The Modern Continuum of Care for Colorectal Liver Metastases: A Comprehensive Review

Colorectal cancer (CRC) remains a leading cause of cancer-related morbidity and mortality worldwide, and the liver is its predominant site of metastatic spread; approximately half of patients with CRC develop colorectal liver metastases (CRLM). Management has shifted from largely palliative intent to a multidisciplinary strategy with curative potential. Complete resection offers a chance of cure, although long-term survival varies substantially with tumor biology, disease burden, and patient selection. This review summarizes advances in prognostic stratification, molecular profiling, and the evolving definition of resectability, together with surgical innovations including parenchymal-sparing and two-stage hepatectomy, portal vein embolization, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), liver venous deprivation, and minimally invasive approaches. We review conversion chemotherapy informed by the TRIBE, TRIBE2, CAIRO5, and PARADIGM trials, perioperative systemic therapy, and biomarker-directed agents for RAS wild-type, BRAF V600E-mutant, KRAS G12C-mutant, and HER2-amplified tumors, alongside immune checkpoint inhibition for microsatellite instability-high disease. Locoregional therapies, including thermal ablation, stereotactic radiotherapy, and selective internal radiation therapy, are discussed in light of the COLLISION and CLOCC trials. Finally, we consider emerging roles for circulating tumor DNA in minimal residual disease assessment and for liver transplantation in highly selected patients with unresectable disease (SECA, TransMet).