Liver metastases
Liver metastases are deposits of cancer that have spread to the liver from a primary tumour elsewhere in the body. They are far more common than cancers arising in the liver itself. The important message, and one that is still not universally understood, is that liver metastases are not automatically incurable — for colorectal cancer in particular, surgical removal offers a genuine prospect of long-term survival and cure in carefully selected patients.
How they form
The liver receives the entire venous drainage of the intestine through the portal vein. Blood leaving the stomach, small bowel, colon, rectum and pancreas passes through the liver before returning to the heart. The liver therefore acts as the first filter for tumour cells shed into the portal circulation, which is why it is the commonest site of spread for gastrointestinal cancers.
Cells that detach from a primary tumour enter the bloodstream, lodge in the fine sinusoidal network of the liver, and most are destroyed. A few survive, adapt to the liver environment, recruit a blood supply and grow into deposits. This process may be well under way before the primary tumour causes any symptoms, which is why metastases are sometimes found at the same time as the primary (synchronous), and sometimes months or years later (metachronous).
The commonest primary sources are colorectal cancer, followed by pancreatic, gastric, oesophageal, breast, lung and neuroendocrine tumours. The origin matters enormously, because it determines whether surgery has a role at all.
Why colorectal liver metastases are different
For most cancers, spread to the liver indicates systemic disease and treatment is systemic. Colorectal cancer is the major exception. Liver metastases from colorectal primaries frequently behave as a limited, resectable pattern of spread, and removing them — combined with chemotherapy — produces long-term survival in a substantial proportion of patients. Five-year survival after complete resection is considerably better than most patients expect when first told the cancer has spread.
Neuroendocrine tumours are a second exception, often indolent, where surgery, ablation and other liver-directed treatments have a well-established role even with extensive disease.
Symptoms
Often none. Liver metastases are usually found on staging scans performed when the primary cancer is diagnosed, or on surveillance imaging afterwards. When symptoms occur they include upper abdominal discomfort, weight loss, loss of appetite, fatigue, and less commonly jaundice.
How the diagnosis is made
Contrast-enhanced CT of chest, abdomen and pelvis is the standard staging investigation. Liver-specific MRI is more sensitive for small deposits and is used when precise mapping is needed before surgery — it frequently identifies lesions that CT misses, which changes the operation. PET-CT is used selectively to exclude disease elsewhere.
Tumour markers such as CEA are useful for monitoring in colorectal cancer. Biopsy is required when the primary is unknown or the diagnosis uncertain, but is often unnecessary when the picture is clear.
Every case is discussed in a multidisciplinary meeting. The decisions — whether to operate, in what order, and what chemotherapy to give — are made jointly by surgeons, oncologists and radiologists, not by any one specialty alone.
Assessing whether surgery is possible
Resectability is not simply a matter of counting lesions. The questions are:
- Can all disease in the liver be removed with clear margins?
- Will enough functioning liver remain afterwards — generally at least 25–30% of a healthy liver, more if the liver has been damaged by chemotherapy?
- Can the vascular inflow, outflow and biliary drainage of the remaining liver be preserved?
- Is disease outside the liver absent, or itself controllable?
The volume figures quoted above are the conventional guideline thresholds; they are a starting point rather than a fixed rule, and the safe remnant differs for a liver damaged by prolonged chemotherapy, by steatosis or by cirrhosis. The plan is built around the individual patient, their liver and the biology of their disease.
Patients told their disease is inoperable have sometimes been assessed only against the number of lesions. That is an outdated criterion, and it is a common reason for a second opinion to change the plan.
Treatment
Liver resection
Removal of the deposits with a clear margin, ranging from limited wedge resections to major hepatectomy. Parenchyma-sparing techniques — taking the metastases with minimal surrounding liver rather than removing whole lobes — are increasingly favoured, as they preserve liver volume and keep open the possibility of further surgery should new deposits appear. Laparoscopic and robotic approaches are used in appropriate cases.
Increasing the future liver remnant
Where too little liver would remain, portal vein embolisation blocks the blood supply to the side being removed, causing the other side to grow over several weeks. Two-stage hepatectomy clears one side, allows regeneration, then removes the other. These techniques convert a proportion of patients from unresectable to resectable.
Chemotherapy
Given before surgery to shrink disease and test its biological behaviour, or afterwards, or both. Modern regimens make some initially unresectable disease resectable. Prolonged chemotherapy damages the liver, so the timing of surgery relative to chemotherapy is a deliberate decision.
