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Surgery of colorectal liver metastasis
Juozas PundziusSurgery clinic of Kaunas university of
medicine
Incidence of liver metastasis in colorectal cancer
At the time of diagnosis of primary colorectal cancer: in 15-20% liver metastases are detectable In 15% udetectable liver metastases present
(Synchronous disease) Sasson A.R., Sigurdson E.R. et al; Seminars in Oncology; Vol 29, No 2, 2002
After curative surgery in 20-30% developing subsequent spread to the liver;
(Metachronous disease)Weinreich D Semin Oncol 29:136:144, 2002
~ 50% of IV stage patients, liver is the only site of metastatic process;~ 30% of patients with liver metastases are suitable for curative surgery.
Sasson A.R., Sigurdson E.R. et al; Seminars in Oncology; Vol 29, No 2, 2002
Methods of treatment of liver metastasis
CurativeSurgical – hepatic resection;With or without adjuvant therapy;
Palliative Medical – chemoterapy (systemic or regional); Surgical; Ablative techniques:
RFA Ethanol injections Cryotherapy;
Vesel ligation, embolization Chemoembolization Radiation
Curative possibilities of colorectal liver metastases
Hepatic resection is the only form of treatment that offers a long-term survival for patients with liver metastases from colorectal cancer, with 5-year survival ranging from 25% to 39%.
Tanaka K, Shimada H. et al Surgery Vol. 137:156-163, 2005
Long term results after CRC liver metastases surgery
Study Year No. of patients
5-year survival
(overall)
Median survival
(Mo)
Hughes et al
Scheele et al
Nordlinger et al
Jamison et al
Fong et al
Iwatsuki et al
1986
1995
1996
1997
1999
1999
607
434
1,568
280
1,001
305
33%
33%
28%
27%
37%
32%
-
40
-
33
42
-
Long term results – our data
Prognostic factors influencing long term results after curative surgery
Extrahepatic disease;
Primary tumor stage;
Number and size of liver matastases;
Disease free interval;
Margins;
Other ( age, CEA).
Prognostic factors for long term results- extrahepatic disease
Mayo Clinic 0% 5 year survival with extrahepatic disease (22 patients);
Memorial Sloan-Kettering Cancer Center Patients with and without extrahepatic disease 5 year survival
18% vs 38%;(1.001pts)Fong Y, Fortner J et al Ann Surg 230:309-318, 1999Elias D, Lasser P, De/Cl/Nouveche, Dec, 1991
Registry of Hepatic Metastases Metastatic lymphadenopathy (portal and celiac nodes)
markedly decreased survival with no 5 year survival reported (850 patients, retrospective study);
Registry of Hepatic Metastases, Surgery, 103:278-288, 1988
Restrictions for surgery in case of extrahepatic disease
Liver resection restricted in:1. Presence of metastasis in two or more organs -
lung, liver, colon (recurence) in case of multiple metastasis in one of them
2. Carcinomatosis, pleuritis, ascitis
3. Presence of portal or celiac lymph node metastasis proved by biopsy and extra pathology?
Prognostic factors for long term results– primary tumor stage
Patients with lymphatic spread have a decreased survival compared to patients without lymphatic spread, 41% vs 32% ( p = 0.05 analysis of 1.001 patients);
Fong Y, Fortner J et al Ann Surg 230:309-318, 1999
Stage II primary have an improved outcome compared to patients with stage III primary;
Scheele J., Stangl R. et al; World J Surg, 19:59-71,1995
Nordliger B., Guiget M et al; Cancer 77:1254-1262,1996
Suggestions for therapy in case of primary tumor spread
Node positive patients – candidates for adjuvant therapy
Prognostic factors for long term results– number of liver metastases
Increasing number of metastases – decreasing survivalExperience-
155 patients who had 4 and more lesions: 5 – year survival after 9 to 20 metastases resected - 14%. increasing number of metastases and positive resection margin -
independent prognostic factors (multivariate analysis).Weber SM, Jarnagin WR et al Ann Surg Oncol7:643-650, 2000
Statement- increased number of metastasis increasing likelihood of
undetectable metastasis
Restrictions for surgery in case of multiple liver metastases
1- 3 metastasis in one liver lobe are suitable for curative liver resection
Patients with 4 and more mts in one or both liver lobes are candidates for neoadjuvant treatment after 2 months chemotherapy in case of no
manifestation of new metastasis possibilities of surgery should be discussed
Prognostic factors for long term results– disease free interval
Experience- Difference of median survival in
synchronous vs. metachronous disease 27 months vs. 37 months
Scheele J., Stangl R. et al; World J Surg, 19:59-71,1995
Statements: Increasing disease-free interval associated with improved
survival.Fong Y, Fortner J et al Ann Surg 230:309-318, 1999
