Liver metastasis

1) Disease Description (Causes and Symptoms)

• Definition: Liver metastasis (hepatic metastasis) is a malignant mass formed when cancer cells originating in other organs (primarily the colon, breast, lung, stomach, pancreas, malignant melanoma, etc.) spread to the liver through the bloodstream or lymphatic system.
• Brief pathophysiology: Because the liver has an abundant blood supply through the portal vein and hepatic artery, it is an organ where hematogenous metastasis from primary cancers commonly occurs. Metastatic cancer may form multiple nodules in the liver parenchyma or may be confined to one lobe, and symptoms occur due to increased tumor volume, reduced liver function, or bile duct involvement.
• Main symptoms:
  • Often asymptomatic in the early stages
  • Loss of appetite, weight loss, fatigue
  • Right upper abdominal pain or pressure, abdominal distension (hepatomegaly, ascites)
  • Jaundice (worsening when the bile ducts are involved), fever, sweating
  • Systemic symptoms (lethargy, anemia, etc.)

2) Treatment Methods and Precautions

• Treatment goals: Along with definitive treatment of the primary cancer, preserve liver function, relieve symptoms, and extend survival when possible (the goal of cure varies depending on the primary cancer and extent of metastasis).
• Standard treatments (vary depending on the primary cancer and the patient's condition):
  • Systemic treatment (chemotherapy)
    • Apply standard chemotherapy according to the primary cancer (e.g., colorectal cancer: FOLFOX, FOLFIRI ± biologic agents, etc.).
    • Consider targeted therapy or immunotherapy based on molecular pathology results (e.g., RAS, BRAF, MSI/HER2, etc.) (e.g., MSI-high → immune checkpoint inhibitors).
  • Surgical resection
    • Hepatectomy (partial resection) is the standard intervention, and when resection is possible, it offers the greatest possibility of long-term survival. Sufficient future liver remnant volume must be secured. Indications for resection are determined according to the number and location of tumors, liver function, and general condition.
  • Local/locoregional treatment
    • Thermal ablation (radiofrequency ablation (RFA), microwave ablation), transarterial chemoembolization (TACE), selective internal radiation therapy (Y-90), stereotactic body radiation therapy (SBRT), etc. These are intended to reduce tumor volume and relieve symptoms in patients who cannot undergo surgery.
  • Tissue biopsy
    • Performed for pathological and molecular testing when the primary lesion is unknown or to establish a treatment plan.
  • Palliative treatment
    • Pain control (analgesics), nutritional management, management of complications such as ascites, jaundice, and hepatic encephalopathy, and psychosocial support.
• Multidisciplinary approach: Collaboration among medical oncology, hepatobiliary surgery (liver surgery), radiology (interventional radiology), radiation oncology, pathology, palliative medicine, and other specialties is recommended.
• Lifestyle management and precautions
  • Absolutely avoid alcohol; avoid hepatotoxic medications (including some analgesics, herbs, and traditional herbal medicines)
  • Because of the risk of infection and food poisoning, be cautious about eating raw fish and raw seafood (especially if immunocompromised)
  • Follow a low-sodium diet (in cases of ascites or edema) and maintain nutritional intake (consult a dietitian if necessary)
  • If there is a risk of hepatic encephalopathy, protein intake should be adjusted and prompt medical evaluation is needed
  • During treatment with anticancer drugs or targeted agents, drug interactions and liver function monitoring are essential
• Risk of complications: Liver failure, severe jaundice due to bile duct obstruction, ascites and infection, bleeding, hepatic encephalopathy, systemic pulmonary embolism, and metastasis to other organs, etc.

3) Checklist Before an Outpatient Visit (Items, Documents, and Records to Prepare)

• Items/documents to bring:
  • A list of currently taken medications (including prescription drugs, OTC medications, traditional herbal medicines, and supplements)
  • Previous test results (blood test values, tumor markers, recent imaging (CT/MRI/PET) results and radiology reports) — if possible, a CD/DVD or link to the electronic medical record
  • History of previous surgeries and treatments (types and schedules of anticancer drugs, radiation therapy, etc.)
  • Records of allergies (medications, contrast agents, etc.) and comorbidities (hepatitis, heart disease, etc.)
• Symptom records:
  • Weight changes (recent weight), appetite, pain (location, intensity, and duration), changes in jaundice, urine, or stool color, presence of ascites (abdominal swelling), fever and chills
  • New symptoms that developed after taking medication (vomiting, diarrhea, rash, etc.)
• Preparation for tests:
  • Prepare imaging performed within the past 3 months (liver-specific MRI or contrast-enhanced CT is recommended)
  • If possible, submit blood tests (liver function tests (LFTs), bilirubin, INR, CBC, electrolytes) and tumor markers (CEA, CA19-9, etc.)

Example questions (to check for yourself during the visit):

• "How much weight have you lost recently?" / "When did the pain begin, and how often does it occur?"
• "Have you recently experienced abdominal distension or digestive problems?"

4) General Example Questions to Ask the Doctor

• What is the purpose of this treatment? (Treatment goal: cure vs. prolongation of survival vs. symptom relief)
• In my case, is the liver metastasis resectable? If surgery is not possible, what are the alternatives?
• What are the main side effects of the recommended anticancer drug (or targeted or immunotherapy), and how can they be managed?
• How will changes in liver function (liver enzyme levels) be monitored during treatment? What symptoms should prompt me to contact you immediately?
• Can I participate in a clinical trial (new drug or new treatment), and what are its advantages and disadvantages?

5) Examples of Disease-Specific Questions

• Regarding surgery, preoperative treatment, and postoperative treatment
  • "How many liver metastases do I have? Are they confined to one lobe? Is hepatectomy currently possible in my case?"
  • "If resection is not possible, would you recommend neoadjuvant chemotherapy to reduce the size or number of tumors?"
• Regarding molecular markers and personalized treatment
  • "If molecular test results for the primary cancer (RAS, BRAF, MSI, HER2, etc.) are available, could you share them with me? Based on the results, what targeted therapies or immunotherapies are possible?"

Additional information:

• The treatment plan and prognosis vary greatly depending on the type of primary cancer, the extent of metastasis (number, size, and location), liver function, and general condition. It is important to determine the optimal individualized strategy through consultation with a multidisciplinary team.