Welcome to our CRC liver metastases guide. This is a crash course for people with stage IV liver mets, specifically people who only have liver mets, or liver mets make up the majority of their metastases.
Believe us, we KNOW how scary it can be when you first hear you have liver mets. Many of us have been there. We hope this guide will help you see how many treatment paths are available — and that new ones are emerging regularly.
So what treatment options are out there? And how do you weigh all your options? Read on to learn more.
What do I really need to know?
- Do your best to see a liver surgeon at a high volume, well-respected cancer center early. This is critical, since generally getting to surgery (whether upfront or further down the line) currently has the best outcomes
- If you hear you are not a surgical candidate, that means you are not a candidate RIGHT NOW. Start with getting a second opinion. Even if the second surgeon agrees, know that there are many treatment options available to get you to a place where you may be eligible for surgery
- One size does not fit all. Disease in the liver varies greatly, and there are a ton of potential liver-specific treatments
- Your treatment plan should keep the long game in mind. Liver mets often return, so it’s best to develop a plan that keeps as many future treatment options on the table
- If you have liver mets (even if you have a primary tumor or other mets) you might hear that you should treat the liver mets first. This is because liver mets grow fast (and can shrink fast!), and the liver does a lot of important work in your body. Getting your liver working well should be your first priority
- Having surgery of any type can delay starting chemotherapy (if needed), so it’s important to come up with a strategy for the order and timing of your treatment plan
The big picture
Colorectal cancer most commonly metastasizes to the liver. Doctors sometimes call these tumors CRLMs (colorectal cancer liver metastases) for short, but usually refer to them as liver mets.
Although there is some disagreement on the exact numbers, about 25-50% of CRC patients will develop liver mets, and most are discovered in the first three years. Men and people with left-sided colon cancer seem to be more likely to get liver mets. Rectal cancer seems to be more likely to metastasize to the lungs.
With so many treatment options for liver mets, many patients are able to manage their disease, or reach no evidence of disease (NED) status. Patients are living longer, with improved quality of life, thanks to cutting-edge treatments and management.
One piece of advice we want to give right up front — make sure you have a liver surgeon on your team before you decide on a treatment plan. This could be a surgical oncologist whose focus includes liver surgery, or a liver surgery specialist (a hepato-biliary surgeon).
Get a surgeon’s eyes, and a surgeon’s opinion, even if this is through your tumor board. Even if you’re not a surgical candidate at the time, they can provide insight into what might need to happen to become surgical — plus, they’ll already be on board as things change with your disease. Learn more as to why in this DocTalk on second opinions with Dr. Lidsky.
What’s a multidisciplinary tumor board?
In some cancer centers, a number of doctors who are experts in different specialties review and discuss a patient’s disease and treatment options. You might see this abbreviated as MDTB or MTB. There are online MDTBs that meet on a regular schedule that most cancer centers are part of. See our glossaries of terms for more words or acronyms that might be unfamiliar!
Patient perspective by Marie
Hello! My name is Marie, and I am a 9-½ year stage 4 colorectal cancer survivor! I was diagnosed stage 4 in September 2013 with 5 tumors in my liver, bilobular. My story really started in 2007 when I was treated for very early stage breast cancer. I had a lumpectomy, radiation, and then took the drug Tamoxifen for 5 years. During those 5 years, I would have my bloodwork done every 3 months. In July 2012, I finished the Tamoxifen. My oncologist at the time then put me on 6 month visits.
It was July 2013, and my bloodwork came back showing I was extremely anemic! He asked if I had fatigue or dizziness. At the time I was working full time, raising 3 children, and had just lost my Dad, so I was pretty much tired ALL THE TIME! So we tried iron supplements and a recheck showed my iron increased. We stopped the supplements and when rechecking my blood, it was low again. He scheduled an iron infusion and had me do a take home stool test. The stool sample came back positive for traces of blood, so he recommended a colonoscopy and endoscopy to see If I was bleeding internally somewhere.
When I woke up from my scope, I could see the look on the doctor’s face and knew it was not good news. He told me I had a mass in my colon that was almost obstructing, and he was not able to get the scope past. That I likely had cancer. I was in shock! We went home, and my sister called me to see how my appointment went. I broke down crying. Her husband is a cardio thoracic surgeon, and he then called my husband to offer his guidance. Of course we accepted. I had CT scans a few days later, and they showed tumors in my liver. My brother in law immediately set up appointments with a liver surgeon and a colorectal surgeon, and I decided to also look for a new oncologist.
Consensus with the team was to do colon resection first then 6 cycles of folfox; PVE; liver resection; then 6 more cycles of folfox with ‘curative intent.’ In my mind, that timeline was basically one year and I would be back to normal. So the end of September I had a PET scan, and a few days later I had my colon resection. Recovery was uneventful. I had a port installed and started chemo in November.
After my 6th cycle, my scans showed progression. Ugh! I had a liver biopsy to make sure the liver mets were not from the breast cancer. I remember my liver surgeon saying that would be bad. Biopsy confirmed CRC mets and so they switched me to FOLFIRI with Avastin. I did 4 cycles and had another CT scan. This scan showed all tumors had decreased in size. My liver surgeon was ready to go. My brother in law, however, wanted me to get a 2nd opinion at MSKCC. So I met with Dr. Jarnagin who basically laid out the same surgical plan. At that time, NO ONE was doing HAI pump except for MSK. He only briefly mentioned to me that it might be an option. But I was resectable so it was not pursued. I went back to Philly and met with a 3rd liver surgeon and ultimately decided to go with my original guy, Dr. Gary Xiao (I like to call him my east coast Dr. Fong :)).
In May 2014, I had surgery to resect 3 tumors, radio frequency #ablation on 2 tumors, and a portal vein ligation. Plan was to go back in and take out my right lobe 6-8 weeks later. Post op scans showed NED so my surgeon said we can do surgery any time so let’s wait and see. I then completed 8 more cycles of FOLFIRI with Avastin.
I stayed NED until May 2015 with one new met showing in my liver and a tiny 8 mm spot in my lung was back (first seen as a 5mm spot in my PET scan). My liver surgeon said it would be an easy resection so I did 4 cycles of FOLFIRI with Avastin. Discussions were had about what to do about the lung. Spot too small to biopsy so we decided to do a VATS wedge resection at the same time as this 2nd liver resection surgery. October 2015, I had both surgeries. While in there, he also ablated the same spots from my first resection surgery. A few days following surgery, I had a bleeding complication and he had to go back in and take my left lobe out. I was in the hospital for 17 days and then acute rehab for another week. To this day, I do not remember the first week of that stay. My oncologist was ok with me not doing follow up chemo but I wasn’t sure about that so we decided to do just 2 more cycles of FOLFIRI with Avastin.
My last chemo treatment to date was March 2, 2016!