Ablation
Radiofrequency or microwave ablation destroys small deposits with heat and is used alone for small lesions, or combined with resection to clear disease from both sides of the liver while preserving volume.
Other liver-directed therapy
Transarterial chemoembolisation, radioembolisation and hepatic arterial infusion have roles in selected patients, and pressurised intraperitoneal aerosol chemotherapy (PIPAC) and HIPEC are relevant where peritoneal disease coexists.
Recovery
Recovery depends on the extent of the resection. A laparoscopic limited resection may mean three to five days in hospital and two to three weeks to ordinary activity. A major open hepatectomy means a longer stay and six to twelve weeks to full recovery. Chemotherapy is usually resumed once healing is established.
Follow-up
Intensive, because recurrence in the liver is common and — crucially — often treatable again. Imaging and tumour markers at regular intervals for at least five years. Repeat liver resection for recurrence is frequently possible and produces outcomes comparable to the first operation, which is precisely why surveillance is worth attending.
When to seek a specialist opinion
Any patient with colorectal liver metastases should be assessed by a liver surgeon as part of their multidisciplinary care, ideally at the time of diagnosis rather than after chemotherapy has run for many months. A second opinion is particularly worthwhile for anyone told that liver metastases are inoperable — the criteria have changed substantially over the past two decades, and the judgement depends on the techniques available to the team making it.
Common questions
My cancer has spread to the liver. Does that mean it cannot be cured?
Not necessarily, and this is the most important point on this page. Bowel cancer that has spread to the liver is one of the few situations in which removing the secondary deposits can cure the disease, and a significant proportion of patients treated this way are alive and well many years later. A patient with liver metastases from bowel cancer should be assessed by a liver surgeon rather than assumed to be beyond cure.
Why is bowel cancer different from other cancers in this respect?
Because the bowel drains directly into the liver through the portal vein, so the liver is frequently the first and sometimes the only site of spread, rather than a sign that disease is everywhere. In many other cancers, liver deposits indicate widespread disease, and the approach is different.
How many deposits can be removed?
The number matters far less than people expect. What determines whether surgery is possible is whether all the disease can be removed while leaving enough healthy liver, with its own blood supply and bile drainage, to sustain you. Patients with multiple deposits are frequently operable, and the old rule limiting surgery to three or four lesions has been abandoned.
What happens if not enough liver would be left?
There are established ways of growing the liver before operating. Blocking the vein supplying the side to be removed causes the other side to enlarge over several weeks, and a two-stage operation clears one side first and the other once it has grown. Combining surgery with ablation of small deposits also reduces how much liver must be removed.
Does the liver grow back?
Yes, remarkably. The liver is the only internal organ with a substantial capacity to regenerate, and after removal of a large portion the remainder enlarges over weeks to months to restore most of the original volume and function. This is what makes major liver surgery possible at all.
Should I have chemotherapy before or after the operation?
Both approaches are used and the decision is individual. Chemotherapy first can shrink deposits, make surgery easier or possible where it was not, and demonstrates how the disease responds — useful information. Too much chemotherapy damages the liver and makes surgery riskier, so the timing and duration are planned jointly by the surgeon and the oncologist.
Can the deposits be treated without an operation?
Small deposits can be destroyed with heat or cold delivered through a needle, either alone or alongside surgery, and this is an established curative-intent treatment for suitable lesions. Treatments delivered through the artery, and precisely targeted radiotherapy, also have a role. Which is best depends on the size, number and position of the deposits.
Will they come back?
Recurrence is common, but it is frequently treatable — repeat liver surgery is well established and gives results comparable to the first operation in suitable patients. This is why follow-up with scans is intensive for the first few years, since recurrence found early is much more likely to be treatable.
Related conditions
Other conditions of the liver covered on this site:
- Liver cysts (simple hepatic cysts)
- Hydatid (echinococcal) cyst of the liver
- Liver haemangioma
- Focal nodular hyperplasia and hepatocellular adenoma
- Liver abscess
- Hepatocellular carcinoma (HCC)
- Intrahepatic cholangiocarcinoma
This page provides general information and does not replace an individual medical consultation. Assessment and treatment are decided for each patient after review of their history, examination and imaging, and in the setting of a multidisciplinary team.