Liver Tumors & Metastases
Colorectal Liver Metastases (CRLM)
Spread of colorectal cancer to the liver is the most common reason for liver surgery — and the setting where surgery offers the greatest potential for cure.
Colorectal Metastases
When Liver Metastases Are Curable
Surgery for colorectal liver metastases (CRLM) is one of the most impactful interventions in surgical oncology — with cure possible in a meaningful proportion of patients.
Who Is a Candidate?
Patients whose liver disease can be completely resected with adequate future liver remnant, and who have no uncontrollable extrahepatic disease. The number and size of lesions matter less than whether a complete resection is achievable.
Staged or Simultaneous Resection
Colorectal cancer and liver metastases may be removed in one operation (simultaneous) or in staged procedures. The choice depends on the extent of both the primary tumor and the liver disease, patient fitness, and institutional approach.
HAI Pump Therapy
Hepatic arterial infusion (HAI) pump delivers FUDR directly to the liver after resection, reducing recurrence rates. It is also used to convert unresectable liver-only colorectal metastases to resectable disease. HAI is offered at select specialized centers including Mount Sinai.
How We Decide
Three Questions Behind Every Decision
When colorectal cancer spreads to the liver, deciding whether and when to operate is rarely a simple yes or no. Three questions guide the plan — and they are answered together, not one at a time.
Can the cancer be removed?
This is a technical question about anatomy: can every tumor be removed while leaving behind enough healthy, well-functioning liver? Modern techniques mean far more patients are operable today than even a decade ago.
Should it be removed?
Just because surgery is technically possible does not always mean it will help. The behavior, or “biology,” of the cancer determines whether an operation is likely to provide a meaningful, lasting benefit.
When should it be removed?
Timing matters. Sometimes surgery comes first; sometimes chemotherapy first helps treat hidden disease and shows how the cancer responds before committing to a major operation.
Resectability Today
What Makes a Liver Tumor “Removable”
In the 1990s, surgery was usually offered only when there were four or fewer tumors confined to one side of the liver. The thinking has changed completely. We no longer simply count tumors.
Today, the question is whether all of the cancer can be removed while leaving an adequate, healthy future liver remnant, with clear surgical margins, in a cancer whose biology suggests surgery will help. Patients with many tumors, or tumors on both sides of the liver, may still be excellent surgical candidates — even if they were told elsewhere that surgery was not possible.
Then vs Now
Tumor Biology
Why the Cancer's Behavior Matters
Two patients with the same number of liver tumors can have very different outcomes, because not all colorectal cancers behave the same way. Modern molecular testing helps us understand a tumor's biology and personalize the plan.
These tests do not usually decide for or against surgery on their own. Instead, they shape how aggressively we treat, how closely we monitor afterward, and what we expect. Surgery can still be the right choice even when biology is less favorable.
What We Test For
Timing
Surgery First, or Chemotherapy First?
When liver metastases are removable, there is often a choice about sequence. Both approaches are valid; the right one depends on the individual situation.
Reasons to operate first
Clearly removable disease with favorable features. Operating early avoids chemotherapy-related liver injury and prevents small tumors from “disappearing” on scans — which can make them hard to locate during surgery.
Reasons for chemotherapy first
Chemotherapy before surgery can shrink borderline tumors, treat microscopic disease early, and — importantly — show how the cancer responds to treatment. A good response helps identify patients who will benefit most from an operation.
Large clinical trials have shaped this thinking. Chemotherapy around the time of surgery can delay recurrence, though it has not clearly improved long-term survival for every patient — which is why treatment is tailored rather than automatic. The lesson from these trials is that more treatment is not always better, and the plan should fit the individual patient.
Expanding Options
Making Unresectable Disease Resectable
A diagnosis of “inoperable” liver disease is not always final. Several strategies can convert tumors that cannot be removed today into ones that can be removed safely.
Growing the future liver
When the liver that would remain after surgery is too small, portal vein embolization redirects blood flow to make the healthy portion grow over several weeks — turning an unsafe operation into a safe one.
Two-stage and ALPPS surgery
When tumors are on both sides of the liver, surgery can be done in planned stages. Specialized techniques such as ALPPS can prompt rapid regrowth of the healthy liver between stages in selected patients.
Conversion chemotherapy
Modern chemotherapy — sometimes combined with HAI pump therapy — can shrink tumors enough to allow a complete, potentially curative removal in patients once told surgery was impossible.
Ablation
For small tumors (generally under 3 cm), heat-based ablation can be a liver-sparing alternative or complement to surgery. For these small lesions, it can work as well as surgery while preserving more healthy liver.
Liver-Directed Therapy
Hepatic Arterial Infusion (HAI) Pump
The liver is the most common place colorectal cancer spreads and recurs. An HAI pump is a small device placed under the skin that delivers chemotherapy directly into the liver's blood supply, concentrating the drug where it is needed while keeping the rest of the body's exposure low.
HAI is always combined with standard chemotherapy. It is used both to lower the chance of recurrence after liver surgery and to convert unresectable, liver-dominant disease into removable disease. In randomized studies, adding HAI improved tumor response compared with chemotherapy alone. Because it requires specialized surgical and medical expertise, it is available only at select high-volume centers — including Mount Sinai.
The bottom line for patients: Even when colorectal cancer has spread to the liver, long-term survival and cure are possible — roughly 1 in 5 patients who undergo complete removal of their liver metastases are alive and cancer-free 10 years later. If you have been told surgery is not an option, a specialized second opinion is worthwhile.
FAQ
Frequently Asked Questions
Get an Expert CRLM Evaluation
If you or a family member has colorectal cancer that has spread to the liver — including a prior opinion that surgery is not possible — a specialist evaluation is appropriate.