I stayed NED until January 2017 when a suspicious spot showed in my liver. We decided to do a biopsy and at the same time ablation. Biopsy came back inconclusive. January 2018 the area where they ablated in 2017 was showing concern. MRI and PET scan showed uptake. Biopsy confirmed CRC met. So now we had to decide whether to do another surgery or just ablation. My liver surgeon was concerned about adhesions and how difficult surgery #2 was because of them. After much discussion and the urging of my brother in law, we decided to go ahead with the surgery. Plan was if he got in there and it was too difficult with the adhesions he would then just do ablation. April 2, 2018, I had surgery and it turned out to be much easier than he thought. I was now NED for the 3rd time. My easiest recovery to date… I was on the dance floor at a family wedding 4 weeks post op!
A few months after this surgery, I started to feel a nodule in my abdomen close to my incision. At first we thought it was scar tissue. In July it did show on my scan but there wasn’t any uptake. We decided to wait to see what it looked like in October at my next scans. Well it had almost doubled in size and was now lighting up on my MRI and PET. It was determined that this nodule was caused by tumor seeding from one of my liver biopsies. They could see the track of the needle from my liver up through the muscle, fascia and skin. They were also concerned that it could be in my rib as well. November 2018 I had surgery to remove the nodule, skin, fascia, muscle and a piece of my liver. Mesh was needed to put me back together because this was the 5th time my abdomen had been cut open and I don’t have much to begin with! Liver pathology was clear. My oncologist recommended “light” radiation to the soft tissue of my abdomen just to make sure anything possibly left behind would be eradicated. NED for the 4th time. I had 15 radiation treatments in Jan/Feb 2019. I am MSS, KRAS G12D, TMB 6.
To date, my scans have been clear and all my bloodwork is normal except for my platelets which have been slowly creeping back up. I had a scare in October 2021 with a new 3mm nodule showing on my chest CT. I’m on a yearly chest CT scan schedule, so we decided to rescan in January and that came back clear! My platelets finally broke into the 100s at my last check. I’ve “graduated” to 6-month liver MRIs (I’ve been scanning every 3 months since diagnosis and more at times).
Next MRI is in April – if clear that will be a MAJOR milestone hitting the 5-year cancer free mark for my liver! I’ve been able to celebrate more milestones than I ever imagined… high school graduations, college graduations, graduate school graduations, my 30th wedding anniversary in 2021, Grandpa David’s 101st birthday, seeing my older daughter get engaged (this is a BIG one since my mother died before I was married), 16 years breast cancer free, my 9th birthday since that fateful colonoscopy in 2013, and many more!
This is my short version. I’ve spared you all the details in between – this has not been an easy road, but I am so grateful to be able to share. My husband has been my ROCK. I have 3 beautiful children; Lauren 27, Michelle 24, and Jack 21. They have had to endure a lot and have stepped up incredibly. I left my job of 13 years in 2016 to concentrate totally on my health.
Educating, encouraging, advocating, and supporting has become my new norm.
I have forever been changed by cancer, and I have chosen to use this experience in the most positive ways. COLONTOWN has allowed me to do that, and working with Paltown gives me purpose. I truly believe COLONTOWN helped save my life. If I can make a difference in someone else’s life, this has all been worth it.
What's going on in the liver?
Liver metastases are most often found by CT scans, but the “gold standard” for really analyzing the situation is a liver MRI. If your doctor sees a potential spot in your liver during a routine CT scan, an MRI is the next step to rule it out.
Labs have limited usefulness at diagnosis, but they can help you monitor your disease over the long term. They can also help you monitor how well your liver is working in general.
Let’s start off with some basic anatomy. The image below shows where the liver is located in the body.
Your liver has a number of important jobs, which explains why you might hear that you should handle liver mets first. The liver is the body’s filter, detoxifying and purifying the blood. Because of this filtering job, large particles (like cancer cells!) can get trapped and grow into metastases.
The liver also produces proteins that make up your blood, and that help your blood clot when it needs to. If this process is not working, many other systems in the body will not function properly. End-stage liver failure leads to fluid leaking into areas where it should not be, like the abdomen or legs.
The liver is one of the only organs that can regenerate (it can grow back!) So you may hear your team use the term “sufficient remaining liver remnant” — how much healthy liver tissue needs to be left after surgery in order for your liver to do its job and start growing back. This number is about 30% in a single piece.
The liver has two lobes (left and right). This is a bit confusing, but the right side of the liver is actually pictured on the left side of the image below, like it is in scans as well! This is because “left” and “right” refer to how the liver is positioned if you look down at your body right now.
The liver is also broken into 8 different sections. Your doctor might use these numbers to refer to where your tumor(s) are located.
What can pain tell me about my liver mets?
The majority of liver mets do not cause pain. If you do have pain from liver mets, it suggests that the growth may be close to the surface of the liver (often described as close to the capsule). Pain does not correlate with severity or lack of severity of disease. However, a decrease in pain on treatment can indicate a response to treatment. Any change in pain (increase or decrease) should be discussed with your care team.
The body is super interconnected, so pain in internal organs can also show up in surprising places. Liver mets sometimes cause pain in your shoulder or back. This is called referred pain. If you’re experiencing this, let your team know.
Finally, be aware that a liver biopsy can cause this referred pain as well.
Patient perspective by Josh
I do cancer well, very well. And I like to dabble in different ones. I dare say it’s my superpower. For the sake of brevity, I have to recount this in bullet format.
Here goes:
July 2012 – basal cell carcinoma skin cancer #1. Just a wee little wedge from my forehead and I’m back in business. Small, well placed scars are cool, right?
May 2017 – melanoma stage 1. Lost about 1/3 of my left ear to that one. Alright universe, this isn’t cool anymore. Enough cancer already.
May 2018 – At this point in life, I was 41 years old and seemingly ridiculously healthy. But after noticing blood and mucus in my stool, I arranged an appointment with a GI. He didn’t hesitate to order a colonoscopy which revealed 50+ polyps (not a typo) and a 5 cm tumor in my sigmoid colon cancer. I had robotic resection shortly thereafter and was given a diagnosis of stage 2A which comes with only a 10% chance of recurrence. Bullet dodged! So I thought…
August 2018 – Basal cell carcinomas #2 and #3. You gotta be kidding me! Another wee wedge from my forehead and a wee wedge from my back.
May 2019 – 1st scans since colon resection a year earlier reveal 2 lung nodules. Rescan ordered for 3 months later. Damn, damn, damn…
August 2019 – Lung nodules resolved! Presumed to have arisen from infection/inflammatory causes. Stand down from stage 4 alarm.
August 2019 to February 2021 – Nice long period with clear #scans and increasing confidence I am done with colon cancer. Rock on.
