Patient Selection for the Surgical Treatment of Colorectal Liver Metastases: Beyond the Abstract

 
The management of colorectal liver mestastases (CRLM) demands multimodal approach especially for resectable lesions.  Comparing to unresectable lesions that are usually treated by systematic chemotherapy as main therapy, either conversion- or palliative-intent treatment, the potentially resectable CRLM need to be treated based on both surgery and systemic therapy.

The management of resectable lesions has many topics in the decision-making process as: tumor burden; clinical and molecular prognostic factors; performance status; site and symptoms of primary tumors; and surgical techniques. Those points can change the order of treatment (chemotherapy versus surgery upfront) according to initial presentation. In our review, we describe advances in surgical fields and chemotherapy regimens that have improved long-term outcomes for patients with CRLM.

We highlight the role of surgery as the main curative-intent treatment for selected cases of CRLM but always associated with systemic therapy. While chemotherapy improves survival in this disease as demonstrated by randomized clinical trials, the optimal timing for the chemotherapy regimen remains unclear. We explore pros and cons for both pre- and postoperative chemotherapy for CRLM, based on literature and clinical dilemmas. Since decision-making process remains unclear, we analyze key points to be considered on this process. We do believe that our review can be useful to better conduct patient selection for surgical treatment based on tumor burden, clinical presentation, and use of chemotherapy as important tool to select patients. 

Written by: Raphael Araujo

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