This is the term reserved for cancer that has spread to the liver from a cancer that has originated either within the colon or the rectum.
The most common types of cancer that spread to the liver, generally start from organs and mos commonly include bowel, breast, pancreas, stomach, lung, ovary and other primary sites. However, colon and rectum cancer spreads to the liver in almost 50% of all colorectal cancers. This is a special group of patients, since, with detection and treatment at the right time, a significant proportion of these can be treated and potentially cured.
Generally spread of cancer to the liver, from the colon is considered as advanced disease and was treated only with palliative intent.
However now with progress in cancer treatment, metastatic disease limited to the liver, although considered as advanced disease can be treated effectively with a combination of treatments including Surgery / Hepatectomy.
- Cancer of the large intestine – colon and rectum: is the 2nd most common cancer in women and 3 rd most common cancer in men..
- 10% of all cancers world over , originated either from the colon and / or rectum
- The highest incidence is in the Western population and the incidence is progressively increasing in India as well
- 25% of all colon and rectum cancers have the disease spread to the liver ( liver metastases ), at the primary diagnosis of the rectum and colon cancer.
- Another 25% of patients who have already been treated for colorectal cancer, will have liver metastases detected at follow up. Hence approximately 50% of all colorectal cancer patients have liver metastases at some point in time, during the course of the natural history of the disease.
With phenomenal progress in the range of chemotherapy medications, liver surgery, and interventional radiology – many of these patients can be effectively treated with curative intent. The liver metastases can be successfully treated – removed surgically in combination with other treatments, thereby helping to control and eradicate the disease from the liver.
The same principle can be applied selectively to secondary liver cancer, which has spread to the liver from other organs. The selection of patients for liver surgery and liver procedures in such cases has to be individualized with a multidisciplinary approach between the treating cancer physician ( medical oncologist ), surgical oncologist, colorectal surgeon and the liver surgeon.
How is liver metastases diagnosed?
Usually, liver metastases are diagnosed during staging investigations carried out for the primary tumour ( eg: tumour in the colon or rectum, breast, lung, etc ).
This is most commonly seen at CT scan / PET scans / Ultrasound, performed either at diagnosis of the primary cancer or during follow up of patients, who have already been treated for their primary cancer.
Metastatic spread of cancer, if restricted to the liver, can be considered for treatment with a potentially curative intent. In select situations, even doubt there is some spread of tumour outside of the liver ( eg: lung, bones, etc ), patients may still be eligible for liver treatment after very careful assessment and evaluation by their team of treating oncologists.
Treatment overview of secondary liver cancer
The choice of treatment for secondary liver cancer depends on
- Where it has spread from: cancers which have spread to the liver from the large intestine: colon and rectum, have the best outcomes for metastatic liver cancer. Similarly, neuroendocrine tumours spread to the liver have a good prognosis and should be treated aggressively with an intent to achieve cure.
- If any other parts of the body are affected : in : lung / brain / bones / peritoneum /, etc.
- How much of the liver has been affected – whether limited parts of the liver are affected ( favourable prognosis ) or large parts of the liver are affected ( unfavourable )
Planning Treatment
Treatment for liver metastases is an organised team effort comprising a group of medical professionals and oncologists. Each and every case is studied in detail and passes through a Multi-Disciplinary team meeting who come to a consensus for the best and most effective treatment.
The team includes
- Liver Surgeon / Hepato Biliary and Pancreatic ( HPB ) Surgeon
- Treating surgical oncologist / colorectal surgeon
- Medical oncologist – chemotherapy physicians
- Radiologist: a radiologist with a special interest in liver radiology to analyse in detail the metastatic disease within the liver
- Interventional Radiologist – interventional radiology plays a pivotal role in the management of metastatic liver disease and offers a host of therapeutic possibilities to enhance the possibility of a cure .
- Histopathologist to study the pathology of the cancer
Treatment for Liver Metastases :
1. Chemotherapy
Most patient with secondary liver tumours will require chemotherapy. Chemotherapy remains the mainstay of treatment of metastatic liver disease and plays an important role in facilitating surgery. Chemotherapy given before surgery, helps in shrinking of the tumours, thereby facilitating surgery. In select cases, the liver operation is done first and chemotherapy may be given later.
2. Surgery – Liver Resection / Hepatectomy
This involves the removal of the parts of the liver, affected with metastases.
Surgery for liver tumours includes – removal of part of the liver bearing the tumour with an adequate part of normal liver ( to obtain tumour free margin ). Surgery may range from removal of a small portion of the liver ( wedge resection of liver, minor hepatectomy ) to large portions of the liver ( major hepatectomy ). The complexity of the operation increases with the extent of liver removed.
Surgery is facilitated by the fact that the liver has a good regenerative capacity and can grow significantly and substantially after removal of parts. Up to 70% of tumour bearing liver can be removed if the remaining liver is healthy and permits.
Certain other procedures such as Portal Vein Embolization ( PVE ) can help increase the size of the liver, prior to surgery, thereby facilitating surgery. Sometimes staged liver resection ( two liver operations – at two different times ), may be required to allow for the healthy non-tumour liver to grow back.
Liver surgery is major surgery and needs an experienced team of hepatobiliary surgeons to collectively perform the same, for best outcomes.
Surgery may be done through the open technique ( cut on the abdomen ) or keyhole technique ( minimally invasive ).
Sometimes both the bowel and the liver procedure can be performed simultaneously ( synchronous resection ) or may be done in a staged manner. The sequence of procedures is determined by joint consultation.
Interventional Radiology in Liver Metastases
1. Radio Frequency Ablation : RFA
This procedure can be done either during surgery or through the skin, under ultrasound / CT guidance – through a needle inserted into the tumour. The RFA procedure makes use of radio waves, to destroy the liver metastases. The high electricity through the needle inserted into the tumour, causes thermal destruction of the tumour. The procedure can be done as a daycare procedure.
2. Hepatic Artery Chemoembolization ( TACE ) –
Chemotherapy drugs into the tumour. This is done as an angiography procedure under a local anaesthetic/sedation.
Other more advanced techniques include
- DEB-TACE: transarterial chemoembolization with drug-eluting beads
- SIRT: Selective Internal Radiation Therapy
Facilities at the Sir H N Reliance Foundation Hospital
Dr Soumil Vyas – MS, DNB, FRCS(Edin), FRCS ( Upper GI/ HPB ), MNAMS, M.Med ( Surg ), FAIS, FEBS, provides comprehensive management of liver metastases.
Dr Soumil Vyas – is a trained liver/gall bladder and pancreas surgeon and gastrointestinal surgeon, with a speciality in Surgical Oncology. He specialises in the surgical management of the cancers of the gastrointestinal tract – stomach, colon, intestine along with the liver, gall bladder and the pancreas.