Feb 2021 – CT shows spot on liver concerning for metastasis. This is rapidly followed up by MRI (better liver imaging) that shows the spot is REALLY, REALLY concerning for metastasis. This in turn is rapidly followed up by liver biopsy that confirms (spoiler alert!) what you already know to be the case, or I wouldn’t be here typing these words. Solitary 1.7 centimeter liver met.
April 2021 through June 2021 – Did 4 rounds of FOLFOXIRI which shrank the tumor to 0.8 centimeters.
July 2021 – Tumor board recommends microwave ablation over resection due to the small size of my tumor. At this small size, the tumor board believes ablation and resection will provide the same effectiveness in terms of local recurrence odds, but ablation will preserve more liver volume and recovery will be a piece of cake. The IR inserted 3 probes around the tumor and cooked that guy down – see picture below. I was under general anesthesia, but I’m pretty sure it smelled like bacon. Recovery was not a piece of cake for me though. For a week I had muscle spasms at the probe insertion sites. I literally couldn’t even talk when the spasms hit. Good times.
August 2021 – Did 2 more rounds of chemo, FOLFOX only, dropped the irinotecan
Oct 2021 – First scans post-treatment show liver looking great, but new lung nodules have appeared??
January 2022 – Lung nodules resolved! Infection/inflammation again. Declared NED. Open letter to lungs…I could really do with less drama if y’all wanna go ahead and chill out.
So here I am in January 2022 basking in the glow of my new NED status. Will it last? I sure hope so. History says I’m a bit of a cancer factory though. But right here, right now, I feel strong, energetic, and full of stamina. My return to health is an amazing gift that I truly cherish (picture below is St Jude’s 5k run in December 2021, around 3 months after finishing chemo).
Betsy asked me to conclude by offering any words of wisdom. I mulled this over, and realized I’m not sure I have any. I have a different offer. I know that what I have gone through is basically stage 4-lite. It pales in comparison to what some of you mighty survivors have pushed through or are pushing through right now. Thus, my offer is the following. If any of you are in the southeast GA or northeast FL area, and you need help of any kind, please reach out to me. I will take you to appointments, cut your grass, shop for your groceries, you name it. I am 100% aware of how lucky I am to have returned to such a healthy state. I want to use my abilities to help those who need a hand. This offer is completely sincere.
Lastly, I want to thank our Admin Angel, Betsy Post. I marvel at her dedication and compassion for the members of this group. Time and time again I’ve witnessed her help newcomers make sense of their diagnoses and treatment options when they were feeling overwhelmed and confused. I can’t say enough how impressed I am. Thank you Betsy. And best of luck to all of my fellow Liver Lovers.
Factors that affect treatment
There are a wide variety of options for treating liver metastases. We’ll go into more detail on this below, but two big factors really determine what treatments are available to you. 1) Is the disease only in your liver or is it other places, too? 2) And, can you have liver surgery or procedures now or in the future (or not at all?)
Why is surgery the gold standard?
You might wonder why surgery is so common for liver metastases. When it comes to liver mets, surgery is considered the most effective and durable treatment. As of right now, surgical resection has the best outcomes for these patients, leading to a 5-year survival rate of roughly 40-60%. And it can lead to long-term NED status for some patients!
A long-term goal can be to get to surgery. This section focuses on liver surgery, but thinking about these factors can also be helpful while considering other treatments.
My surgeon doesn’t recommend removing the primary tumor first. Why?
If you are new to a stage IV cancer diagnosis, it can seem confusing if your care team doesn’t seem to have a sense of urgency to remove your primary tumor. However, studies show that removing the primary tumor is not associated with an improvement in quantity or quality of life.
The focus is almost always on treating the metastases first. If you were to focus on removing the primary tumor, surgery recovery usually requires being off chemotherapy — which would leave the metastases untreated and at risk of growth or spread.
Also, in many cases, the primary tumor will shrink in response to chemotherapy. Plus, if surgery is planned for your mets, the primary tumor may be removed during this surgery too. Doing chemo first keeps disease stable during surgery recovery, until you can restart chemo as needed.
Am I eligible for surgery?
The liver is a complex organ with ducts, arteries and veins. So when making decisions about whether or not a patient is a surgical candidate, surgeons take many factors into consideration. Ultimately, the goal is to conserve the essential blood flow and structures, as well as a sufficient remaining liver remnant (typically at least 30%).
Surgeons can remove an entire lobe, tissue across lobes, one or more segments, or just a wedge of liver. So if you have tumors on the outer sides of the liver, they’re easier to remove. Tumors deeper in the liver can be harder to remove.
Similarly, tumors that are grouped together are easier to remove in a single surgery than tumors that are spread out throughout the liver.
All in all, the number of liver tumors is less important than:
- How spread out the tumors are (and therefore how much healthy liver will be left after surgery), and
- How close the tumors are to vital structures like arteries and bile ducts
Some terms you might hear:
- Portal vein — brings nutrient-rich blood from the digestive organs to the liver for processing
- Hepatic vein — carries blood out of your liver
- Hepatic artery — supplies oxygenated blood to the liver
- Bile ducts — carry bile out of the liver to the gallbladder and intestine
- Biliary tree — network of ducts inside and outside the liver that carry bile from the liver, pancreas, and gallbladder to the small intestine
- Gallbladder — stores and releases bile. It’s attached to the liver, and is often removed as a part of liver resection surgeries
The liver is a highly vascular organ. This means that it has a lot of blood supply, with a lot of arteries and veins — and because of this blood flow, liver mets can grow fast. The flip side is they often shrink fast with treatment. More blood flow to an organ means cancer can get there more easily, but so can treatment. So hold on to your hat. Speedy growth means things may move really fast with assessment, planning and treatment.
There are some big decision points and information to be gathered that will help your team and you manage a diagnosis of liver mets. Nothing is set in stone with the treatment of CRC liver mets. There are lots of treatment options and additional ones may become available to you as you navigate your treatment plan.
Big factors to consider
There are two major factors that guide your treatment plan:
1. Are your metastases only in the liver, or do you have tumors elsewhere too?
Tumors inside the liver are called intrahepatic mets. Tumors outside the liver are called extrahepatic mets.
There are big differences in how your team will approach your treatment options in these two scenarios: only intrahepatic mets vs both intrahepatic and extrahepatic mets.
2. Can you have surgery to remove the liver metastases now or in the future?
Even if you are told you are not a surgery candidate, that means you’re not a surgery candidate RIGHT NOW. Down the road, other interventions and treatments may put you in the surgery category. Many COLONTOWNies in Liver Lover’s Lane were told they weren’t surgical candidates at first, but became so later. However, some people may never become surgical candidates.
If you are told no to surgery, you should ask your team for more information. Why isn’t surgery an option “now”? What, if anything, would need to happen to change your situation into a surgical one? This is a situation where getting a second opinion from a high-volume liver surgeon is especially important.
