title: Management of colorectal cancer presenting with synchronous liver metastases.
abstract: Up to a fifth of patients with colorectal cancer (CRC) present with synchronous hepatic metastases. In patients with CRC who present without intestinal obstruction or perforation and in whom comprehensive whole-body imaging confirms the absence of extrahepatic disease, evidence indicates a state of equipoise between several different management pathways, none of which has demonstrated superiority. Neoadjuvant systemic chemotherapy is advocated by current guidelines, but must be integrated with surgical management in order to remove the primary tumour and liver metastatic burden. Surgery for CRC with synchronous liver metastases can take a number of forms: the 'classic' approach, involving initial colorectal resection, interval chemotherapy and liver resection as the final step; simultaneous removal of the liver and bowel tumours with neoadjuvant or adjuvant chemotherapy; or a 'liver-first' approach (before or after systemic chemotherapy) with removal of the colorectal tumour as the final procedure. In patients with rectal primary tumours, the liver-first approach can potentially avoid rectal surgery in patients with a complete response to chemoradiotherapy. We overview the importance of precise nomenclature, the influence of clinical presentation on treatment options, and the need for accurate, up-to-date surgical terminology, staging tests and contemporary management options in CRC and synchronous hepatic metastatic disease, with an emphasis on multidisciplinary care.
authors.affiliation: Hepatobiliary Surgery Unit, Manchester Biomedical Research Centre and NIHR Greater Manchester Research Network, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK.
authors.forename: Ajith K
authors.initials: AK
authors.lastname: Siriwardena
authors.affiliation: Durham Clinical Trials Unit, School of Medicine, Pharmacy and Health, Wolfson Research Institute, Durham University Queen's Campus, University Boulevard, Stockton-on-Tees TS17 6BH, UK.
authors.forename: James M
authors.initials: JM
authors.lastname: Mason
authors.affiliation: Department of Medical Oncology, Christie Hospital, Wilmslow Road, Manchester M20 4BX, UK.
authors.forename: Saifee
authors.initials: S
authors.lastname: Mullamitha
authors.affiliation: Durham Clinical Trials Unit, School of Medicine, Pharmacy and Health, Wolfson Research Institute, Durham University Queen's Campus, University Boulevard, Stockton-on-Tees TS17 6BH, UK.
authors.forename: Helen C
authors.initials: HC
authors.lastname: Hancock
authors.affiliation: Hepatobiliary Surgery Unit, Manchester Biomedical Research Centre and NIHR Greater Manchester Research Network, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK.
authors.forename: Santhalingam
authors.initials: S
authors.lastname: Jegatheeswaran
mesh_terms: D015179:Colorectal Neoplasms / Q000473:pathology* / Q000628:therapy*; D006801:Humans; D008113:Liver Neoplasms / Q000556:secondary* / Q000628:therapy*; D009367:Neoplasm Staging