title: Colorectal Liver Metastases: A Critical Review of State of the Art.
abstract: BACKGROUND
  Over 50% of patients with colorectal cancer will develop liver metastases. Only a minority of patients present with technically resectable disease. Around 40% of those undergoing surgical resection are alive five years after their diagnosis compared with less than 1% for those with disseminated disease treated with systemic chemotherapy. Surgical resection remains the only possibility for long-term survival for these patients and great efforts have been made to increase the rates of resection whilst improving long-term outcomes.
  
  
  CONCLUSIONS
  This review considers current technical and oncological criteria for resection, as well as targeted approaches to stratify underlying tumor biology in order to better predict long-term benefit. The role of neoadjuvant and perioperative systemic chemotherapy is critically reviewed, with suggestions for patient stratification in order to identify those who are likely to derive the greatest benefit. The key role of multidisciplinary assessment and decision making for these complex patients is also discussed.
  
  
  CONCLUSIONS
  Surgery remains the optimal treatment for colorectal liver metastases (CRLM). Despite the curative intent of surgical resection, the majority of patients develop recurrence. Surgical strategies should therefore be adopted to maximize the potential for repeat resections in the event of recurrence. Although a number of preoperative prognostic markers have been identified, none are absolute contraindications to resection. In order to reduce postoperative recurrence, neo-adjuvant chemotherapy is now the standard of care in a number of countries. The evidence base for this approach is contentious, and the potential benefit of such a strategy is likely to be greatest in patients with high oncological risk disease. Multidisciplinary care is essential to ensure the optimal management of these complex patients. In addition, all patients with CRLM should be discussed with specialist hepatobiliary surgeons.
authors.affiliation: School of Cancer Studies, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom; North Western Hepatobiliary Unit, Aintree University Hospital, Liverpool, United Kingdom.
authors.forename: Robert P
authors.initials: RP
authors.lastname: Jones
authors.affiliation: Department of Surgery, University of Tokyo, Tokyo, Japan.
authors.forename: Norihiro
authors.initials: N
authors.lastname: Kokudo
authors.affiliation: University Hospital Carl Gustav Carus, University Cancer Center, Dresden, Germany.
authors.forename: Gunnar
authors.initials: G
authors.lastname: Folprecht
authors.affiliation: Department of Surgery, University of Tokyo, Tokyo, Japan.
authors.forename: Yoshihiro
authors.initials: Y
authors.lastname: Mise
authors.affiliation: Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan.
authors.forename: Michiaki
authors.initials: M
authors.lastname: Unno
authors.affiliation: North Western Hepatobiliary Unit, Aintree University Hospital, Liverpool, United Kingdom.
authors.forename: Hassan Z
authors.initials: HZ
authors.lastname: Malik
authors.affiliation: North Western Hepatobiliary Unit, Aintree University Hospital, Liverpool, United Kingdom.
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Fenwick
authors.affiliation: North Western Hepatobiliary Unit, Aintree University Hospital, Liverpool, United Kingdom.
authors.forename: Graeme J
authors.initials: GJ
authors.lastname: Poston
keywords: Chemotherapy; Liver cancer; Surgery