# How to Integrate Surgery into the Multidisciplinary Treatment of Liver-Only Metastatic Colorectal Cancer

## TL;DR

This review discusses how surgery can best be used with other treatments for liver-only metastatic colorectal cancer to improve patient outcomes.

## Contribution

The paper provides a contemporary, practice-oriented perspective on integrating surgery into multidisciplinary CRLM treatment.

## Key findings

- Multidisciplinary team meetings are crucial for defining resectability and treatment sequencing.
- Parenchyma-sparing surgery and locoregional therapies are supported by current evidence for multimodal treatment.
- Individualized, biology-driven approaches improve patient selection and long-term outcomes in CRLM.

## Abstract

Colorectal liver metastases (CRLM) represent a major determinant of prognosis in metastatic colorectal cancer. Despite an improvement in survival as a result of advances in systemic therapy, surgical techniques, and multidisciplinary management, the optimal integration of surgery with systemic and locoregional treatments remains an area of ongoing debate. This narrative review is proposed to clarify the contemporary role of surgery within a multidisciplinary framework for CRLM. Specifically, the review aims to delineate the technical, oncological, and biological factors that guide resectability assessment, treatment sequencing, and therapeutic intent, including upfront resection, neoadjuvant or conversion strategies, and staged approaches. By addressing parenchyma-sparing surgery, locoregional therapies, and challenging clinical scenarios, this review seeks to provide a coherent, practice-oriented perspective. The findings are expected to support more consistent, individualized, and biology-driven decision-making, thereby informing multidisciplinary discussions and contributing to improved patient selection and long-term outcomes in CRLM.

Background: Colorectal liver metastases (CRLM) represent a major determinant of prognosis in patients with metastatic colorectal cancer and account for a substantial proportion of cancer-related mortality worldwide. Over the last decades, survival outcomes have improved significantly as a result of advances in systemic therapies, refinement of surgical techniques, and, most importantly, the widespread implementation of multidisciplinary management strategies. Within this evolving landscape, surgery remains the cornerstone of potentially curative treatment, although its optimal integration with systemic and locoregional therapies requires careful patient selection and individualized treatment planning. Methods: This narrative review explores the contemporary role of surgery within the multidisciplinary management of CRLM, emphasizing how surgical decision-making is integrated with medical oncology, radiology, interventional procedures, and emerging technologies. Results: The pivotal role of multidisciplinary team meetings in defining resectability, treatment sequencing, and therapeutic intent is highlighted. Key technical and oncological criteria guiding upfront resection, neoadjuvant or conversion strategies, and staged approaches are reviewed, including assessment of future liver remnant, optimization of liver volume and function, tumor burden, molecular profile, and dynamic prognostic models. In addition, the review summarizes current evidence supporting parenchyma-sparing liver surgery and the integration of local therapies such as thermal ablation, irreversible electroporation, stereotactic body radiotherapy, selective internal radiation therapy, and hepatic artery infusion chemotherapy within multimodal treatment algorithms. Complex clinical scenarios, including synchronous disease, extensive bilobar metastases, chemotherapy-associated liver injury, and the emerging role of liver transplantation in highly selected patients with liver-only disease, are also addressed. Conclusions: Modern CRLM management has evolved toward a highly individualized, biology-driven approach in which surgery is optimally integrated within a multidisciplinary framework to maximize curative potential and long-term survival.