Métastase colorectale unique ≤ 3 cm

Hépatectomie droite ou Résection limitée ?Une étude LiverMetSurvey

Isamu HOSOKAWA, René ADAM

• Occasionally, right hepatectomy (RH), rather than

parenchymal-preserving hepatectomy (PH), has

performed for solitary small colorectal liver metastasis

(CLM) in the right liver.

• The relative oncological benefit of PH and RH for

solitary small CLM is unclear.

Introduction

25,868 Pts , Dec. 2015

• Patients: LiverMetSurvey (2000-2015)

• Tumor number and size: Solitary, ≤ 30 mm in histology

• Tumor location: Right liver (Segment 5, 6, 7, 8)

• Surgical procedure:

PH group: Partial hepatectomy, Segmentectomy, Bisegmentectomy,

Sectionectomy

RH group: Right hepatectomy

• Primary end points: Major complications (Clavien-Dindo, grade III-

IV), 90-day mortality, recurrence-free survival (RFS), time to last

unresectable recurrence, overall survival (OS)

• Secondary end points: Liver recurrence, repeat hepatectomy

Patients and Methods

Study Population

Solitary, ≤ 30 mm tumor in histologyn=3890

PH groupn=1478 (86%)

RH groupn=242 (14%)

Segment 5, 6, 7, 8n=2060 n=340patients excluded:

• Portal vein embolization: n=50• R2 resection: n=76• Concomitant extrahepatic disease:

n=214

LiverMetSurvey (2000-2015)Total no. of liver resection for CLM

n=21072

Remaining study populationn=1720

Comparisons of Characteristics of Each Group

PH group(n=1478)

RH group(n=242) p

Variables No. % No. %Patients Age, years (mean ± SD) 64.1 ± 11.0 64.0 ± 10.0 0.96 Sex: Male 888 60 141 58 0.62Primary tumor Location: Rectum 498 34 84 35 0.77 T stage: 3/4 1193 88 176 87 0.65 N positive 846 62 126 61 0.76CLM characteristics Timing of diagnosis: Synchronous 721 49 121 50 0.78 Tumor size, mm (mean ± SD) 19.3 ± 7.6 20.4 ± 8.0 0.04 CEA level, ng/mL (mean ± SD) 65.7 ± 303.0 159.7 ± 1347.6 0.06 Initially unresectable 57 4 16 7 0.03Periopearative management Preoperative chemotherapy 455 32 84 36 0.23 Laparoscopic approach 140 10 5 2 <0.001 Postoperative chemotherapy 659 57 93 47 0.02

Comparisons of Surgical and Long-Term Outcomes of Each Group

PH group(n=1478)

RH group(n=242) p

Variables No. % No. %

Surgical outcomes

Blood transfusion 97 8 40 18 <0.001

Hospital stay, days (mean ± SD) 10.5 ± 8.1 12.7 ± 12.5 <0.001

R0 resection 1238 94 215 95 0.64

Major complications 49 3 24 10 <0.001

90-day mortality 11 1 7 3 0.008

Long-term outcomes

Recurrence 529 36 84 35 0.77

Liver recurrence 294 20 54 22 0.39

Liver-only recurrence 172 12 35 14 0.20

Extrahepatic disease recurrence 357 24 49 20 0.19

Repeat hepatectomy 187 13 18 7 0.02

Comparisons of RFS and Time to Last Unresectable Recurrence of Each Group

Time to last unresectable recurrenceRFS

PH group (n=1478)RH group (n=242)

p=0.17p=0.54

62%

64%

52%

48%50%

51%43%

41%

PH 1478 874 543 361 255 194 131RH 242 144 98 65 53 34 21

PH 1478 967 662 472 328 245 162RH 242 158 116 83 65 42 25

Comparison of OS of Each Group

OS

PH group (n=1478)RH group (n=242)

p=0.29

75%

78%

63%

62%

PH 1478 1058 781 571 398 291 184RH 242 178 135 101 80 54 34

Comparisons of Characteristics in Patients with Liver-Only Recurrence of Each Group

PH group(n=172)

RH group(n=35) p

Variables No. % No. %Patients Age, years (mean ± SD) 63.7 ± 10.9 63.6 ± 10.5 0.99 Sex: Male 104 60 20 57 0.71Primary tumor Location: Rectum 61 35 14 42 0.55 T stage: 3/4 140 89 24 80 0.22 N positive 105 66 20 67 1.00CLM characteristics Timing of diagnosis: Synchronous 103 60 13 37 0.02 Tumor size, mm (mean ± SD) 17.7 ± 8.0 17.6 ± 7.5 0.97 CEA level, ng/mL (mean ± SD) 41.3 ± 127.4 58.0 ± 110.2 0.60 Initially unresectable 10 6 2 6 1.00Periopearative management Preoperative chemotherapy 58 34 11 33 1.00 Laparoscopic approach 13 8 0 0 0.13 Postoperative chemotherapy 68 48 16 53 0.69

