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Met hepsarcoma pequim final

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  • 1. www.CirurgiaOnline.com.brOncology Surgeon of the Brazilian National Cancer InstitutePresident of the Brazilian Chapter of the International Hepato Biliary Pancreatic Association (CB-IHPBA)Compagnon Hepatobiliare
  • 2. www.CirurgiaOnline.com.brHEPATIC METASTASES OF SARCOMAINTRODUCTIONSarcomas are mesodermic origin tumors, low frequencyand several times arrived with advanced disease in ourcenter.NCI Brazil66587 last 10 y => near 1531 (2,29%) sarcomasHepatic Metastases = stage IVUp to 60% Hepatic Metastases in Abdominal Sarcomas
  • 3. www.CirurgiaOnline.com.brResections of Colorectal MetastasesWell EstablishedHepatic Metastases of Sarcomas?HEPATIC METASTASES OF SARCOMAINTRODUCTION
  • 4. www.CirurgiaOnline.com.brHepatic resection for Noncolorectal Nonendocrine LiverMetastases. Analysis of 1452 patients and development of aPrognostic Model.Adan R, Chiche L, Aloia T and others.Ann Surg. 2006 Oct;244(4):524-35; French Group
  • 5. www.CirurgiaOnline.com.br1452 patients 1983 – 200456% solitary - 71% unilateral - Med 5,05 cmGIST/Sarcoma (33/125 - 13,5%)Metachronous 76%83% R0, Mortality rate 2,3%Overall 5 and 10 years => 36% and 23%Recurrence free survival 11 months5y surv GIST 70% and Sarcoma 31%Hepatic resection for Noncolorectal Nonendocrine LiverMetastases. Analysis of 1452 patients and development of aPrognostic Model.Adan R, Chiche L, Aloia T and others.Ann Surg. 2006 Oct;244(4):524-35; French Group
  • 6. www.CirurgiaOnline.com.brExcept for patients with gastrointestinal stromal tumors(GIST), systemic chemotherapy in patients with liver metastasisof soft-tissue sarcoma (STS) is not effective.We believe that all patients with resectable liver metastasesshould underwent surgical therapy.HEPATIC METASTASES OF SARCOMAINTRODUCTION
  • 7. www.CirurgiaOnline.com.brResults of hepatic resection for sarcoma metastatic to liver.DeMatteo RP, Shah A, Fong Y, Jarnagin WR, Blumgart LH, Brennan MF.Ann Surg. 2001 Oct;234(4):540-7; discussion 547-8. Memorial Sloan-Kettering Cancer Center56 pac in 331 between 1982 – 200034 (61%) GIST or Leiomyossarcoma Gastrointestinal50% Major Hepatectomies ( > 3 Segments)Zero MortalitySurvival in 1, 3 and 5 y R0 = 88%, 50% and 30%5 y survival R1 and R2 = 4%Median surv 39 months GIST = LeiomyossarcomaHEPATIC METASTASES OF SARCOMABefore Imatinib
  • 8. www.CirurgiaOnline.com.brResults of hepatic resection for sarcoma metastatic to liver.DeMatteo RP, Shah A, Fong Y, Jarnagin WR, Blumgart LH, Brennan MF.Ann Surg. 2001 Oct;234(4):540-7; discussion 547-8. Memorial Sloan-Kettering Cancer CenterMultivariate Analysis => Metachronous > 2 years45 (80%) Metachronous disease > 2 years in 57%Recurrence 47 (84%) Med 16 months (liver)Highly selectedConclusion:Hepatectomies must be performed when R0 ispossible and increase survival.HEPATIC METASTASES OF SARCOMA
  • 9. www.CirurgiaOnline.com.brResults of a single-center experience with resection andablation for sarcoma metastatic to liver.Pawlik TM, Vauthey JN, Abdala EK, Pollock RE, Ellis LM, Curley SA. Arch Surg. 2006Jun;141(6):537-43. Huston Texas1996 – 200566 patients, Median 3 lesions with 3,9 cm, bilobar36 GIST , 18 Leiomyosarcoma, 12 Others35 Resection, 13 Radiofrequency, 18 Both66,7% Recurrence, More Radiofrequency (p < 0,05)1, 3 and 5 years survival 91,2%, 65,4% and 27,1% (47,2 months)GIST with Imatinib Mesylate => Longest Survival p = 0,003 andDisease free survivalComplication Rate 15,2%, Mortality 4,5%HEPATIC METASTASES OF SARCOMA
  • 10. www.CirurgiaOnline.com.brResults of a single-center experience with resection andablation for sarcoma metastatic to liver.Pawlik TM, Vauthey JN, Abdala EK, Pollock RE, Ellis LM, Curley SA. Arch Surg. 2006 Jun;141(6):537-43.Huston TexasGood Prognostic Factors• Size < 3 cm• Surgery alone• Chemotherapy pre or post op• Imatinib in GISTHEPATIC METASTASES OF SARCOMA
  • 11. www.CirurgiaOnline.com.brHepatic metastasectomy for soft-tissue sarcomas: is it justified?Rehders A, Peiper M, Stoecklein NH, Alexander A, Boelke E, Knoefel WT, Rogiers X.World J Surg. 2009 Jan;33(1):111-7• 27 hepatic resection patients; 1995 to 2008.• 59% Solitary metastasis, 22% had two metastases, and 18% had threeor more metastatic nodules.• Mortality 7%.• The median survival was 44 (range, 1-123) months, and the 5-yearsurvival was 49%.• Repeated resection for recurrent tumor was performed in eightpatients, which yielded a median survival of 76 months.CONCLUSIONS:Patients who have hepatic metastases that are functionally andtechnically resectable should be considered for surgery because thistreatment offers the chance for long-term survival (>5 years).