What “chemo for life” really means
Hearing “chemo for life” can be a pretty scary thing. But keep in mind a few things:
- It doesn’t mean that you will be on the same chemotherapy drugs forever. Those can change over the course of treatment or you can go to “maintenance” chemo. There are a limited number of chemo lines available though, so you will want to work with your team to balance using each treatment line as long as possible, and align them with your goals of care.
- Most people can take chemo breaks
- Think of chemo for life as “chemo until something changes.” New treatments and options are evolving every day (as is your disease).
Patient perspective by Hillary
October 22, 2020, my world turned upside down, or so I thought. After an unexpected hospital stay in August, I went in for a colonoscopy to confirm I’d just had a bout with acute diverticulitis and nothing else.
I remember waking up in recovery and hearing the nurse calling my husband inside, the doctor wanted to discuss my results. I knew at that time things were not okay.
After he came in and sat down, my doctor walked in and sat down beside me. She then let us know she’d found a large mass and was 99.999% sure it was rectal cancer. She let me know she was referring me to oncology and colorectal surgery.
I cried walking out of there, full of fear and uncertainty, but my husband was quick to make light of it all and we laughed. (I can’t thank him enough for his unwavering love and support.)
Five days later it was confirmed adenocarcinoma of the rectum and I was sent into a whirlwind of scans, appointments and more testing. To say I had time to blink would have been a lie.
After meeting with several doctors and different teams. I buckled up for a long hard year. A year full of FOLFIRINOX, 30 rounds of radiation with Xeloda followed by LARS. October 2021 I had completed the entire treatment plan. My scans and bloodwork were clear. I was dancing with NED.
Unfortunately, that dance with NED was cut short. In January of 2022, I received a diagnosis of Stage IV terminal cancer. A blood clot in the portal vein along with 3 large masses and innumerable spots in my liver were present on the 3 month surveillance scans.
The doctor told me they didn’t discuss years at this time, and I needed to go on all the small or big trips I ever wanted. She would start me on chemo again to buy time.
Chemo again… something I couldn’t understand when 3 months prior they didn’t want to put me on it for clean up because my body had been through enough.
After my appointment, I sat in my car and cried. I just couldn’t accept what had been said. I rebuked that diagnosis. I went home and broke the news to my family.
The very next morning I began reaching out to COLONTOWN and was moved to LIVER LOVERS LANE. I started asking for suggestions and recommendations of doctors.
By the end of the day, I’d scheduled an appointment with 3 doctors in 3 states. One of them just happened to be less than an hour from me, so I met with him first.
As soon as I walked into my appointment, Dr. Abdalla had reviewed 15,000 images of me. He stated me he wanted additional images and asked me if I’d be willing to meet with another oncologist.
I told him yes because the oncologist who oversaw my treatment plan had moved to Arizona and I was not okay going back to the one who recently took over her patients.
So, I met with Dr. Jolly. He was amazing just like Dr. Abdalla. They both agreed on additional scans. After the scans, I met with Dr. Abdalla. He said he didn’t see anything anatomically preventing him from doing the surgery.
There was 1 mass in the upper right lobe and the 2 masses on the lower and right lobe were no longer there. We scheduled laparoscopic surgery.
On preop day, Dr. Abdalla decided to do open surgery so he could remove the blood clot and mass. I was too young to be on Xarelto for the rest of my life he said.
Surgery day arrived and as soon as he opened me up he saw the blood clot was an actual tumor in the portal vein. He used an ultrasound to find the best place to tie the veins off to prevent proliferation while performing the resection.
Turns out what was thought to be the size of a pizza slice removal ended up being a removal of 65% of the liver, gallbladder and surrounding lymph nodes.
The tumor in the portal vein is rare and complicated. Seen maybe 1-2 times in 20 years which is like 2-4 times in 2,000 resections. Thank goodness Dr. Abdalla had encountered it before and had even written about it.
During my post op, I learned I had a handicapped P53 and MET gene and tested positive for KRAS. Something the previous never found.
There were no targeted therapies so Dr. Jolly agreed with integrative care and I began holistic and functional treatment. I have continued with my protocols and care with Dr. Jolly and Dr. Abdalla.
Today, February 23, 2024, I celebrate my 2nd NEDiversary!!! I can’t thank those in this group who led me to my current team of doctors and taught me how to advocate for myself enough. I am forever grateful!
If you are not at peace or feel uncomfortable with what is being told to you, advocate for yourself! Your stage does not define you or your outcome!!!
Watch this video to learn more about second opinions:
Treatment options
As we mentioned above, two big factors really determine what treatments are available to you. Is the disease only in your liver or other places, too? And, can you have liver surgery or procedures now or in the future (or not at all?)
Let’s start with standard of care. If you have unresectable liver mets (mets that can’t be surgically removed) or mets in other places in your body, you’d likely start with chemotherapy (a systemic treatment). This strategy has been the most successful place to start.
If you only have mets in the liver, there are a range of options that might fit your situation. Keep in mind, not every cancer center will offer all treatments (and their recommendations will often align with what they can offer) so ask for details. If you weren’t offered something from the list, it could be that your center doesn’t have that treatment or that your disease is not yet controlled enough to gain benefit from some treatments. Just open a dialogue with your team to understand the reasoning and seek second opinions for potential additional options.
Now, let’s talk about local treatments. Local treatments are almost always done as part of a plan that includes systemic treatment (something that treats the whole body). Once cancer has spread beyond the primary site, there is concern there might be more spread that is not yet visible — so systemic treatment is important to not only help treat the liver mets but clean up also any other microscopic disease. This is used especially in cases where a person’s liver mets are currently unresectable.
This is where a really good multidisciplinary team becomes especially important. Having a liver surgeon, medical oncology, interventional radiology, radiation oncology and any other needed specialties Involved in your care together in a group discussion (remember that term MDTB?) can provide solutions that a single doctor may not.
Combined treatments have some special considerations. The best order of treatment may vary. Also, certain drugs such as Avastin need to be paused for as much as 10 weeks in total (before and after) some procedures. This is because Avastin raises your risk of bleeding post-procedure.
Chemotherapy is hard on the liver. If you have liver mets, your liver is not working at 100%, so your team will take this into consideration while managing your treatment.
Some oncologists may feel that local treatments may not add much to extending a patients life if they have extensive liver mets. It’s always a good idea to have an experienced liver surgeon or interventional radiologist who is guiding the addition of these techniques to your treatment plan.
We can’t say it enough – the most important thing to do when you first find out about liver mets is to get a liver specialist on board. They can help you choose the treatments that benefit you the most while minimizing risks.
To understand why you might be offered localized treatment first, check out this DocTalk:
Some acronyms you might hear:
- OS — overall survival. The length of time that a patient lives after being diagnosed with cancer
- PFS — progression-free survival. The length of time that passes before there is further growth or progression of cancer after a treatment or procedure.
