Do you consult a gastroenterologist (GI) for a patient with liver metastases (mets)?

Consultation for Liver Metastases: Multidisciplinary Team, Not Gastroenterology Alone

Patients with liver metastases should be referred to a specialized hepatobiliary multidisciplinary team (MDT) that includes hepatobiliary surgeons, medical oncologists, interventional radiologists, and other specialists—not to gastroenterology in isolation. 1

Core Principle: Multidisciplinary Management is Mandatory

The management of liver metastases requires expertise that extends beyond traditional gastroenterology practice:

• All patients with liver metastases should be discussed at a hepatobiliary MDT that has specific experience in managing metastatic liver disease 1
• The MDT should include at least two specialist hepatobiliary surgeons trained in liver resection, a medical oncologist, diagnostic and interventional radiologists with hepatobiliary expertise, a histopathologist, and clinical nurse specialists 1
• A hepatobiliary MDT should be based in a cancer center serving a population of at least two million to ensure adequate volume and expertise 1

Why Not Gastroenterology Alone?

While gastroenterologists may play a role in certain aspects of GI cancer care, liver metastases require specialized surgical and oncological expertise:

• Gastroenterologists can participate in GI cancer care including screening, diagnosis, staging, and management of complications, but their role in chemotherapy administration requires dedicated subspecialty training and cannot be a "part-time sideline" 1
• The optimal management of liver metastases involves complex decisions about resectability, liver-directed therapies (resection, ablation, stereotactic radiotherapy, selective internal radiation therapy), and perioperative chemotherapy that require hepatobiliary surgical expertise 1
• Surgical resection offers the only potential for cure in selected patients with colorectal liver metastases, with 5-year survival rates of 25-46%, and this requires specialized hepatobiliary surgical evaluation 1, 2

Specific Referral Pathway

The appropriate consultation pathway depends on the primary tumor:

For Colorectal Cancer Liver Metastases:

• Refer directly to a hepatobiliary MDT for evaluation of resectability 1
• Approximately 20-30% of patients with colorectal liver metastases have potentially resectable disease 1
• Timing is critical: surgeons should evaluate patients before chemotherapy begins to properly visualize all metastases, as responsive lesions may become difficult to locate after treatment 3

For Gastric Cancer Liver Metastases:

• Refer to tertiary centers with hepatic resection expertise for highly selected patients 1
• Surgery is considered only when ≤3 metastatic nodules are diagnosed with modern imaging, as 5-year survival ranges from 0-37% in retrospective series 1
• Most gastric cancer liver metastases are not resectable and require systemic chemotherapy as primary treatment 1

For Other Primary Tumors:

• Neuroendocrine tumors, breast cancer, and selected other primaries may benefit from hepatic resection and should be referred to hepatobiliary MDT 2, 4, 5
• Treatment strategy should be determined case-by-case in a multidisciplinary setting 4

Common Pitfalls to Avoid

• Do not delay referral to hepatobiliary MDT while pursuing isolated gastroenterology consultation, as this delays potentially curative treatment 1
• Avoid prolonged chemotherapy before surgical evaluation, as extended chemotherapy can cause liver steatosis and hepatocyte damage, compromising post-resection liver function 3
• Do not biopsy lesions discovered during primary tumor resection; instead, refer to hepatobiliary unit for planned resection after recovery 6
• Do not assume all liver metastases are unresectable without formal hepatobiliary surgical evaluation, as modern techniques have expanded resectability criteria 1