Transcript Surgical management of hepatic metastasis from colorectal cancer

Surgical management of
hepatic metastases from
colorectal cancer
Joint Hospital Surgical Grand Round
Dr HH Wong
Department of Surgery
PYNEH
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Liver is the commonest site of distant metastasis
of colorectal cancer
Nearly half of the patients with colorectal cancer
ultimately develop liver metastasis during the
course of their diseases
Liver metastasis may be present in as many as
35% of patients with colorectal cancer at the
time of operation
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Prognosis of patients with untreated liver
metastasis
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extent of hepatic involvement at the time of
diagnosis
Histological grade of the primary tumour
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0 % five-year survival for patients
with untreated but potentially
resectable liver metastases
28 % five-year survival for operated
patients with resected liver
metastases
- Wilson SM, Adson MA. Surgical treatment of hepatic
metastases from colorectal cancer. Arch Surg 1976; 111:
330-334 )
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patients with an untreated single liver
metastasis had a median survival of 19 months,
with no patients surviving 5 years
while patients with a resected single liver
metastasis had a median survival of 36 months
with 25 % of patients surviving five years
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Wanebo HJ, Semoglou C, Attiyeh F, Stearns MJ Jr. Surgical
management of patients with primary operable colorectal
cancer and synchronous liver metastases. Am J Surg 1978; 135:
81-85
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Surgical resection of distant metastases
in colorectal cancer can produce longterm survival and cure in some selected
patients.
Five-year survival rates after
resection of all detectable liver
metastases range from 6 to 52 %
Traditional selection criterion
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No more than 3 metastases
Unilobar disease
Tumours < 5cm
Metachronous detection of metastases
Resection margin > 1cm required
No extrahepatic disease
Not > 65 of age
No portal nodal involvement
Unilobar or bilobar disease
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Only 1/3 of patients with colorectal liver
metastases have disease limited to one
lobe
segment-based resection allows excision
of bilateral or multiple liver lesions that
might previously have been deemed
unresectable
Unilobar or bilobar disease
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Up to 75 % of the liver can be removed if
the liver function is normal
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Vauthey JN. Liver imaging. A surgeon's perspective. Radiol Clin
North Am 1998;36(2):445-57
Number of metastases
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Long-term survival is rare in patient with
resection of four or more lesions
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Ekberg H. determinants of survival in liver resection for colorectal
secondaries. Br J Surg 1986; 73: 727-31
patients who underwent resection of more than
four colorectal liver metastases revealed an
overall 5 year survival rate of 23%
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Weber SM et al. Survival after resection of multiple hepatic
colorectal metastases. Ann Surg Oncol 7: 643-650, 2000
Number of metastases
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no significant difference in the mortality,
morbidity and five-year survival between
patients whose lesions more than four and
those less than four
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Morris DL. Surgery for liver metastases: How many? ANZ J
Surg 2002; 72: 2
Minagawa M et al. Extension of the frontiers of surgical
indications in the treatment of liver metastases from colorectal
cancer: Longterm results. Ann Surg 231: 487-499, 2000
Resection margin
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Patients with incomplete removal of
tumour have similar outcomes to nonoperated patients
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Scheele J et al. Hepatic metastases from colorectal carcinoma:
impact of surgical resection on the natural history. Br J Surg, 77,
1241-6
Resection margin
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Registry of Hepatic Metastases
Margin greater than 1cm was associated
with a 45% 5-year survival
Only 23% survived 5 years if the margin
was less
Resection margin
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Recent reports suggest a generous
margin is not essential for achieving a
curative outcome
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Yamamoto J et al. Factors influencing survival of patients
undergoing hepatectomy for colorectal metastases. Br J Surg,
86, 332-7
Minagawa M et al. extension of the frontiers of surgical
indications in the treatment of liver metastases from colorectal
cancer. Ann Surg, 231, 487-99
Resection margin
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1mm tumour –free resection margin
is enough to achieve comparable
survival and disease-free survival
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Hamady Z et al. Current techniques and results of liver resection
for colorectal liver metastasis. Br Med Bull 2004; 70: 87-104
Other factors associate with poor
prognosis
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Metastasis greater than 6cm
Presence of extrahepatic metastases
Portal LN involvement
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None of these patients survives 5 years after
hepatectomy
Elevated pre-operative CEA level
Synchronous colorectal and liver
resection
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Liver metastasis may be present in as
many as 35% of patients with colorectal
cancer at the time of operation
Combined single-stage resection of
colorectal cancer and liver metastases
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Earlier initiation of adjuvant therapy
Avoiding a second laparotomy
Synchronous colorectal and liver
resection
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Safe and feasible with no increase in
perioperative morbidity or mortality
No difference in survival compared with
staged resection
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Lyass S et al. combined colon and hepatic resection for
synchronous colorectal liver metastases. J Surg Oncol, 78, 17-21
Jeack D et al. Strategie Chirurgicale dans le traitement des
mestatases hepatiques synchornes des cancers colorectaux.
Analyse d’une serie de 59 malades operes. Chirurgie, 124, 25863
Synchronous colorectal and liver
resection
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R Martin et al.
