Treatment of metachronous liver metastases from colorectal cancer sees surgery as the primary therapy. However, in recent years, several factors have emerged that have led to considering liver resection as an increasingly personalized practice. Liver resections are now placed within the "precision surgery". Even if in the presence of different guidelines published in the scientific literature, very often the attitude of the various hepatobiliary surgery centers, and even of the individual surgeons, is not homogeneous and different (sometimes very different) are the attitudes that direct towards the 'one or the other surgery.

1. Gian Luca Grazi
Hepato-Biliary-Pancreatic Surgery
National Cancer Institute Regina Elena
Rome
What strategy in metachronous metastases

2. What strategy in metachronous metastases
https://www.chirurgiadelfegato.it/il-fegato/linee-guida-metastasi-epatiche/
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3. What strategy in metachronous metastases

4. What strategy in metachronous metastases
Garden OJ, GUT 2006; 55(Suppl III): iii1-iii8

5. What strategy in metachronous metastases
• The aim of LR (resectability) is to remove all macroscopic disease with clear (negative) margins and leave sufficient functioning liver.
(Category of evidence II; strength of recommendation B)
• Patients with solitary, multiple, and bilobar disease who have had radical treatment of the primary colorectal cancer are candidates for
liver resection. (Category of evidence III; strength of recommendation C)
• The ability to achieve clear margins (R0 resection) should be determined by the radiologist and surgeon in the regional hepatobiliary unit.
(Category of evidence III; strength of recommendation C)
• The surgeon should define the acceptable residual functioning volume, approximately one third of the standard liver volume, or the
equivalent of a minimum of two segments. (Category of evidence III; strength of recommendation C)
• The liver surgeon and anaesthetist should take the clinical decision regarding fitness for surgery. (Category of evidence III; strength of
recommendation C)
• If deemed medically unfit for surgery, patients should be considered for ablative therapy. (Category of evidence IV; strength of
recommendation D)
• Patients with extrahepatic disease that should be considered for liver resection include:
• (1) resectable/ablatable pulmonary metastases;
• (2) resectable/ablatable isolated extrahepatic sites—for example, spleen, adrenal, or respectable local recurrence; and
• (3) local direct extension of liver metastases to, for example, diaphragm/adrenal that can be resected. (Category of evidence IV;
strength of recommendation D)
• Normal contraindications to liver resection would include uncontrollable extrahepatic disease
Garden OJ, GUT 2006; 55(Suppl III): iii1-iii8

6. What strategy in metachronous metastases
Vera R, Clin Transl Oncol 2020, 22: 647-662

7. What strategy in metachronous metastases
Algorithm for the management of liver metastases in patients with colorectal cancer.
Fit patients.
Vera R, Clin Transl Oncol 2020, 22: 647-662

8. What strategy in metachronous metastases
Algorithm for the management of liver metastases in patients with colorectal cancer.
Unfit patients.
Vera R, Clin Transl Oncol 2020, 22: 647-662

9. What strategy in metachronous metastases
Salvatore L, ESMO Open 2017; 2:e000147

10. What strategy in metachronous metastases
Salvatore L, ESMO Open 2017; 2:e000147
It is possible to identify four different scenarios with different medical approaches
Patients with First Line Therapy Followed by
Limited resectable disease Surgery Perioperative or postoperative
‘adjuvant’ chemotherapy
Limited unresectable disease Conversion therapy Radical surgery when possible
Widespread and aggressive
mCRC and disease-related
symptoms
Palliative therapy with the aim
of rapid tumour shrinkage
Widespread, unresectable and
asymptomatic disease
Palliative therapy with the aim
of disease control to maintain
a good quality of life

11. What strategy in metachronous metastases
Salvatore L, ESMO Open 2017; 2:e000147
Surgery: SIGN recommendations

12. What strategy in metachronous metastases
Agreement (Percentage) Among Experts for Each Clinical Case
Ignatavicius P, Ann Surg 2020, 272(5): 715-722

13. What strategy in metachronous metastases
Ignatavicius P, Ann Surg 2020, 272(5): 715-722

14. What strategy in metachronous metastases
Conclusions
Ignatavicius P, Ann Surg 2020, 272(5): 715-722
Choices of therapeutic strategies among expert liver surgeons
actually look like ‘‘a throw of the dice.’’
This alarming data should trigger major efforts in establishing
guidelines of standard of care, and recommendations to protocol any
deviation from standard care.
In this setting, registries are important to prospectively collect data,
and enable international analysis contributing to constructive
consensus conferences and the design of widely accepted guidelines.

15. What strategy in metachronous metastases
Bonney GK, Lancet Gastroenterol Hepatol 2021; 6: 933–46

16. What strategy in metachronous metastases
Viganò L, World J Gastroenterol 2022;28(6):608-623
Is precision medicine for colorectal liver metastases still a utopia?

17. What strategy in metachronous metastases
Question: What strategy in metachronous metastases?
Answer:

18. What strategy in metachronous metastases
Ignatavicius P, J Hepatol 2022;77:837–848

19. Gian Luca Grazi
Hepato Biliary Pancreatic Surgery
National Cancer Institute “Regina Elena”, Rome, Italy
gianluca.grazi@ifo.it
www.chirurgiadelfegato.it
What strategy in metachronous metastases

20. What strategy in metachronous metastases

21. What strategy in metachronous metastases
Salvatore L, ESMO Open 2017; 2:e000147
Algorithms for the management of metastatic colorectal cancer
Resectable metastatic disease

22. What strategy in metachronous metastases
• Patients under consideration of treatment of hepatic metastases should be
discussed at a multidisciplinary meeting which has experience in the
management of liver metastases.
• A hepatobiliary multidisciplinary team (MDT) which carries out liver
resection should be based in a cancer center serving a population of at least
two million. When two or three networks cooperate to create a single joint
team, there should be explicit arrangements for referral between networks.
(Category of evidence II ; strength of recommendation B)
• Consideration of patients for resection of liver metastases should be carried
out at a single high volume center. (Category of evidence II; strength of
recommendation B)
Garden OJ, GUT 2006; 55(Suppl III): iii1-iii8