  • 12. www.CirurgiaOnline.com.brHepatic Resection of Soft Tissue SarcomasSilva R., Kesley R., Santos CER., Melo E., Dias J., Bravo GP.Rev.Col. Bras. Cir. 2006; 33(6): 380-386.• INCA 1992 - 2002 – 11 cases• 5 gastrointestinal tract, 4 retroperitoneum, 1 uterus and 1 deltoid muscle.• 10 leiomyosarcomas and 1 dermatofibrosarcoma.• 6 G2 and 5 G3 tumors.• 5 segmentectomies, 4 lobectomies and 2 major hepatic resections.• 2 extra-hepatic associated resections.• 7 R0• OS complete resection with a 49-month survival for R0 resections compared toa 15-month with residual disease (p<0.05).• G2 a 49-month survival compared to a 15-month with G3 tumors (p<0.0447).
  • 13. www.CirurgiaOnline.com.brHepatic Resection of Liver Metastases of SoftTissue SarcomaSilva R., Kesley R., Santos CER., Melo E., Dias J., Bravo GP.Rev.Col. Bras. Cir. 2006; 33(6): 380-386.ConclusionLiver resections for hepatic metastasis of soft tissuesarcomas can improve overall survival particularlyfor patients with complete resection (R0) and for lowgrade tumors.Lead us to increased indication and pursuit ofradicality
  • 14. www.CirurgiaOnline.com.brAuthors: Santos CER, Rosa BR, Meton F, Monteiro MBrazilian National Cancer InstituteAnalysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011
  • 15. www.CirurgiaOnline.com.brAngiomyosarcoma Leiomyosarcoma
  • 16. www.CirurgiaOnline.com.brMaterial and Methods• Retrospective study based on aprospective data base of 28 patientswith hepatic metastases ofsarcoma, ressected at Brazilian NationalCancer Institute - INCA-Rio deJaneiro, between 1996-2011.Analysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011
  • 17. www.CirurgiaOnline.com.brResults• Patients• Gender: 17 women (60.7%)• 11 men (39.3%)•• Age: 30 - 72 y (median 55 y)Analysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011
  • 18. www.CirurgiaOnline.com.brResults• Tumour 26 abdominal origin• 8 Gastric;• 7 Small Bowel;• 6 Retroperitoneal;• 2 Uterine;• 1 IVC, Kidney, Colon, Breast and Deltoid.Analysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011
  • 19. www.CirurgiaOnline.com.brResults• Histology:• 16 (54.1%) - Leiomyosarcoma• 8 (28.6%) - GIST• 2 Endometrial Sarcomas• 1 Fibrosarcoma• 1 AngiosarcomaAnalysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011
  • 20. www.CirurgiaOnline.com.br• Histology:Analysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011Histology MedianVisceral 66.33NonVisceral33.23Overall 62.73P= 0.208
  • 21. www.CirurgiaOnline.com.brResults• Histology:Analysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011P= 0.171Histology MedianGIST -OthersSarcomas37.97Overall 62.73
  • 22. www.CirurgiaOnline.com.brResults• Tumour Grade:G3 - 11 (39.3%)• G2 - 8 (28.6%)• G1 - 2 (7.1%)GX – 4 (14.3%)• Metastases Size: 2 to 25 cm (median 6 cm)• 20 cases Metachronic – Median 30 months (5 - 292)• 8 Synchronic diseaseAnalysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011
  • 23. www.CirurgiaOnline.com.brResults• Tumour Grade:Analysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011P= 0.529
  • 24. www.CirurgiaOnline.com.brResults• Diagnostic• CT 26 cases• US 4 cases• MRI 1 caseAnalysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011
  • 25. www.CirurgiaOnline.com.brResults• Surgery• - Types of resection:• 15 Major Hepatectomies (2 1992-2002)• 13 Segmentectomies (1, 2 or 3 seg)• - Synchronic resection 5 cases (62.5%)• - Synchronic resection of extra hepaticdisease in 13 cases (46.5%) (2 1992-2002)MORE AGRESSIVE APROACHAnalysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011
