Colorectal liver metastases diagnosed
Liver-only or liver-dominant disease. Discuss every patient at a multidisciplinary team (MDT) meeting with a hepatobiliary (HPB) surgeon.
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Hepatobiliary SurgeryDiagnostic
Colorectal Liver Metastases Resectability Assessment
Colorectal Liver Metastases Resectability Assessment: Colorectal liver metastases diagnosed → Complete staging and tumour biology → Before any systemic ...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Action Complete staging and tumour biology
CT chest, abdomen and pelvis. Liver MRI. PET-CT to exclude extrahepatic disease before liver surgery.
- Confirm liver-only or limited extrahepatic disease
- Assess the primary tumour: symptomatic (obstruction, bleeding) is treated first; rectal primary needs pelvic MRI and an MDT plan for the order of treatment
- Test RAS, BRAF V600E and dMMR/MSI before systemic therapy
- Test for DPD deficiency before 5-FU or capecitabine
- Baseline CEA; assess fitness for major surgery and the background liver
03Warning Before any systemic therapy: check RAS, MSI and DPD results, and pregnancy
Pregnancy: obstetric and oncology planning before any chemotherapy or surgery.
- RAS-mutant: do not give cetuximab or panitumumab
- dMMR/MSI-H: medical oncology review; immune checkpoint inhibitor (for example pembrolizumab) is first-line standard
- DPD deficiency: 5-FU or capecitabine can be fatal; reduce the dose (partial) or avoid (complete)
04Decision Technically resectable? (HPB surgeon at MDT)
Decide on R0 resection (with ablation if needed) and the future liver remnant (FLR).
- R0 resection of all lesions possible, with ablation if needed
- FLR ≥20% normal liver; ≥30% after extensive chemotherapy; ≥40% cirrhosis
- At least 2 contiguous segments with adequate inflow, outflow and biliary drainage
- Patient fit for surgery; extrahepatic disease absent or treatable
- Resectable, FLR adequate
05Action Resectable now with adequate FLR: assess oncological risk
R0 possible. FLR ≥20% normal liver, ≥30% after extensive chemotherapy, ≥40% cirrhosis.
- If perioperative chemotherapy: fluoropyrimidine + oxaliplatin only; no anti-EGFR or bevacizumab (worse survival with cetuximab, New EPOC)
- Cirrhosis, steatohepatitis or portal hypertension: specialist liver assessment before major hepatectomy
06Decision Favourable oncological criteria?
Favourable: metachronous, few lesions, unilobar, no extrahepatic disease. Unfavourable: synchronous, more than 3 lesions, bilobar, limited extrahepatic disease.
- Fong clinical risk score (1 point each): node-positive primary; disease-free interval <12 months; more than 1 lesion; CEA >200 ng/mL; largest lesion >5 cm
- Unclear prognosis: treat as unfavourable
- If Yes
- Favourable
07Action Favourable criteria: upfront resection
Perioperative chemotherapy may not be needed. Perioperative FOLFOX improved disease-free survival but not overall survival (EORTC 40983): MDT decision.
- Metachronous: resection
- Synchronous primary: simultaneous or staged resection (MDT decides the order)
08Action Hepatic resection (R0)
Timing: 3-4 weeks after the last chemotherapy (with or without anti-EGFR); at least 5 weeks after the last bevacizumab dose.
- Resect all sites seen before chemotherapy; lesions that disappeared on imaging: MDT plan (microscopic disease often remains)
- Parenchymal-sparing resection where oncologically adequate
- Add ablation for small deep lesions if needed
- Laparoscopic approach where expertise allows
09End After resection: complete chemotherapy and surveillance
Complete planned post-operative chemotherapy (MDT). Surveillance: CT (or MRI) and CEA every 3 months for 2 years, then every 6 months.
If No- Unfavourable or unclear
10Action Unfavourable or unclear criteria: perioperative chemotherapy
FOLFOX (or CAPOX) for about 3 months before and 3 months after resection. No targeted agents.
- Do not add cetuximab, panitumumab or bevacizumab to perioperative chemotherapy for resectable disease
- Relapse within 12 months of adjuvant oxaliplatin: medical oncology chooses another regimen
- Lesions 10-15 mm may disappear: limit pre-operative chemotherapy to 2 months, or discuss upfront resection or ablation
- Restage with the same imaging (CT and liver MRI); resect as soon as resectable. Progression on chemotherapy: back to the liver MDT
- Path rejoins step 08Shared downstream outcome
- R0 possible, FLR too small
11Action R0 possible but FLR too small: FLR augmentation
Portal vein embolisation (PVE) is the standard first option.
- PVE; PVE plus hepatic vein embolisation (liver venous deprivation) in selected centres
- Two-stage hepatectomy for bilobar disease
- ALPPS only in selected patients at experienced centres (higher morbidity and mortality)
- Re-measure FLR and restage after about 4-6 weeks; insufficient growth or progression: back to MDT
- Path rejoins step 08Shared downstream outcome
- Potentially resectable
12Action Potentially resectable after downsizing: conversion intent
Tumour must shrink before R0 resection is possible. Plan with the HPB surgeon and medical oncologist.