- Hepatic PFS — the length of time that a patient lives without progression in the liver
In this guide, we have categorized liver-directed treatment into 2 broad categories:
1) Established Treatments — These are treatments that have been around for some time and we know a lot about them.
2) Emerging Treatments — These are new treatments. Not as much is known about them, and they may be more difficult to access.
Though there are a number of treatment options, not all are applicable to all patients with liver mets. When you meet with a liver specialist, you can ask about each of these and have them explain which would be the preferred options for you (considering the number and location of your liver mets). You could make a list prioritizing these in a specific order and have your second opinion doctor review this list as well. This way, you could narrow the list down to the one or two strategies best suited for you.
Established treatments
What do we mean by established treatments? To be clear, we don’t necessarily mean standard-of-care. Here we go over treatments that are relatively well known and have established pathways to access treatment options.
We can classify these treatments into three broad categories: cutting it out, killing it locally, and inserting treatment into the liver.
Whew! We know this is a long list and it can be confusing to figure out the best options from what is clinically relevant to you. So chat with your care team, make sure you are seeing the right specialists, and seek second (or more!) opinions to learn more about what would be best in your case.
Cut it out
Click on an established treatment below
SINGLE-STAGE RESECTION
What is it?
A surgery that removes part or all of an organ or structure. It is also called surgical resection, or hepatectomy. This procedure removes a portion (up to ⅔) of the liver.
Who does it?
Hepatobiliary Surgeon
Typical patient considerations
- Is this resectable initially? Sufficient liver remnant and no risk to blood/bilary structures.
- Will it need two surgeries?
- Do the liver mets need to be shrunk before a surgery is possible?
Resources to learn more
DocTalk: Optimal management of colorectal liver mets & HAI discussion: Dr. Padmanabhan
TWO-STAGE RESECTION
What is it?
Parts of liver with disease are removed in two separate surgeries.
There are two types of more complex liver resections:
Two-staged hepatectomy (TSH): Performed when it isn’t safe to remove all the tumors at one time, with a goal of preventing liver failure. The first surgery removes as many tumors as possible without impacting too much liver function. After some weeks, in which the liver can regenerate, the rest of the tumors are removed. It may be performed alongside other types of treatment.
Associating Liver Partition and Portal Vein Ligation for Stage Hepatectomy (ALPPS): A very advanced procedure done in two surgeries, it is reserved for cases where standard surgery would leave too little surviving liver.
Who does it?
Hepatobiliary Surgeon
Resources to learn more
DocTalk: Modern-day Management of Liver Metastases: Dr. Soares
DocTalk: Advanced Surgical Treatments for CRC Liver Mets, Dr. Hernandez-Alejandro
PVE (PORTAL VEIN EMBOLIZATION)
What is it?
Portal vein embolization (PVE) is not a treatment choice on its own, but it may be performed before a hepatic resection to enlarge the liver segments that will remain after the surgery. It redirects portal blood flow to segments that will remain. Typically is performed about 6 weeks prior to surgery.A procedure that aims to increase healthy liver to be sufficient for surgery. This is a possible pre-procedure to resection.
Who does it?
Interventional radiologists and/or liver surgeons
Resources to learn more
Video: Portal Vein Embolization (PVE) for Contralateral Liver Hypertrophy
Kill it locally
Click on an established treatment below
ABLATION
What is it?
Uses a probe with extreme temperature (hot or cold) to burn or freeze the tumor.
Can be performed along with surgery or alone. The goal is to destroy cancer cells without damaging the surrounding liver. Ablation can be completed in one session or multiple sessions. If done without surgery, ablation can often be completed with less sedation. It is often an outpatient procedure, with results comparable to surgery.
There are several types:
- MWA, microwave ablation creates high temperatures that damage cancer cells.
- RFA, radiofrequency ablation uses high-frequency electrical current that heats needles inserted into the tumor.
- CA, cryoablation freezes the cancer cells with very cold gasses.
Less common and for specific patients:
- PEI, percutaneous ethanol injection instills pure alcohol directly into the tumor, killing cancer cells. This is only used if thermal ablation is not an option.
Who does it?
Interventional radiologists and/or liver surgeons
Typical patient considerations
- Number of tumors to ablate? Generally, more than three require multiple sessions.
- Tumor size? Three cm maximum is ideal because the ablation zone is 2 cm larger than tumor.
- Location? If tumor is near critical structures, it may not be a safe candidate for ablation.
- The decision of what type of ablation is used may be made simply by what technology your cancer center has available to them.
- Since repeat ablation is easier than surgery, would I be a candidate for repeat ablations, if needed?
- If other treatments are recommended, what order will be followed?
- Do you expect I will experience post-ablation syndrome with aches, fatigue and a low-grade fever?
Resources to learn more
DocTalk: How ablation can be a cancer terminator for liver and lung mets: Dr. Arellano
SBRT (STEREOTACTIC BODY RADIATION THERAPY)
What is it?
Stereotactic body radiation therapy (SBRT) is a very precise, non-invasive form of radiation therapy that delivers high doses of radiation to tumors while sparing surrounding healthy liver tissue. It is usually used on metastases 5 cm or smaller in 1 to 3 different sites. Some treatment centers might push beyond these parameters with careful planning. You must have sufficient healthy liver to get SBRT.
SBRT can be used when a tumor is deep or difficult to reach, such as near major blood vessels or bile ducts. It might be used to control tumor growth prior to trying for surgery.
Pre-treatment planning will include creating a custom body mold to hold you still during the treatment. Three to five 30 to 60 minute sessions are typically needed and can be done while on chemotherapy.
Keep in mind that if a metastasis reoccurs in the same location, it often cannot be retreated with SBRT since there can be too much radiation to a single area. However, in some special cases, retreatment with SBRT may be okay.
Who does it?
Radiation oncology team
Typical patient considerations
- Insurance companies can be more reluctant to cover SBRT.
- How many days of SBRT do you recommend for me?
Resources to learn more
DocTalk: SBRT for liver and lung mets: Dr. Miller
Insert treatment into the liver
Click on an established treatment below
HAI (HEPATIC ARTERY INFUSION) PUMP
What is it?
High dose chemo (FUDR, which is similar to 5FU) is given via a hepatic artery infusion pump, a device implanted under the skin in the abdomen, and connected to the hepatic artery through a catheter. It’s a similar idea to a port-a-cath. But it is significantly larger in size (hockey puck size under the skin, implanted above the liver).
It allows a much higher dose of chemotherapy to be administered directly to the liver (and protects the rest of the body from the drug). FUDR (the drug used in the HAI pump) is completely broken down in the liver, so no active drug enters circulation outside the liver. Usually done in conjunction with systemic chemo.
