Radiation and surgery don't have much to offer met CRC except in very
specific circumstances

Hi Joe,
A compilation...of two webistes
http://www.mskcc.org/mskcc/html/1006.cfm
Metastatic liver cancer is most often treated by surgery. However, if a patient's
cancer has spread to the liver, it may also have spread to other areas of the
body. One notable exception to this is metastatic colorectal cancer. In this
disease, the liver is often the first site of spread. Surgery to remove the
tumors is most effective for this type of cancer. Memorial Sloan-Kettering is a
leader in the treatment of colorectal cancers that have spread to the liver.
Patients with this type of metastatic liver cancer may be treated with a
combination of surgery and chemotherapy.

The liver has the capacity to regenerate. Up to 80 percent of the organ can be
surgically removed and within several weeks, the liver will have entirely
regenerated itself. If one lobe -- along with the blood vessels on that side --
is surgically removed, the other lobe will compensate for the loss.

Operating on the liver can be difficult for several reasons. Many of the major
blood vessels to and from the heart pass behind or through the liver, so in
essence, the liver is "attached" to the heart. Also, the anatomy of the liver is
not always obvious from the surface. The organ is large, dense, and delicate, and
covered in part by the rib cage. It bleeds profusely when injured and its tissue
tears easily. An experienced surgeon can offer a patient the best chance for a
good outcome. Our surgeons perform the highest number of liver resections of any
cancer center in the country -- 200 to 300 per year.

New technologies are allowing surgeons to remove increasingly smaller portions of
the liver. This results in less loss of blood and a quicker and less complicated
recovery. Recent improvements in anesthesia have also led to less blood loss
during surgery. Our surgeons are also pioneering laparoscopic surgical methods.
In this type of surgery, a small incision is made and a tube with a small camera
on its end is passed through the abdominal wall. This technique can be used in
selected cases to remove part of the liver (partial hepatectomy). Since the
procedure is less invasive than traditional surgery, recovery is quicker.

Thanks in part to these surgical techniques and improvements most of our liver
surgery patients stay in the hospital less than 10 days, and the majority do not
require blood transfusions.

When the liver is burdened with another disease aside from the cancer, surgery is
complicated and sometimes impossible. A disease such as cirrhosis dramatically
weakens the liver and often leaves it permanently damaged, with limited
regenerative capacity. A patient with a liver hampered by both cirrhosis and a
tumor is more likely to be treated with a method other than surgery.

http://www.nccs.com.sg/epub/CU/vol_04/p2.htm
Up to half the patients with colorectal cancer develop metastases, and the
commonest site for metastases is the liver. The peculiarity of the portal venous
system means that not infrequently the liver is the first and only site of stage
IV disease. Although the understanding from most cancers is that stage IV disease
carries a poor prognosis and management is thus geared towards palliation, there
is increasing evidence that the picture is quite different for stage IV
colorectal cancer when metastases are found only in the liver.

At present, liver resection is considered the gold standard of treatment for
metastases from colorectal cancer that are confined to the liver. Surgery offers
the best results, with 5-year and 10-year survival rates of up to 45% and 21%,
respectively. By comparison, 5-y survival is less than 5% and median survival
about 6 to 9 months if surgery is not possible.

Work-up for metastases
The aim of follow-up in colorectal cancer patients is thus to detect recurrences
early, when these are still potentially confined to the liver. The role of tests
for carcinogenic embryonic antigen (CEA) and ultrasonography in follow-up is well
established. When a lesion is suspected, a triphasic CT scan is required for
assessment of operability and planning of the operation. In addition, there
should be extensive work-up to exclude extrahepatic disease. Such investigation
includes CT or PET-CT of the thorax, brain, and bone.

Assessment for surgery
The criteria for liver resection used to be three or fewer lesions, with the
largest smaller than 3 cm and confined to one lobe of the liver. Today,
irrespective of size, number, and extent of lesions, surgical resection may be
offered to patients (1) with adequate hepatic reserve, (2) with no extrahepatic
metastases, and (3) in whom a 1 cm tumour-free margin is achievable.

Several factors are associated with a better survival rate after liver resection
for colorectal metastases and these are taken into consideration in the decisions
about surgery. These factors include (1) colorectal primary at N0-N1 stage, (2)
largest metastasis less than 7 cm in diameter, (3) postoperative normalising of
serum CEA level post-operatively (in patients whose preoperative CEA were
elevated >4 ng/dl) (4) wedge instead of lobar resection. Negative prognostic
factors include (1) signs and symptoms of extra-hepatic metastases, (2)
substantially raised CEA level, (3) more than 6 lymph nodes involved in the
primary lesion, (4) a satellite pattern of metastases in the liver, (5) bilobar
hepatic disease, (6) likelihood of a positive resection margin, (7) extrahepatic
nodal involvement, and (8) poorly differentiated primary tumour.

Results of surgery
Liver resection is fairly safe and postoperative mortality rates of less than 2%
are reported in well-established hepatobiliary units. In addition, morbidity
rates are generally less than 10% and usually relate to minor problems, such as
wound infection.