Tumor staging is crucial to formulate surgical operation plan. Stage 4 colorectal cancer with liver metastases. “We do high-quality CT scan of chest, abdomen and pelvis. We do triple-phase contrast CT scan of the liver. We also insist on MRI scan of the liver with liver-specific contrast. We also do a PET CT scan to look for colorectal cancer metastases in other organs”. Why are all these clinical trials required? Metastatic colon cancer staging methods. Dr. Graeme Poston, MD. Metastatic colorectal cancer staging is crucial for best treatment results. PET CT, MRI and CT of liver with triple phase contrast has to be done before liver metastatic cancer resection. Dr. Anton Titov, MD. Correct staging of metastatic stage 4 colorectal cancer allows to select only those patients for surgery who will benefit the most. Colorectal cancer liver metastases treatment. Video interview with leading British liver cancer surgeon specializing in colorectal cancer metastases resection. Advanced stage 4 colon cancer surgery for liver metastases. Dr. Graeme Poston, MD. Medical second opinion confirms that stage 4 colorectal cancer diagnosis is correct and complete. Medical second opinion also confirms that liver metastases surgery is possible in stage 4 colon cancer. Best treatment for advanced stage 4 colon cancer with liver metastatic lesions. Dr. Anton Titov, MD. Medical second opinion helps to choose the best treatment for stage 4 colorectal cancer with liver metastases. Get medical second opinion on advanced colorectal cancer and be confident that your treatment is the best. Best colorectal cancer treatment center for liver metastases. Dr. Graeme Poston, MD. Video interview with leading expert in colorectal cancer liver metastases treatment surgery. Metastatic colon cancer staging methods. Dr. Anton Titov, MD. It is very important to select correct metastatic colon cancer patients for the correct type of surgical operation. It is matching correct patient with advanced colon cancer with a specific method of surgery. Surgeon can resect metastatic lesion from the liver. Dr. Anton Titov, MD. What kind of methods do you use in preoperative staging of the patients with liver metastases? You wrote extensively about methods of imaging for preoperative staging of metastatic colon cancer patients. Dr. Graeme Poston, MD. Leading liver cancer surgeon. To start, the most basic test of all is a high-quality CT scan of chest, abdomen and pelvis. Ideally, triple-phase contrast should be used for CT scan of the liver. Dr. Graeme Poston, MD. That gives you the basic imaging of advanced colon cancer patient before surgical operation. We also insist on MRI scan of the liver with liver-specific contrast. Because MRI scan of the liver gives you very good information about liver. We can see down to tumors of 2, 3, 4 millimeters in size on MRI of the liver. We also do a PET CT scan to look for colorectal cancer metastases in other organs. Dr. Anton Titov, MD. An MRI and CT? They are both required in preoperative evaluation of advanced colon cancer patient for resection of metastases? Dr. Graeme Poston, MD. Leading liver cancer surgeon. MRI and CT scans complement each other. CT scan a very good basic thing to do. Dr. Graeme Poston, MD. Particularly, a CT of the lungs is by far the best imaging test for the lungs to identify lung metastases from colon cancer. CT scan is a very good basic test. CT scan is relatively cheap. All hospitals have got a CT scanner. PET CT scanning is more difficult to do and it is more expensive. But we can have access to PET CT. We will do a PET CT scan on all advanced colon cancer patients. We are considering for surgery to remove liver metastatic lesions. We will also do a liver MRI on everybody. Dr. Graeme Poston, MD. All patients we are considering for surgical operation to resect liver metastases from advanced colorectal cancer. Doing PET CT and MRI of liver adds about 2,000 euros to the cost of the treatment. But these tests allow much better preoperative evaluation of patients with advanced colon cancer. Dr. Graeme Poston, MD. Leading liver cancer surgeon. 15 years ago I was operating on advanced colon cancer patients to remove liver metastases. We did not have a PET CT and a MRI scan. In 1 out of 5 (20%) of advanced colon cancer patients, we would start surgical operation. Dr. Graeme Poston, MD. Then we would discover more advanced metastatic colon cancer than we thought before the surgery. We would say. "Oh, my god, cancer has gone too far. The surgical operation is futile." We would close these patients up. Then we had to say to them. "I'm very sorry, we have done a major operation. We haven't been able to do anything." We have not removed colon cancer metastases from the liver, because metastases are too many or too large. Now, we use PET CT and MRI before surgical operation on all patients with advanced colorectal cancer. We discover during surgical operation that cancer is more extensive that we thought before the surgery in only 2% of metastatic colon cancer patients. Dr. Anton Titov, MD. MRI of liver and PET CT has made a very big difference. Dr. Graeme Poston, MD. Those are the basic diagnostic tests of patients with advanced colon cancer before surgical operation to remove metastases. The important thing is to work very closely between the liver surgeon and the medical oncologist. Dr. Anton Titov, MD. Multidisciplinary team. Dr. Graeme Poston, MD. It has to be multidisciplinary team to treat patients with advanced colon cancer. Because what worries us as liver surgeons is that the chemotherapy for colon cancer is toxic to the liver. Oxaliplatin damages the liver. Irinotecan damages the liver. Sometimes you get up to six cycles of chemotherapy, the liver damage is minimal. But once you do 12 cycles of colon cancer chemotherapy. Then the liver damage is quite significant. Such toxic liver damage adds to the complications. It add to the mortality of the surgery to remove liver metastases from colorectal cancer. Dr. Graeme Poston, MD. Leading liver cancer surgeon. The second thing is the interval between completing the colorectal cancer chemotherapy and the surgical operation. Sometimes you do surgical operation too quickly after the chemotherapy. Then the complications of surgery, particularly infection, are much, much higher. Dr. Anton Titov, MD. In your experience, what is the optimal time between the chemotherapy and surgery? Dr. Graeme Poston, MD. Leading liver cancer surgeon. I like to wait six to eight weeks after six cycles of chemotherapy. Last thing is disappearing lesions. Where the chemotherapy makes the liver metastatic lesions disappear. I can't find them. I look at the liver and I can't find them. I do an ultrasound scan during my operation. Dr. Graeme Poston, MD. I still can't find these metastatic lesions. Those metastatic lesions could be close to the edge of the liver. Then it is not unreasonable just to remove the bits of liver where you think metastatic lesions were located. Dr. Anton Titov, MD. But disappearing metastatic lesions could be in the center of the liver. The last thing you want to do is take out half of the liver. Then three months later, metastatic colon cancer lesion comes back on the edge of the liver half that remains. Dr. Graeme Poston, MD. Leading liver cancer surgeon. That is my other concern. It is disappearing metastatic lesions from colorectal cancer. Preoperative staging for metastatic stage 4 colon cancer. PET CT, MRCP. Liver MRI allow for accurate estimate of liver metastases burden before operation.