Who does it?
Liver surgeon implants the HAIP. Medical oncology manages the chemotherapy.
Typical patient considerations
- Used after liver resection to reduce the chance of future liver mets (called adjuvant therapy).
- It may also be used to shrink the tumor before surgery (called neoadjuvant or conversion therapy) to become surgical. It seems very helpful in many of these situations.
- Usually for more extensive disease in the liver.
- Use is usually limited to only patients without extrahepatic disease.
- Does have toxicities that must be considered. For example, the HAI pump has the potential to damage the hepatic artery, resulting in scarring in the biliary tree. Potential leakage of chemo outside the liver could result in side effects in nearby organs, such as stomach ulcers.
- There are lifestyle considerations to keep in mind — an HAI pump is a long-term implant, which needs to be filled directly with chemo or flushed at an HAI pump center every few weeks
Resources to learn more
DocTalk: HAI for metastatic CRC: Dr. Connell
DocTalk: Interview with an icon: Dr. Kemeny on HAI pumps
DocTalk: HAI pump trial: Drs. Cercek, D’Angelica, Lidsky and Maithel
Join the HAI PUMP PEOPLE group in COLONTOWN
Y90 (RADIOEMBOLIZATION)
What is it?
Y90 stands for yttruim-90, a radioactive form of a rare metal. It’s used in radiation therapy to treat some types of tumors.
The yttrium is injected into tiny glass or plastic beads that are inserted in to the blood supply of the tumor, delivering high doses of targeted radiation.
It can be used to treat part or all of liver, can be done multiple times on different parts of liver, and has the additional potential benefit of growing healthy liver for potential resection (though more slowly than PVE). This is a good option for when there’s disease spread in liver, can’t do before HAI. It’s done under sedation, often an outpatient procedure.
Who does it?
Interventional radiologist
Resources to learn more
DocTalk: Y90 for CRC liver mets — What patients need to know: Dr. Dayyani
Featured posts in COLONTOWN Mighty Y90 group
TACE (TRANSARTERIAL CHEMOEMBOLIZATION)
What is it?
Transarterial chemoembolization is a minimally invasive, image-guided procedure to treat liver mets. A dye is used to find the arteries feeding the tumors. Then chemotherapy and a drug to block the artery are injected. Used mainly internationally.
Who does it?
Interventional radiology or liver surgeon
Resources to learn more
Information on TACE
Keep in mind recurrence can be common
Liver mets often come back, especially in the first two years. Even if local treatments are initially able to get rid of liver mets, a large percentage of patients will likely experience a recurrence. However, because the liver can regenerate, the liver can often be retreated if recurrences do occur.
As you are planning out treatments, think about this factor in your long term plan. Early treatment decisions can affect your eligibility for treatments down the line, if you end up needing them. For example, if you get Y90, you can’t have a HAI pump in the future. Also, if a HAI pump damages your biliary tree (a risk of that treatment), you would not be able to get any other treatment in that area. Then you may need to consider a liver transplant.
However, it’s important to note that the most potentially effective treatment for you now is the priority.
Emerging treatments
We just went over established treatments, and now we’ll look at some of the latest options. The newest procedures may not be available at many centers, so be sure to ask at yours. With all treatments, what works well for one person may not be the best option for the next.
As these treatments are emerging, we don’t know as much about them compared to treatments that are much more well-established.
Finally, insurance coverage can be tricky for newer treatments. If you encounter problems, ask your treatment team for help and reach out in the COLONTOWN online support groups for advice. Many COLONTOWNies have overcome these barriers and can give you advice.
Click on an emerging treatment below
HISTOTRIPSY
What is it?
A relatively new, non-invasive procedure authorized by the FDA in 2023 that uses precisely targeted sound waves to destroy cancer tissue in the liver.
How does it work?
A wand outside the body sends high-intensity sound waves that create microbubbles within the tumor. The bubbles rapidly expand and collapse, which breaks down the tissue at the cellular level.
What are the benefits?
Histotripsy doesn’t require incisions, radiation, or needles. It also doesn’t create heat or ions that damage healthy DNA. The procedure can be used to treat patients who aren’t eligible for surgery or other ablation techniques.
How do I monitor my disease?
Doctors use ultrasound imaging to locate the tumor, monitor the treatment area, and adjust for better results.
What does recovery look like?
The destroyed cancer cells leave behind a harmless liquid that the body’s natural drainage systems absorb. The immune system may also be stimulated to recognize and destroy any remaining cancer cells.
Other considerations
Keep in mind, if ablation is not working for you, histotropsy is not going to be a curative solution. Histotropsy is basically just a way to do the same thing with less damage to the areas around it. Although there are many ways to treat liver tumors, unfortunately for many techniques, if one doesn’t work, it’s likely that other similar ones won’t work either. At the end of the day, all of these treatment techniques destroy tumors. Always consult with your surgeon to see if new techniques are applicable to you.
How can I get it?
Check out our Liver Lover’s Lane group for more information. Join the public Facebook group “Histotropsy Interest Group.” It isn’t part of COLONTOWN but is specific to this treatment.
To find a center that offers it check out this website.
More centers are purchasing the necessary equipment, so this list will grow. However, make sure you ask how many procedures your center has completed as this is such a new treatment. In general, it’s preferable to have complex treatments performed at high volume centers.
Insurance coverage for histotropsy may vary. If you are a candidate and insurance denies coverage, ask your treatment team for help. Also, ask for advice in the online COLONTOWN support groups as others have overcome this barrier successfully.
Resources to learn more
DocTalk: Multimodal Management of Liver Mets: Dr. Rocca
DocTalk: Histotripsy for mCRC liver mets: Dr. Hernandez
IRE (IRREVERSIBLE ELECTROPORATION)
What is it?
Irreversible electroporation is similar to ablation, but is non-thermal and has lower risk of causing bile duct or blood vessel injury. It is used more often for tumors near the central bile ducts. IRE uses a high voltage electrical current to destroy tumors without heating nearby tissue. NanoKnife is a common brand name of IRE systems used by treatment centers.
Requires general anesthesia.
Who does it?
Interventional radiologist and/or liver surgeon
Typical patient considerations
Similar tumor size considerations to ablations
Resources to learn more
Irreversible electroporation for colorectal cancer liver metastasis: a review
TRANSPLANT
What is it?
A liver transplant is a procedure where a patient with a liver diseased with tumors receives a healthy liver from a donor. A transplant may be considered for people with multiple large, unresectable liver mets and no extrahepatic disease (no mets outside the liver).
There are two types of liver transplants. The older style uses a complete liver from a deceased donor, where a living-donor transplant removes a portion of the liver from a healthy person to replace the diseased liver in the cancer patient. Because CRC patients almost always get a living-donor transplant, we will focus on that type here.