Comparisons of Surgical and Long-Term Outcomes in Patients with Liver-Only Recurrence of Each Group

PH group(n=172)

RH group(n=35) p

Variables No. % No. %Surgical outcomes Blood transfusion 12 8 10 33 0.001 Hospital stay, days (mean ± SD) 10.3 ± 6.1 15.6 ± 21.7 0.008 R0 resection 133 90 29 97 0.32 Major complications 6 3 2 6 0.63Recurrence characteristics Time to recurrence: <12 months 88 51 13 65 0.34 Tumor number (mean ± SD) 2.4 ± 2.9 1.4 ± 0.8 0.15 Maximum tumor size, mm (mean ± SD) 27.7 ± 23.2 26.0 ± 14.2 0.78 Tumor distribution: Bilober 53 32 0 0 CEA level, ng/mL (mean ± SD) 175.0 ± 621.9 96.4 ± 126.7 0.72 Repeat hepatectomy 115 67 11 31 <0.001

Distribution and Side of Liver Recurrence in Patients with Liver-Only Recurrence after PH

Liver-only recurrence after PH(n=172)

n %

Bilobar 53 32

Unilobar 119 68

Right (ipsilateral) liver 32 27

Left (contra-lateral) liver 87 41

Liver Recurrence and Repeat hepatectomy According to the Initial Hepatectomy Procedure in Patients with Liver-Only Recurrence after PH

Liver recurrence (n=172)

Repeat hepatectomy(n=115) %

Non-anatomical partial resection 110 80 72

Anatomical resection 62 35 56

Segmentectomy 41 22 54

Bisegmentectomy 12 7 58

Sectionectomy 9 6 67

*

* p=0.04

Comparisons of RFS and Time to Last Unresectable Recurrence in Patients with Liver-Only Recurrence of Each Group

p=0.005

p=0.72

25%

51%

35%

9%

PH 172 85 31 12 8 5 3RH 35 21 9 3 0 0 0

PH 172 134 86 67 44 33 21RH 35 27 15 8 4 2 1

PH group (n=172)RH group (n=35)

Time to last unresectable recurrenceRFS

Univariate and Multivariate Analysis of Survival in Patients with Liver-Only Recurrence

Variables n 5-yr OS (%) Univariate p Multivariate p RR 95% CIPatients Age, years ≤65 115 49 0.69 >65 92 51 Sex Male 124 59 0.02 0.07 1.77 0.96-3.27 Female 83 37Primary tumor Location Rectum 75 51 0.88 Colon 130 49 T stage 3/4 164 50 0.91 1/2 23 47 N stage 1/2 125 42 0.02 0.04 0.47 0.23-0.95 0 65 64CLM characteristics Timing of diagnosis Synchronous 116 49 0.71 Metachronous 90 52 Tumor size, mm ≤20 136 54 0.11 >20 71 42 CEA levels, ng/mL ≤15 76 57 0.01 0.05 1.85 1.01-3.37 >15 51 36 Initial resectability Resectable 185 51 0.92 Unresectable 12 39

Univariate and Multivariate Analysis of Survival in Patients with Liver-Only Recurrence (Continue)

Variables n 5-yr OS (%) Univariate p Multivariate p RR 95% CI

Hepatectomy characteristics Preoperative chemotherapy + 69 45 0.96 - 133 54 Type of approach Laparoscopic 13 0 0.12 Open 192 49 Type of procedure PH 172 55 <0.001 0.001 3.70 1.77-7.72 RH 35 23 Blood transfusion + 22 44 0.24 - 155 54 Hospital stay, days ≤14 163 53 0.004 0.10 1.82 0.89-3.72 >14 33 37 Margin status R0 162 53 0.99 R1 16 43 Major complications + 8 56 0.14 - 199 50 Postoperative chemotherapy + 84 49 0.79 - 89 57

En analyse multivariée : • Ganglions métastatiques de la T primitive, • ACE pré-op ≤ 15 ng/mL, • Hépatectomie limitée

indépendamment associés à un meilleur pronostic chez les patients ayant une récidive purement hépatique…

• Hépatectomie droite plutot qu’ Hep. limitée: 14% des cas

• Moins souvent par voie laparoscopique (2% vs 15% …)

• Risque augmenté de complications post-op majeures et de

mortalité à 3 mois vs hépatectomies limitées.

• La fréquence des récidives n’en est pas diminuée...

• En revanche, en cas de récidive purement hépatique, la

rehépatectomie est moins souvent réalisée et la survie sans

récidive en est très nettement diminuée (9% vs 35% à 5 ans)

Conclusions

Conclusions

Une hépatectomie limitée en cas de métastase unique

du foie droit doit etre considérée comme la procédure

standard lorsqu’elle est techniquement réalisable.