be made by someone who operates on livers, not only by someone who reads the imaging.
What to Do When You Have Been Told "Inoperable"
"Inoperable today" does not always mean inoperable. Specific strategies exist to convert an unresectable case into a resectable one:
Conversion chemotherapy: shrinking lesions until they can be removed. Between 15 and 30% of initially unresectable patients reach surgery by this route.
Portal vein embolisation and hypertrophy: the future liver remnant is made to grow before surgery, so that enough functional volume remains.
Two-stage hepatectomy: the resection is divided into two procedures weeks apart, allowing the liver to regenerate in between.
Hepatic arterial infusion chemotherapy (HAI): delivered directly into the hepatic artery, with response rates far above the systemic route in colorectal metastases.
Combination with interventional radiology: resecting what is resectable and ablating the rest in the same procedure, through combined techniques.
Have you been told your liver metastases cannot be operated on? It is the most common reason patients come to us, and in a proportion of cases a surgical route exists that had not been considered. We review your imaging and give you a clear answer on resectability. Request an assessment.