What is the next step in management for a patient with a liver mass and colon mass on computed tomography (CT) scan?

Management of a Patient with Liver and Colon Masses on CT

The patient with both liver and colon masses on CT should be immediately referred to a hepatobiliary multidisciplinary team (MDT) for comprehensive evaluation and treatment planning. 1

Initial Assessment

A patient presenting with both liver and colon masses requires careful evaluation to determine the relationship between these findings and develop an appropriate management plan:

• Imaging review: The existing CT scan should be reviewed by radiologists with expertise in hepatobiliary imaging

• Additional imaging needed:

  • Liver MRI with contrast enhancement to better characterize liver lesions 1, 2
  • Complete colonoscopy to visualize the entire colon and obtain biopsies of the colon mass 1
  • Chest CT to evaluate for potential pulmonary metastases 1

• Laboratory tests:

  • Carcinoembryonic antigen (CEA) baseline measurement 1
  • Liver function tests
  • Complete blood count

Multidisciplinary Team Composition

The hepatobiliary MDT should include 1:

• Medical oncologist
• Colorectal surgeon
• Hepatobiliary surgeon
• Diagnostic and interventional radiologist
• Pathologist
• Radiation oncologist
• Clinical nurse specialist

Important Cautions

• Do not perform liver biopsy without prior discussion with the hepatobiliary MDT, as this could lead to tumor seeding and reduced survival prospects 1, 2
• Avoid delay in referral, as early evaluation by specialists improves outcomes 3
• The most common pattern for colorectal cancer is liver metastasis, but unusual patterns of spread can occur 4

Management Algorithm

1. MDT assessment to determine:

   • Whether the colon mass is primary colorectal cancer
   • Whether the liver mass represents metastatic disease or a separate primary
   • Resectability status of both lesions

2. If liver mass is potentially resectable colorectal liver metastasis:

   • Assess technical resectability (sufficient remnant liver volume)
   • Assess oncological factors (tumor biology, extent of disease)
   • Consider timing of surgeries:
     • Simultaneous resection of primary and metastases
     • Two-stage approach (primary first, then liver)
     • Liver-first approach in selected cases

3. If liver mass is unresectable metastatic disease:

   • Systemic chemotherapy with FOLFOX (oxaliplatin, leucovorin, and fluorouracil) 5, 6
   • Consider addition of targeted biological agents based on molecular testing
   • Re-evaluation for conversion to resectability after 2-3 months of therapy 1
   • Consider locoregional therapies such as thermal ablation, SBRT, or transarterial approaches 7

4. If liver mass is a separate primary:

   • Develop separate treatment plans for each primary malignancy

Evidence Strength and Considerations

The recommendation for MDT referral is strongly supported by guidelines 1 showing improved outcomes when patients with colorectal liver metastases are evaluated by specialized teams. Studies demonstrate that patients assessed by hepatobiliary MDTs achieve higher resection rates and improved survival 3.

A population-based study found that an additional 12.9% of patients with colorectal liver metastases could potentially undergo curative resection if properly evaluated by a specialized MDT 3. This highlights the critical importance of ensuring all patients with suspected colorectal liver metastases receive expert multidisciplinary assessment.

The MDT approach ensures that all treatment options are considered, including surgical resection (which offers the best chance for long-term survival), systemic therapy, and locoregional treatments, leading to optimal patient outcomes.