A 45-year-old man is found to have multiple synchronous liver metastases from colorectal cancer — 4 lesions, all in the right lobe, with no extrahepatic disease. After 3 months of FOLFOX chemotherapy, repeat imaging shows 30% size reduction. What is the next best step?

• A Continue chemotherapy for 6 more months
• B Portal vein embolisation (PVE) of the right portal vein followed by right hepatectomy
• C Radiofrequency ablation of all four lesions
• D Proceed to right hepatectomy if predicted future liver remnant is adequate ✓

Explanation

After successful downstaging with chemotherapy, surgical resection of colorectal liver metastases (CRLM) offers the only potential for cure. With 4 lesions in the right lobe, right hepatectomy should be assessed; if the future liver remnant (FLR) — left lateral segments — is predicted to be at least 25-30% of total liver volume (or 40% in cases of chemotherapy-associated liver injury), surgery can proceed directly. PVE is reserved for cases where the FLR is inadequate (typically <20-25%), not when it is already sufficient.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.