Synchronous or early manifestation of liver metastases are poor prognostic factors
Suggestions after liver resection in case of short disease free interval
Strong follow up protocol of resected patients with intent to detect new manifestation of metastasis
Neoadjuvant, adjuvant chemotherapy
Prognostic factors for long term results– size of liver metastases
Controversial opinions:Increasing tumor size – poor prognostic factor;Iwatsuki S, Dvorchik I et al, J Am Coll Surg 189 :291-299,1999
Tumor size – no influence on survival;Cady B, Jenkins RL et al Ann Surg 227:566-571, 1998
Clinical consideration (hypothesis):Large and solitary tumor because of long growing period should decrease likelihood of manifestation of new metastasis, Current consensus:
There is no absolute metastasis size limit for surgical resection
Prognostic factors for long term results - margins
Studies: Patients with positive resection margins ( noncurative) had
a life expectancy similar to that of patients with unresectable disease;
Steele G Jr, Bleday R et al J Clin Oncol 9:1105-112, 1991
Patients with minimally negative microscopic margins (1 to 9 mm) compared to patients with margins greater than 10 mm:
1. decreased 5-year survival; 34% vs 41% (p = 0.009)
Scheele J., Stangl R. et al; World J Surg, 19:59-71,1995
23% vs 47% (p < 0.01) Registry of Hepatic Metastases, Surgery, 103:278-288, 1988
2. Increase in hepatic recurrence;Hughes KS et al Surgery 100:278-284, 1986
Obligations and Suggestions for surgeon in aspect of margins
Obligation- to resect with minimally clear margins > 10mm
Suggestion-To try expand clear margins to 30mm
Poor prognostic factorsAs guidelines for patient selection
Study Age
Primary
Tumor Stage
No. of lesions
Size Satellite lesions
Bilobar Margins
(<1cm)
Disease
Free
Interval
CEA Extra
Hepatic
disease
Fong
Iwatsuki
Lise
Cady Nordlinger
Jamison
Wanebo
Scheele
Doci
+
+
+
+
+
+
>1
>2
>1
>3
>3
>3
>5
>8
>3
>5
>5
+
+
+
+
+
+
+
+
+
<1yr
<2,5yr
<2yr
+
+
+
+
+
+
+
Actuality of surgical resection (I)
Short term results
Short term results after liver resection
morbidity - <25%
mortality - <4%
Study Mortality Morbidity Hepatobiliary
compl.
Infectious compl.
Scheele et al
Iwatsuki et al
Nordlinger et al
Cady et al
Fong et al
Doci et al
Our data
4%
1%
2%
4%
3%
2%
-
16%
8%
23%
-
24%
18%
21%
8%
-
-
3%
4%
6%
7%
3%
-
-
6%
6%
8%
9%
Morbidity and Mortality after liver resection
General complications:
cardiovascular, pulmonary, etc.
Infection, abscess;
Hemorrhage.
Specific complications:
bile leak, biliary fistula,
Liver failure
( can be decreesed < 5% with proper patient selection despite agresive surgical treatment).
Low morbidity and mortality depends on patient selection
Preoperative evaluation:
1. Medical condition similar to other major abdominal surgery ( particular attention to pulmonary and cardiac systems).
2. Preoperative Hepatic function;
Main contraindication for expanded liver resection
Inability to preserve an adequate reserve of functional hepatic tissue;
Chance for survival after liver resection with normal liver function
70-75% of the liver can be resected without increasing the risk of postoperative liver failure in the absence of cirrhosis or fatty liver.Sasson A.R., Sigurdson E.R. et al; Seminars in Oncology; Vol 29, No 2, 2002
Patient selection – preoperative evaluation of Hepatic function
Main question – extent of the operation?
Clinical evaluation (Child – Pugh);
Level of Bilirubinaemy;
Indocianine green (ICG-5);
CT volumetry.
Clinical evaluation (Child – Pugh) 1964m
A B C
Albuminaemy (g/l) >35 30-35 <30
Bilirubinaemy (mkmol/l) <40 40-35 >50
Ascites No Easy control
Hard control
Encephalopathy No I – II III – IV
Nutrition Excelent Good Bad
Operation risk Minimal Medium Big
Postoperative mortality 0-5 % 10-15 % >25 %
1 year mortality Minimal 20-40 % 40-60 %
No ascites or easy control
Bilirubinaemy
normal 18.8-25.6 μmol/l 27.4-32.5 μmol/l > 34.2 μmol/l
Limitedresection
Enucleation Not resectableICG-5
normal 10-19% 20-29% 30-39% > 40%
Major surgery
Bisegment-ectomy
Segment-ectomy
Limited resection
Enucleation
Liver resection volume guides
CT volumetry of liver
Liver sector Volume cm3 %
Posterior 207.4 27.7
Anterior 149.9 19.7
Medial 163.3 21.5
Lateral 177.9 23.4
Caudal 22.7 2.9
Tumor 36.7 4.8
Preoperative procedures to increase volume of the liver
Decreasing of blood supply to diseased part of the liver with intent to enlarge normal liver lobe:
Portal vein embolisation Embolisation of hepatic artery
Intent to enlarge normal liver before surgery
• Transhepatic portal vein embolisation
Transileocolic portal vein embolisation scheme
Laparotomy and catheterisation of ileocolic vein
RPV
SMV
Intent to enlarge normal liver before surgery