  • 26. www.CirurgiaOnline.com.brRADIOFREQUENCYABLATION
  • 27. www.CirurgiaOnline.com.brResults• Radicality– R0: 18 patients (64.3%)– R1: 03 patients (10.7%)– R2: 7 patients (25%)Analysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011
  • 28. www.CirurgiaOnline.com.brResults• RadicalityAnalysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011P= 0.876MeanR0 – 63 monthsR1 + R2 – 34 months
  • 29. www.CirurgiaOnline.com.brResults• RadicalityWithout GISTAnalysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011P= 0.229MeanR0 – 63 monthsR1 + R2 – 33 months
  • 30. www.CirurgiaOnline.com.brResults• Surgery• Average Surgical time 332 min (180-840)3h to 14hAnalysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011
  • 31. www.CirurgiaOnline.com.brResults• Surgery• Hospitalisation 10 days• Morbidity 25% - 7 cases• Post op mortality (30 days): 1 case (3.6%)• Pneumonia and wound infectionAnalysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011
  • 32. www.CirurgiaOnline.com.brResults• Disease free survival 11 months (5-37)Analysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011
  • 33. www.CirurgiaOnline.com.brResults• Median Overall Survival 63 months (1 – 105)Analysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-20115y surv – 52.7%
  • 34. www.CirurgiaOnline.com.brResults• Blood Transfusion x Survival– No: 19 patients (68%) - SV 74 months– Yes: 09 patients (32%) - SV 21 months• Mean 1200 ml ( 600-1800 ml)Analysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011
  • 35. www.CirurgiaOnline.com.brAnalysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011P= 0.001
  • 36. www.CirurgiaOnline.com.brResults• Recurrence- 76.5% R0 patients recurred (50% liver)-7 patients 2nd resection-4 patients 3rd resection-2 patients 4th resectionAnalysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011
  • 37. www.CirurgiaOnline.com.brResults• Repeat ResectionAnalysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011P= 0.060RepeatResectionMedianYes 66.33No 33.23Overall 62.73
  • 38. www.CirurgiaOnline.com.brResults• Treatment• Neoadjuvant Radiotherapy 1 case• Neoadjuvant Chemo 5 cases• Adjuvant Radiotherapy 1 case• Adjuvant Chemo 15 cases• Adjuvant Radio + Chemo 3 cases• No Other treatment 8 casesAnalysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011
  • 39. www.CirurgiaOnline.com.brResults• Neo or Adjuvant treatment X Survival (R0)Analysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011P= 0.212 P= 0.668
  • 40. www.CirurgiaOnline.com.brResults• OS Neo or Adjuvant treatment X Survival (All patients)Analysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011P= 0.703
  • 41. www.CirurgiaOnline.com.brResults• OS Neo or Adjuvant treatment X Survival (GIST)Analysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011P= 0.051Adv.Treat.MedianGIST -OthersSarcomas33.23Overall 62.73
  • 42. www.CirurgiaOnline.com.brGENERALIZED PROGRESSIONMetastasisSURGERY NOTRECOMMENDED
  • 43. www.CirurgiaOnline.com.brConclusionAlthough only 8 patients are alive at themoment ( 6 GIST) and 2 are disease freeImatinib - 2003The Complete Resection and RepeatResection should improve survival andis recommended.Blood Transfusion should be AvoidedHEPATIC METASTASES OF SARCOMA
  • 44. www.CirurgiaOnline.com.brGood news Sir, We achieve a complete resection !
  • 45. www.CirurgiaOnline.com.br