The death of Fang Jing, the former famous CCTV host, once again aroused people’s concern about their own health and cancer screening. The culprit of Fang Jing’s illness was stomach cancer, but the final cause of her death was liver metastasis. This seemingly mysterious phenomenon is actually very common in clinical practice, and liver metastasis from gastric cancer has been one of the hot spots of international research in recent years. What exactly is the state of liver metastasis of gastric cancer? What is the current status of international treatment? What should we do if we encounter such patients with liver metastasis of gastric cancer in the clinic again? What should be the position of hepatobiliary surgeons in gastric cancer liver metastasis? Is it that all patients with liver metastasis from gastric cancer have no chance of cure? Liver is a common metastasis site of gastric cancer, 4-14% of patients will find liver metastasis when gastric cancer is diagnosed; 37% of patients will develop liver metastasis after gastric cancer surgery, and liver metastasis is also the main cause of death in middle and late stage gastric cancer. Unlike liver metastases from colorectal cancer, liver metastases from gastric cancer have been considered as a systemic disease, often accompanied by multiple metastases throughout the body or in the liver at the time of detection, therefore, most scholars in the early stage believed that surgical resection of liver metastases could not achieve curative effect. Although palliative chemotherapy is the standard treatment option for stage IV gastric cancer, the 5-year survival rate is only 1.7%, with a median survival of 7-15 months. In recent years, with the development of systemic chemotherapy for gastric cancer and the advancement of surgical techniques, more and more scholars have pondered whether the treatment of colorectal cancer liver metastases (CRLM) could be borrowed and surgical resection of LMGC could be attempted. before 2000, there were studies on the effect of surgical resection of LMGC, but most of the studies focused solely on the surgical technique on resectability, and the 3-year survival rate of surgical resection was only The 3-year survival rate of surgical resection was only 14.3-22%, and the 5-year survival rate was 0%. However, after 2000, studies paid more attention to the biological behavior of the tumor, and by screening specific patients, it was found that surgical resection could significantly improve the 1-, 3-, and 5-year survival rates of LMGC compared with chemotherapy alone (84%, 50%, and 37%). Therefore, the surgical treatment strategy for liver metastases from gastric cancer is gradually changing from “can we operate” to “select suitable patients for surgery”, and the indication of “suitable” surgery is The answer to this “suitable” surgical indication must be found by looking for prognostic factors in the previous literature. A total of 16 single-center (between 2000-2015), retrospective studies of surgical resection of LMGC were searched. The results showed that 5-year survival rates of 11-37% could be achieved by surgical resection, with a median survival of 10-38 months, which is significantly better than patients who underwent palliative chemotherapy alone. 1. Prognostic factors of the primary tumor In summary of the literature, the prognostic factors associated with the primary tumor are: (1) T-stage of the primary tumor; (2) vascular-lymphatic invasion; (3) size of the primary tumor. One paper each mentioned the above factors. 2. Prognostic factors of liver metastases The prognostic factors associated with metastases were: (1) single or multiple liver metastases; (2) whether the liver metastases were confined to 1 lobe; (3) the size of the metastases; (4) whether the metastases had a pseudo-envelope. Among them, as many as 11 papers considered multiple liver metastases as a significant factor influencing poor prognosis, and 3 papers mentioned liver metastases larger than 5 cm, and 1 paper mentioned each of the other two factors. Prognostic factors related to surgery The prognostic factors associated with surgery are: (1) the condition of the incision margin (2) the extent of resection. Early on, it was thought that micrometastases around LMGC lesions were more common, and therefore the liver margin had to be greater than 1 cm to provide a survival benefit. More scholars now believe that since LMGC recurrence is often multicentric in the remaining liver due to cancer cell infiltration through blood vessels, in situ recurrence is rare and extensive resection cannot reduce the recurrence rate; moreover, with the development of perioperative chemotherapy, the in situ recurrence rate decreases. Therefore, the literature suggests that for liver metastases from gastric cancer, an R0 resection of >1 mm is guaranteed, but an R1/2 resection has a poor prognosis. The German single-center study showed that survival was significantly better with R0 resection than with R1/2 resection (5-year survival rate 20% vs 0%). By reviewing the above literature, we can basically divide the prognostic factors into three parts: primary foci, metastases, and surgery-related. After summarizing these prognostic factors, we found that the prognostic factors that can really be judged preoperatively are mainly several: number of metastases, metastasis diameter, metastasis distribution, and surgical margins. Therefore, we concluded that only patients with a single tumor less than 5 cm and who can ensure R0 resection during surgery can have a better prognosis. In today’s era of systemic chemotherapy, the response to chemotherapy directly predicts the biological behavior of the tumor and the patient’s prognosis. phase III RCTs such as MAGIC have demonstrated the survival benefit of neoadjuvant chemotherapy in patients with gastric cancer without distant metastases, providing a strong basis for neoadjuvant chemotherapy in LMGC. The advantages of neoadjuvant therapy include: 1) screening and predicting patients with good response to chemotherapy; 2) killing and controlling micrometastases and reducing the risk of recurrence; 3) improving R0 resection rate and preserving sufficient residual liver volume. A multicenter study initiated by Peking University Cancer Hospital reviewed the effect of chemotherapy combined with surgery compared with palliative chemotherapy alone in patients with concurrent LMGC, and the chemotherapy regimens selected were SOX regimen and DCF regimen, and the results showed that the median survival of patients in the surgery