Can Liver Metastases Be Operated On? 6 Questions for a Surgical Oncologist

Can liver metastases be operated on?

Yes, but not all of them and not for every type of cancer. Most of the evidence concerns metastases from colorectal cancer. The liver is affected in about half of people with bowel cancer^[2], and removing the metastases in selected patients has long been a standard of care^[1][6].

Surgery is considered when four conditions are met:

• all lesions can be removed completely, with a margin of healthy tissue;
• enough well-functioning liver will remain after the operation;
• there is no disease outside the liver, or it is under control;
• the person is fit enough for a major operation.

How these conditions are checked and what is done when surgery is not yet possible is described on the page colorectal liver metastases. Metastases from other tumours, such as neuroendocrine tumours, stromal tumours or kidney cancer, are operated on selectively and by different rules. They have a separate page, liver metastases.

I perform liver surgery together with a team of surgical oncologists, and the treatment plan is approved by a tumour board. The types of operation, from resection to ablation, are described on the page liver metastases surgery.

Do liver metastases mean stage 4? Is it a death sentence?

Yes, it is stage IV: under the international TNM classification, in bowel cancer, as in most other cancers, any distant metastases mean stage IV^[7]. But stage IV covers very different situations. A single liver lesion that can be removed and disease in many organs have the same stage, but different treatment and a different outlook.

For bowel cancer metastases that have been removed, there are long-term follow-up data. At Memorial Sloan Kettering Cancer Center in New York, researchers followed 612 patients who had liver metastases removed between 1985 and 1994. Of these, 102 lived ten years, and 99 of those 102 had no signs of disease at their last check-up. The authors conclude that in well-selected patients the chance of cure after surgery is at least one in six^[1]. These were operations from 1985–1994; both chemotherapy and surgery have changed since then.

How long do people live with liver metastases?

No one can give an individual prognosis over the internet: it depends on the primary tumour, the number of lesions and how the disease responds to treatment. For bowel cancer metastases after surgery, pooled data exist. A review of 60 studies showed that about 38% of patients are alive five years after the metastases are removed (the median across studies), while in individual studies this figure ranged from 16% to 74%. At ten years, the figure is about 26%^[2].

The wide range reflects how different patients are. The outlook is worse if lymph nodes were involved in the primary tumour, there is more than one metastasis, a lesion is larger than 3 cm, the CEA tumour marker is high, there is disease outside the liver, the tumour could not be removed with a clear margin, or it was poorly differentiated^[2]. Yet unfavourable factors do not rule out long survival after surgery: among those who lived ten years, half had a primary tumour that had spread to lymph nodes, 39% had more than one metastasis and 35% had a lesion larger than 5 cm^[1].

Follow-up does not end after surgery: about a third of those who lived five years later died when the disease came back^[1]. That is why regular CT or MRI scans and CEA tests are needed after a resection. New lesions found in time can sometimes be removed too. How I follow patients after surgery is described on the page one-year follow-up with a surgical oncologist.

Can liver metastases be seen on ultrasound? Can they be confused with a haemangioma?

Large lesions are usually visible on ultrasound, small ones not always. Ultrasound is often the first test to find changes in the liver, but it does not answer the questions that matter for surgery: how many lesions there are and how they lie in relation to the blood vessels.

Even contrast-enhanced CT misses some small metastases. In a meta-analysis of 15 studies (1,842 patients with bowel cancer), liver MRI with a liver-specific contrast agent detected 89% of metastases up to 1 cm in size, while contrast-enhanced CT detected 29%. Lesions larger than 1 cm were found almost always by both methods: 98% and 95%^[3]. That is why an MRI is needed before a decision about liver surgery; otherwise the plan may be drawn up without some of the lesions^[6].

A haemangioma is the most common benign tumour of the liver. In most cases it is told apart from a metastasis by its typical appearance on contrast-enhanced MRI or CT. If a person is already being treated for cancer, a new liver lesion is assessed with contrast-enhanced imaging, meaning CT, MRI or contrast ultrasound, not with standard ultrasound alone^[4]. If doubt remains even then, the doctor decides whether a biopsy is needed or a repeat scan after some time. The tests needed before surgery are listed on the page tests before surgery.

Can metastases disappear after chemotherapy?

On the scans, yes. In reality, usually not. In a study at Ambroise Paré Hospital near Paris, 66 metastases disappeared on CT after chemotherapy. During surgery, in the removed tissue under the microscope or within a year after the operation, residual tumour or regrowth was found at the site of 55 of them (83%)^[5].

This leads to a practical rule: a surgeon should see the scans before chemotherapy starts or early in the course. The surgeon then knows exactly where all the lesions were and can plan the operation to also remove the areas where a lesion is no longer visible after treatment. If the scans are shown only after chemotherapy has finished, some lesions may no longer be visible on them.

Are liver metastases painful?

Usually not, especially small ones. They are found on follow-up scans before any symptoms appear. Heaviness or pain under the right ribs, weakness, weight loss and jaundice usually appear when there are many lesions, when they are large or when they press on the bile ducts. The absence of pain says nothing about the stage or about whether surgery is possible.

Jaundice that appears for the first time is a reason to see a doctor the same day. Jaundice with a high temperature and chills, a high temperature during chemotherapy, or severe abdominal pain: call an ambulance on 103.

What to do if liver metastases have been found

1. Ask for your scans on a discCT and MRI are needed as images, not just as a written report. Add the histology of the primary tumour, discharge summaries and treatment regimens, if treatment has already started.
2. Show the scans to a surgeon who operates on the liverIdeally before chemotherapy starts or early in the course. You can send the scans to me: the online consultation is free.
3. If you were told “inoperable”, ask whyThere can be several reasons: the number of lesions, closeness to major blood vessels, too little remaining liver, disease outside the liver. The reason determines whether a second opinion makes sense.
4. If surgery is not possible now, the question is not closedIn some patients the lesions shrink after chemotherapy, and surgery is then discussed again on new scans.

Sources

1. Tomlinson JS, Jarnagin WR, DeMatteo RP, et al. Actual 10-year survival after resection of colorectal liver metastases defines cure. J Clin Oncol. 2007;25(29):4575–4580. PMID 17925551
2. Kanas GP, Taylor A, Primrose JN, et al. Survival after liver resection in metastatic colorectal cancer: review and meta-analysis of prognostic factors. Clin Epidemiol. 2012;4:283–301. PMID 23152705
3. Chen S, Wen M, Lv F, et al. Diagnostic value of Gd-EOB-DTPA-enhanced MRI versus contrast-enhanced CT for detecting liver metastasis in colorectal cancer: a systematic review and meta-analysis. BMC Gastroenterol. 2025;25(1):888. PMID 41310515
4. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on the management of benign liver tumours. J Hepatol. 2016;65(2):386–398. PMID 27085809
5. Benoist S, Brouquet A, Penna C, et al. Complete response of colorectal liver metastases after chemotherapy: does it mean cure? J Clin Oncol. 2006;24(24):3939–3945. PMID 16921046
6. Cervantes A, Adam R, Roselló S, et al. Metastatic colorectal cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol. 2023;34(1):10–32. PMID 36307056
7. Brierley JD, Van Eycken LJ, Giuliani ME, Rous BA, et al. The 9th Edition of the UICC TNM Classification of Malignant Tumours: Updates and Rationale for Change. Int J Cancer. 2026;159(7):1588–1601. doi:10.1002/ijc.70561

This article is for general information and does not replace a consultation: the treatment plan is based on your own scans and histology.