People who have a living-donor liver transplant seem to have fewer medical problems after the procedure than those who receive a liver from a deceased donor. And patient’s receiving a partial liver from a living donor also tend to have longer survival. The liver’s unique regenerative physiology allows for both donor and recipient to have a fully functioning liver.
Liver transplants are a new procedure for mCRC patients, so there is limited data and limited centers providing this procedure. Only 20-30 per year were completed in the U.S. in 2022 and 2023 for CRC patients with liver mets.
A transplant may be considered for people with multiple large, unresectable liver mets. There are a number of criteria both the cancer patient and the donor must meet to make a good match and qualify for the surgery. In addition to being medically appropriate, both parties must pass psychological screening, consult with social work to make arrangements for a longer hospitalization, and make sure their insurance will cover them. Although it can seem daunting and exclude some patients who would like to be considered, following a rigorous screening process dramatically improves the chances of a successful outcome.
What does recovery look like?
Recovery time in the hospital is usually about six days for the donor and ten days for the recipient. Because it’s a major surgery, recipients must plan to remain in the transplant hospital’s area for up to six weeks after discharge.
Other considerations
- Many centers use a scoring system called an OSLO score or something similar. This system attempts to understand the liver mets biology and any other factors that could impact a patient’s response. (See Dr. Roberto Hernandez-Alejandro’s DocTalk video below for details of this scoring)
- Tumors with BRAF mutations may not qualify for transplantation, but talk to your center.
- Immunosuppressive drugs are required post-transplant. If you have extra-hepatic disease, or cancer outside of the liver, the suppression of the immune system may cause the cancer to spread more quickly.
- Donors can be family or anyone who meets the criteria for your specific case.
- Transplant centers can fill you in on their requirements.
As the transplant center screens potential donors, they cannot share details about those people with the recipient due to HIPAA restrictions. - Patients will need to be off of chemotherapy for several weeks prior to the transplant surgery.
- Having a HAI pump can make it harder to transplant down the road, so talk to your team about the possibility of transplantation before getting a pump.
- Recurrence of mCRC in the new liver is possible.
How can I get it?
Speak to your doctor about potential pathways to a transplant.
Resources to learn more
DocTalk: Liver transplants: Examining the evidence with Dr. Hernandez Alejandro
DocTalk: Transplant patients are in the house
PROTON THERAPY
What is it?
Proton beam radiotherapy is a type of treatment using protons—charged particles—rather than traditional X-rays (photons) to deliver radiation to cancer cells. Conventional X-ray radiation can damage healthy tissues as it leaves the body. Proton beams deposit almost all of their energy right at the target, minimizing the damage to tissues around the tumor.
Proton therapy may be used in patients with a limited number of liver metastases, especially when those metastases are not amenable to surgical resection or ablation. There are numerous critical structures within and around the liver, and these can be damaged by traditional radiation. The precision of this technology helps avoid dose-limiting toxicity to healthy liver tissue, which can be a major concern in conventional radiation therapy.
Other considerations
- While proton therapy has great promise, especially in minimizing damage to healthy tissue, more research is needed to establish its superiority over traditional X-ray radiation for all types of cancer. In some cases, photon therapy may be just as effective or more cost-efficient so as mentioned earlier, insurance may balk at covering this treatment.
- There may be limits on the size and number of liver metastases that can be treated.
- Treatment planning for proton therapy may be more involved and slower than traditional radiation.
How can I get it?
Proton beam requires a very large and expensive piece of equipment called a cyclotron. As a result, only a small number of centers offer this technology and insurance may be reluctant to cover it. However, Colontownies have been successful in receiving proton beam coverage so ask for details in our online support groups. You can also solicit help from the team at your treatment center – they likely will have appealed cases successfully in the past.
In the U.S. the National Association of Proton Therapy keeps an up-to-date list.
Outside of the U.S. the Particle Therapy Co-Operative Group maintains a database of centers.
CLINICAL TRIALS
Cancer research is very active in the U.S. and around the world, and there could be trials applicable to your case. Searching for trials can be overwhelming and confusing but COLONTOWN has resources available to help you become more comfortable with the process.
In COLONTOWN University, you will find basic education on clinical trials, lists of questions to ask if considering a trial, practical tips for accessing trials, and thriving private support groups to help you weed through options.
Resources:
Learning Center: Clinical Trial Basics
Course: Searching Safari (for stage IV MSS patients and caregivers)
Patient perspective by Tim
My name is Tim. It was 2020, and I was 52 at the time. I was enjoying the pandemic at home in Tampa with my wife. We made the best of not going out by hosting our own game nights and dance parties, hiring our favorite local musicians to play a few songs for us and our friends on Zoom, and even rented an Airbnb place in Ft. Lauderdale right on the canal with a pool, bringing everything we needed for food and drinks. Our socialization was waving hello to the boaters on the canal, and we sat in the pool, listening to our music.
Despite the challenges, I was in overall good health and tried to stay active. Thanksgiving came, and it was one of the first bittersweet times since we had been staying isolated. We enjoyed getting together with friends and family during the holidays, but this year we were alone. Then, a pain in my right side started. Initially, I thought it would just go away, but instead, it got progressively worse. By Sunday, it hurt so bad that I walked over to the Urgent Care in our neighborhood. They weren’t exactly sure what it was, and all I heard as conjecture was “possibly a kidney stone.” They wanted me to get a CT scan, so I did first thing on Monday.
When I received the call to come in, I had a sense that something was up. I arrived and, without delay, the doctor came in with a single piece of paper and uttered the three words I will never forget, “You have cancer.” I remained calm and rational. I reminded myself that there was nothing I could do at this point to change the diagnosis. What mattered most was knowing what to do next. The doctor referred me to a gastrointestinal doctor friend of his, and within days, I had my colonoscopy confirming the cancer and the insertion of a stent.
At the beginning of my journey, I was amazed by the compassion shown by nurses and doctors. Maybe I didn’t fully grasp the severity of the situation, or perhaps I was overwhelmed with all the information, but their kindness and care touched my heart. I started my chemo treatment, and during this time, I received valuable advice from my first oncologist that I still pass on to others: always seek second, third, or even fourth opinions. Trust your instincts and don’t be afraid to advocate for yourself.
When a second oncologist gave me a grim prognosis, I refused to accept it as my fate. That was not my story! So, I sought a new team of experts at Moffitt Cancer Center. It was there that I was told I wasn’t a surgical candidate, but put on FOLFOXIRI until I started experiencing neuropathy and they switched me to FOLFIRI. I was seeing good results on my CT scans and decided to learn about other options through COLONTOWN.
This is where I learned about the potential for a liver transplant. Excited about this possibility, I had Betsy Post help me set up an appointment with the renowned Dr. Roberto Hernandez Alejandro at the University of Rochester Medical Center in New York.