13Action Conversion chemotherapy
Choose the regimen by RAS, BRAF and MSI status, primary side and fitness. Restage every 8-12 weeks. Resect as soon as resectable: prolonged chemotherapy injures the liver and increases post-operative morbidity.
- RAS and BRAF wild-type, left-sided primary: FOLFOX or FOLFIRI + cetuximab or panitumumab
- RAS-mutant or right-sided: FOLFOXIRI + bevacizumab if fit; otherwise doublet + bevacizumab
- No FOLFOXIRI if age over 75 years, performance status 2 or significant comorbidity
- Raised bilirubin or biliary obstruction: medical oncology to reduce or avoid irinotecan (no dose established above 34 µmol/L); relieve obstruction first
- BRAF V600E: poor prognosis; medical oncology chooses the regimen (triplet with or without bevacizumab, or BRAF-targeted therapy)
- dMMR/MSI-H: immune checkpoint inhibitor (medical oncology)
- Last bevacizumab dose at least 5 weeks before hepatectomy
- Chemotherapy-refractory liver-only disease: hepatic arterial infusion or SIRT (Y-90) only in selected patients
14Decision Restaging after conversion therapy: resectable now?
MDT review of each restaging scan. Include every site seen before chemotherapy. After extensive chemotherapy the FLR must be at least 30% (40% in cirrhosis); smaller FLR: FLR augmentation.
- Resectable, FLR adequate
- Path rejoins step 08Shared downstream outcome
- Resectable, FLR too small
- Path rejoins step 11Shared downstream outcome
- Still unresectable
15End Not resectable: systemic therapy for disease control
Medical oncology care. Local therapy (ablation, SBRT) in selected patients. Supportive and palliative care. Refer back to the liver MDT if the disease becomes resectable.
- Never resectable
16Action Never resectable: systemic therapy with palliative intent
For example widespread extrahepatic disease, liver disease that cannot become resectable, or unfit for surgery.
- Path rejoins step 15Shared downstream outcome
Guideline Source
ESMO Clinical Practice Guideline: Metastatic colorectal cancer (Cervantes et al., Ann Oncol 2023)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Decision support only: every patient needs liver MDT review with an HPB surgeon; resectability is a specialist judgement
- Systemic therapy choices summarise ESMO 2023 (a 2026 ESMO update exists); regimens, doses and newer first-line agents (nivolumab + ipilimumab for dMMR, encorafenib-based therapy for BRAF V600E, HER2 therapy) need medical oncology input
- FLR thresholds are consensus values; volumetry and liver function tests vary by centre
- Covers colorectal liver metastases only; not for other primary cancers
Contraindicated Populations
Liver metastases from a non-colorectal primary (for example neuroendocrine tumour)Pregnancy: systemic therapy and surgery need specialist obstetric and oncology planning
Applicable Regions
USAUUKEU
AU: Optimal care pathway for colorectal cancer (Cancer Council/Cancer Australia): liver MRI if CT shows liver-confined disease; PET-CT to restage potentially resectable disease; MDT care.
EU: ESMO 2023 metastatic colorectal cancer guideline.
UK: NICE NG151: consider simultaneous or sequential resection after specialist MDT; consider perioperative systemic therapy; do not offer SIRT first line.
US: NCCN colon and rectal cancer guidelines; AHPBA/SSO/SSAT 2013 expert consensus on selection for hepatic resection.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Colorectal Liver Metastases Resectability Assessment?
The Colorectal Liver Metastases Resectability Assessment is a diagnostic clinical algorithm for Hepatobiliary Surgery. It provides a structured decision tree to guide clinical decision-making, based on ESMO Clinical Practice Guideline: Metastatic colorectal cancer (Cervantes et al., Ann Oncol 2023).
What guideline is the Colorectal Liver Metastases Resectability Assessment based on?
This algorithm is based on ESMO Clinical Practice Guideline: Metastatic colorectal cancer (Cervantes et al., Ann Oncol 2023) (DOI: 10.1016/j.annonc.2022.10.003).
What are the limitations of the Colorectal Liver Metastases Resectability Assessment?
Known limitations include: Decision support only: every patient needs liver MDT review with an HPB surgeon; resectability is a specialist judgement; Systemic therapy choices summarise ESMO 2023 (a 2026 ESMO update exists); regimens, doses and newer first-line agents (nivolumab + ipilimumab for dMMR, encorafenib-based therapy for BRAF V600E, HER2 therapy) need medical oncology input; FLR thresholds are consensus values; volumetry and liver function tests vary by centre; Covers colorectal liver metastases only; not for other primary cancers. Individual patient factors may require deviation from these recommendations.
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