The evolving landscape of colorectal liver metastasis management: from resection to transplantation – a narrative review

Colorectal cancer remains a leading cause of cancer-related mortality worldwide, with the liver representing the most common site of metastatic spread. The management of colorectal liver metastases (CRLM) has undergone a profound transformation over the past three decades, evolving from a surgical discipline focused solely on resectability to a complex, multimodal enterprise integrating advanced systemic therapies, refined surgical techniques, regional chemotherapy, local ablative procedures, and most recently, liver transplantation for highly selected patients. This narrative review synthesizes contemporary evidence from recent landmark trials and large cohort studies to provide a comprehensive overview of the current treatment landscape. We examine the evolution of surgical resection as the cornerstone of curative-intent therapy, the ongoing debate surrounding perioperative chemotherapy timing and regimens, and the emerging role of thermal ablation as a non-inferior alternative for small metastases. The revival of hepatic arterial infusion pump chemotherapy and the place of targeted therapies are contextualized within modern treatment algorithms. A central focus is the notable introduction of liver transplantation for non-resectable CRLM, with critical appraisal of selection criteria including metabolic tumor volume, the Oslo score, and tumor biology. We conclude by proposing a framework for personalized, biology-driven treatment selection that balances oncologic efficacy with patient quality of life and ethical considerations surrounding organ allocation.