The journey was not without its emotional ups and downs. Finding a living liver donor was challenging, but something extraordinary happened along the way. As I tried to help others by creating ShareMyLiver.com, more people stepped forward to be my potential donor. It was a powerful reminder that when we extend kindness and support to others, it comes back to us in unexpected ways.
With the love and support of a selfless donor named Beth, I underwent the life-changing transplant surgery.
Recovery was tough, but I kept pushing forward, embracing the new lease on life that had been given to me. My first post-transplant scan brought incredible news – “Your new liver looks beautiful.” I am now officially NED – no evidence of disease.
Through this challenging journey, I’ve learned valuable lessons. First, be your own advocate. Trust your instincts and pursue the treatment that feels right for you. Second, always believe in yourself and the power of hope. And lastly, regardless of your beliefs, be open to the love, energy, and support offered by others. Gratitude is a powerful force.
When you find yourself in a challenging situation, with the odds seemingly stacked against you, always remember this: you are not just a statistic. You are an extraordinary human being, possessing boundless potential to achieve the unimaginable.
Want to learn more about clinical trials?
If you are looking for discussions about liver mets trials, try joining our liver-focused support groups.
Then do a search in each group for the word trial or trials:
- Liver Lovers Lane
- The HAI Pump People
- Mighty Y90
- Transplantation Station
We also have several support groups dedicated to trials:
- In Tom’s MSI-H Clinic, we discuss treatments and trials for MSI-H patients
- In Tom’s MSS Clinical Trials, we chat about trials open to mSS patients
- In Tom’s NIH Lounge, we discuss trials run by the National Institute of Health (NIH)
- In TOM’S CELL THERAPY TRIALS CLINIC, we discuss cell therapy trials including: TIL, CAR-T, TCR, and NK
Want to join? Fill out the registration form here.
Building a care team
As you spend more time in the COLONTOWN you will notice that many patients seek second, third or more opinions as they build a treatment plan.
One criteria is looking for a high-volume provider and team – current research indicates the more patients like you your team sees and treats, the better your outcome may be. Increasing subspeciality training is usually better. Ask your specialists, especially your surgeons, how many CRC patients they work with annually, how many liver resections they successfully complete per year, and how long they have been doing this work. It is worth going to a high volume center for surgery, even if you have to travel. Remember, chemotherapy can be given closer to home in most cases.
In addition, some people utilize specialists at multiple cancer centers and ask these experts to coordinate their care across systems. This can be a bit more complicated but can offer you an opportunity to select the best practitioners in each speciality. Remember that the best doctor for you may not be the best for someone else. Not only should you look for expertise, but communication skills, willingness to learn and treatment philosophy matter just as much. These are people with whom you are trusting your life and will spend a lot of time, so pick them with that in mind.
When patients are asked what made them choose a particular doctor or center, they often say they really trusted that person or group the most. There is an element of personal choice in all of this. However, a few characteristics that are positive indicators include doctors who admit if they don’t know something, who communicate well with their colleagues, and who “stay in their lane” of speciality – in other words, medical oncology shouldn’t determine a surgery plan or vice versa. The specialists should work together through a multidisciplinary tumor board.
The goal is to develop a customized plan for your situation. And the priority is YOUR best interest.
Key questions to ask
Here’s a questionnaire to use at second opinion appointments:
Life with liver mets
Monitoring
There are people where you get rid of liver mets, so then you focus on handling other mets.
ca 19-9 and CEA are general biomarkers, but can provide some insight into what’s happening in the liver (if you only have liver mets).
Link out to the content on other biomarkers.
Labs — the Liver Main Four
Here are some labs that are commonly used to see how your liver is functioning. All four of these are usually included in standard blood work. Every patient will get these tests as part of a standard panel.
Your liver is being very taxed from chemotherapy and other treatments. It’s important to note that all four of these labs may be elevated somewhat when you are in active treatment. Remember “normal” ranges for labs are based on people without cancer. Like many other labs, dehydration can also impact the results. However, if you are not in treatment and are not significantly dehydrated, seeing these numbers rise can be a sign you need more testing. They may or may not be impacted by liver mets so they shouldn’t be relied on to understand what’s happening with your disease.
If these four labs are out of range for what is expected for you, your doctor may also recommend some additional lab work.
This information can help you assess your general liver health, whether or not you might qualify for a trial, and as your disease progresses, these values can be helpful to keep track of.
Your team will know what labs to focus on throughout the process. It’s important to note that these labs tell you about your liver health, but do not provide direct information about the extent of your metastases.
AST (aspartate aminotransferase)
AST is an enzyme (something that speeds up chemical reactions in the body, such as food breakdown or molecule building) that is found mostly in the liver, but it’s also found in muscles and other organs in your body. When cells that contain AST are damaged, they release AST into your blood. An AST blood test helps diagnose liver damage or disease. There are a number of factors that can elevate AST, so your doctor will know what level would be considered abnormal for your specific case.
ALP/ALK (alkaline phosphatase)
ALP or ALK is an enzyme found in many parts of the body, including the liver, bile ducts, and bones. An abnormally high level may indicate liver problems.
ALT (alanine aminotransferase test)
ALT is an enzyme found primarily in the liver, but can also be found in other tissues like the heart, kidneys, and muscles. When liver cells are damaged, they release ALT into the bloodstream, which can result in elevated ALT levels.
Bilirubin
Every year, about half a million people in the US have their gallbladder removed (called a cholecystectomy), usually due to pain and inflammation caused by gallstones. An imbalance in the chemicals in bile are the usual cause of gallstone formation. But CRC patients may have gallbladder problems related to tumors. A tumor can grow into the bile duct or can push on the outside of the duct, blocking the flow of bile.
Bile is a yellowish-green, thick digestive fluid produced by the liver and stored in the gallbladder that helps break down fats and carry away waste. This substance is made from a variety of products including bilirubin – a waste product from the breakdown of red blood cells. Bilirubin is toxic to the body and should be removed, but a tumor blocking bile from leaving through normal processes will cause it to build up in the liver.
Eventually this raises bilirubin levels in the blood and is detectable in labs. This type of blockage can cause liver failure. About 10% of CRC liver metastases involve the bile duct.
A bonus lab — is ctDNA or MRD testing right for you?
Once you have mets removed, ctDNA testing (such as Signatera) happens to be pretty sensitive to liver met recurrence. This is called minimial residual disease (MRD) testing. Ask your team if this test is available in your area.
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How to use this guide
- Does it apply to me?
- Do you offer it here?
- Who is an expert that I can talk to about this technique?
These are all specialized procedures, so you should not take someone who does not practice the procedure for granted.
Building a treatment plan
Note here about ordering treatments to make sure that you maximize the number of treatments that you are eligible for. For example if you get Y90, you are not eligible for an HAI pump.