Simultaneous liver and colorectal resections
are safe for synchronous colorectal liver metastasis. Journ Am Col
Surg 2003; 197: 233-241
240 patients were treated surgically for primary
adenocarcinoma of the large bowel and
synchronous hepatic metastasis
134 patients underwent simultaneous resection
106 patients underwent staged operations
Synchronous colorectal and liver
resection
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Complications were less common in the
simultaneous resection group
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65 patients (49%) sustaining 142 complications for simultaneous
resection group
71 patients (67%) sustaining 197 complications for both
hospitalizations in the staged resection group (p < 0.003)
Patients having simultaneous resection required
fewer days in the hospital (median 10 days
versus 18 days, P = 0.001)
Perioperative mortality was similar (simultaneous,
N = 3; staged, N = 3).
Laparoscopic liver resection
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Not widely accepted in view of technical
difficulties
Tumour cell seedings at port sites
Overall morbidity has been shown to be
lower with laparoscopic resection
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Gigot J et al. laparoscopic liver resection for
malignant liver tumours. Ann Surg, 236, 907
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Doubling of resection rates
Only 25 % of patients with colorectal liver
metastases are candidates for liver
resection
Various methods to increase resectability
Neoadjuvant chemotherapy
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Downstaging of tumour to convert unresectable tumours
into potentially resectable ones
Permit resection of about 15% of metastases which have
previously been considered unresectable
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Adam R et al. Five-year survival following hepatic resection after
neoadjuvant therapy for nonresectable colorectal liver metastases. Ann
Surg Oncol, 8, 347-53
It rarely changes the tumour relationship to the vascular
structures
Preoperative portal vein
embolization
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Inducing ipsilateral atrophy and contralateral
hypertrophy of the liver remnant in these
patients
Increase 50% the size of the non-embolized
lobe in 4-6 weeks
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Abdalla EK, Hicks ME, Vauthey JN. Portal vein embolization: rationale,
technique and future prospects. Br J Surg. 2001;88:165–175
Preoperative portal vein
embolization
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Curative liver resection expected to be
feasible in ~50% patient who were initially
considered inoperable
5 year suvival apporaching 37%
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Elias D et al. Preoeprative selective portal vein embolization
before hepatectomy for liver metastases: long term results and
impoact on survival. Surgery, 131, 294-9
Two-stage resection
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Convert non-resectable liver metastases
into potentially curable cases
Especially applied to multinodular bilobar
metastase
First-stage resection remove the highest
possible number of tumour lesions
Two-stage resection
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Followed by liver regeneration period and
chemotherapy
2nd stage only perfomred if potentially curative
and only if enough parenchymal hypertrophy
has occurred to reduce the risk of postoperative
liver failure.
 Adam R, Laurent A, Azoulay D, et al. Two-stage hepatectomy: a planned strategy
to treat irresectable liver tumors. Ann Surg. 2000;232:777–785.
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Only 25 % of patients with colorectal liver
metastases are candidates for liver
resection
Other treatment modalities, such as local
ablative therapy, systemic chemotherapy,
hepatic artery infusion and isolated
hepatic infusion may offer palliation and
prolongation of disease-free and overall
survival
Local ablative therapy
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Radiofrequency ablation
Cryotherapy
Percutaneous ethanol injection
Laser and photodynamic therapy
Radiofrequency ablation
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An electrode delivers a high-frequency
alternating current to the tissue, causing
hyperthermia and finally inducing
coagulative necrosis
Single rigid probes inducing a cylindrical
necrotic lesion
Multi-tined expandable electrodes induce a
spherical lesion
Radiofrequency ablation
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Multiple insertions may be necessary when
tumours are >3cm in diameter
Probe placed under ultrasound or CT
guidance
RFA can be performed in combination
with resection
Radiofrequency ablation
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High complete response rates of 52%95% are achieved by RFA
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Curley SA et al. radiofrequency ablation of malignant liver
tumours. Ann Surg Oncol 2003; 10: 338-237
Ruers TJ et al. Long –term results of treating hepatic colorectal
metastases with cryosurgery. Br J Surg 2001
Radiofrequency ablation
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Prolongation of disease free and overall
survival to repectively 50% and 94% at 1
year
Median survival time of 30-34 months
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Solbiati L et al. Radiofrequency thermal ablation of hepatic
metastases. Eur J Ultrasound 2001; 13: 149-158
Hepatic resection vs. RFA
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Aloia, Thomas A et al. Solitary Colorectal Liver Metastasis:
Resection Determines Outcome. Arch Surg 141(5), 2006, p 460–467
150 underwent HR and 30 underwent RFA
Local recurrence (LR) rate was markedly lower
after HR (5%) than after RFA (37%) (P<.001).
Treatment by HR was associated with longer 5year survival rates than RFA
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LR-free (92% vs 60%, respectively; P<.001)
disease-free (50% vs 0%, respectively; P = .001)
overall (71% vs 27%, respectively; P<.001) survival rates
Hepatic resection vs. RFA
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Tumors 3 cm or larger (n = 79)
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LR occurred more frequently following RFA
(31%) than after HR (3%) (P = .001)
5-year LR-free survival rate of 66% after RFA
vs 97% after HR (P<.001).
Tumors < 3cm
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longer 5-year overall survival rates after HR
(72%) as compared with RFA (18%) (P
= .006).
Conclusion
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Hepatic resection remains the only possible cure
for colorectal liver metastases
Changing criteria for hepatic resection has
doubled the resection rate
Promising treatment modalities to increase
resectablitiy
RFA can achieve good results in patient with
non-resectable disease, however, itself alone
cannot replace hepatic resection in potentially
curative cases
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