Caren van Roekel

258 Chapter 10 What are the treatment options for patients with colorectal cancer liver metastases and when comes radioembolization into play? Without treatment, the median overall survival for patients with colorectal liver metastases upon diagnosis is only 4.5 months (1). As a disease-free status offers the best chance on long-term survival, theoretically, the most logical order of treatment options would be surgery, followed by local-regional therapies such as radiofrequency ablation (RFA). In the case of disease confined to the liver, but not amenable to surgery or ablation strategies, radioembolization, as another local-regional strategy, could theoretically be treatment of choice, giving local control and/or a bridge to surgery with limited impact on quality of life. If local-regional treatment options fail, systemic treatment would be indicated. However, this ‘local-followed-by-systemic’ approach is not (yet) according to the guidelines and current clinical practice, as radioembolization is only indicated in unresectable, systemic therapy-refractory patients (2, 3). An explanation of the reason why radioembolization is not given prior to systemic treatment will be given below, after a summary on the treatment options for colorectal liver metastases. The treatment of choice for patients with liver-limited disease remains surgical resection. Surgical resection offers the best chance on long-term survival or even cure, with five-year survival rates of up to 60% (4, 5). Surgery is indicated when a radical excision (R0 resection) is possible, with a future liver remnant of ≥20% (3). Unfortunately, up to 80% of patients with hepatic metastases is deemed unresectable because of multifocality, tumor size or inadequate hepatic reserve (6). Furthermore, patient factors such as age and comorbidities may preclude surgery. However, patients may become amenable for surgery after neoadjuvant chemotherapy. Ten to twenty percent of patients with initially unresectable, liver-isolated disease fall into this category after treatment with neoadjuvant chemotherapy (7). After surgery of hepatic metastases, disease recurrence occurs in up to 45% of patients, and over 50% occurs in the liver (8). Repeated hepatic surgery is possible in some patients and if so, it was found to be associated with improved survival (9). Otherwise, patients will be treated with systemic therapy and have a five-year survival of less than 10% (10).