combined with perioperative chemotherapy group reached 22 months compared with 5.5 months in the palliative chemotherapy group (P = 0.000), and the chemotherapy combined with surgery group patients all underwent surgery after achieving objective remission (CR+PR). Another retrospective study confirmed that survival with postoperative adjuvant chemotherapy for LMGC was superior to that of patients who underwent surgery alone, with a 5-year survival rate of 54.1% vs 0%. We therefore believe that perioperative chemotherapy for LMGC is effective and reasonable. If preoperative treatment is effective, combined surgical treatment can provide a survival benefit in this group of patients. In addition neoadjuvant chemotherapy can convert potentially resectable patients to resectable, reduce the risk of surgery and increase the resectability rate. The clinical risk factor score for liver metastases from gastrorectal cancer, and the concurrent presence of liver metastases is one of the risk factors for poor prognosis, while there is no clear conclusion about liver metastases from gastric cancer. In a retrospective study, Qiu et al. found that for appropriate patients undergoing surgery, 1-, 3-, and 5-year survival rates reached 96%, 70.4%, and 29.4%, respectively, with a median survival of 38 months. similar conclusions were obtained in a study by Tsujimoto et al. where 5-year survival could reach 22-48%. In addition, a study in 2015 showed that for concurrent LMGC, the prognosis is best with resection of both primary foci and liver metastases, and both are generally chosen for simultaneous resection, but complications are increased if combined with extensive liver resection; staged resection is not evidenced at present, mainly because gastric cancer itself has poorer biological behavior than colorectal cancer, and staged resection may have the possibility of disease progression. Therefore, we believe that concurrent LMGC liver metastases are not a contraindication to surgical resection The intrahepatic recurrence rate of LMGC is high, about 50%, and the treatment after recurrence directly determines the survival of patients, and the median survival of palliative chemotherapy will not exceed one year. A review of previous treatment of patients with recurrence after LMGC resection by Japanese authors found that the prognosis was significantly better than that of patients treated with palliative chemotherapy and maintenance therapy if hepatic resection could be performed again, but it should be emphasized that patients with early recurrence (within 1 year) had a significantly worse prognosis and did not benefit from reoperation. In a single-center retrospective study in Japan, patients with LMGC were divided into hepatectomy + HAI group, hepatectomy alone group, HAI alone group, and palliative care group, and the results showed that the 5-year survival rate of surgery combined with HAI reached 75%, and although the long-term survival was not significantly better than surgery alone due to the small sample size, the survival benefit was still significantly better than that of HAI alone and palliative chemotherapy. Therefore, in the future, for LMGC with metastases confined to the liver, surgery-based treatment combined with HAI has the potential to improve patient prognosis. The development of radiofrequency ablation technology in recent years has led to its more widespread application. In addition to primary liver cancer, more and more centers are using it in liver metastases. the advantages of RFA are less invasive, faster recovery, and suitable for patients who are intolerant to surgery; however, the long-term results need to be verified because of the high local recurrence rate due to the inability to clarify the tumor destruction. In a single-center retrospective study from Korea, a total of 15 patients with LMGC (15/73) received RFA ± chemotherapy, and the rest received chemotherapy, palliative care, and TACE. The median survival of RFA combined with chemotherapy was found to be 27 months, which was significantly better than palliative chemotherapy, and multifactorial analysis showed that the choice of treatment was one of the factors affecting prognosis. The 2015 NCCN guidelines remain conservative in the treatment of liver metastases from gastric cancer, and the recommended treatment for patients with metastasis, local progression, and recurrence is palliative treatment (chemotherapy, clinical trials, and best supportive care), with surgery as a treatment modality for some patients with local recurrence. The third edition of the Japanese Gastric Cancer Guidelines (JGCA) for the treatment of patients with metastases also clearly suggests that surgical intervention for metastatic gastric cancer should be avoided, arguing that liver resection cannot achieve a cure for LMGC. However, in 2014, several experts from the Japan Gastric Cancer Association suggested that the guidelines for the treatment of resectable M1 patients should be revised and a working group was formed to explore the following as indications for surgery: 1) the presence of resectable liver metastases; 2) positive cytology on abdominal lavage; and 3) the presence of reinforcing nodes adjacent to the abdominal aorta. Therefore, worldwide, more and more oncologists are recognizing the prospect of surgical treatment of liver metastases from gastric cancer, and we expect stronger evidence to drive the revision of guidelines. Although there are no guidelines to recommend surgical resection for LMGC, a review of previous literature still confirms that surgical resection has a place in LMGC, especially the studies in the last decade, which invariably emphasize the possibility of maximizing the survival benefit of patients through surgical resection by controlling the indications. Therefore, for liver metastases from gastric cancer, extrahepatic metastases should first be excluded and evaluated. If the liver metastases are single and less than 5 cm, neoadjuvant chemotherapy should be administered first, and after excluding patients with poor biological behavior, surgery should be performed for patients who achieve objective remission, and adjuvant chemotherapy should be continued after surgery. It is the treatment direction of LMGC to screen suitable patients for individualized and comprehensive evaluation by MDT so that patients who can really benefit from surgery will undergo surgery. And we believe that with the advancement of systemic chemotherapeutic agents, there will be more and more room for surgical treatment of LMGC in the future.