Colorectal liver metastases (Dr Juan Carlos Meneu Diaz). Oncocir. Clinica Ruber

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Liver metastases
Liver resection Hepatobiliary Unit

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Colorectal liver metastases (Dr Juan Carlos Meneu Diaz). Oncocir. Clinica Ruber

  1. 1. COLORECTAL LIVER METASTASES Surgery, cryotherapy, radiofrequency and chemotherapy An-update Juan Carlos Meneu Diaz MD PhD Chief of Section Department of General, Digestive and Abdominal Organs Transplantation University Hospital 12 de Octubre Department of Surgery And Organ Transplantation “Doce de Octubre” Hospital - Complutensis University
  2. 2. COLORECTAL LIVER METASTASES Natural history of colorectal liver metastases Cancer Research Compaign, 1999 • CRC: the second cause of cancer death in Europe • A 80% surgery (curative intent) • Between 20%-50% will relapse Local Peritoneal Distant • 33% isolated liver deposits
  3. 3. COLORECTAL LIVER METASTASES Natural history of colorectal liver metastases Midgley R. Lancet 1999 • 80% of patients will die with liver mets • 20% first relapse: liver • For advanced disease Systemic chemotherapy 5-Fluorouracil (5-FU) Merely palliative 12 months
  4. 4. COLORECTAL LIVER METASTASES Natural history of colorectal liver metastases Stangl R. Lancet 1994 No treatment of LM (median: 9 mos) • Prospective study • 1980-1990 • 484 untreated hepatic metastases 31% at 1 year 7.9% at 2 years 2.6% at 3 years 0.9% at 4 years
  5. 5. COLORECTAL LIVER METASTASES Natural history of colorectal liver metastases Cancer Research Compaign, 1999 • Untreated liver metastases: Dismal outcome • Lymphatic and blood borne spread from liver metastases Lung mets Intrabdominal lymph nodes
  6. 6. COLORECTAL LIVER METASTASES Natural history of colorectal liver metastases Penna C. British Medical Bulletin 2002 Liver resection for LM (median 36 mos) Retrospective studies comparing resection vs no treatment • Wilson (1976): 28% 5y-survival • Wanebo (1978): 25% 5y-survival
  7. 7. COLORECTAL LIVER METASTASES Chemotherapy (systemic vs intrahepatic) for colorectal liver metastases Kerr DJ, The Lancet 2003
  8. 8. Penna C. British Medical Bulletin 2002 Selection of patients for resection • Patient´s condition • Extension of the disease • Liver function Goals of pre-op assessment • Patient´s ability to tolerate surgery • Non resectable extrahepatic disease? • Anatomy of liver and metastases COLORECTAL LIVER METASTASES Assessment for liver resection
  9. 9. Penna C. British Medical Bulletin 2002 Patient´s condition • Cardiocirculatory status (clamping manouevres) • Coagulation profile (hemorrhagic surg) Liver function • 75% of liver volume (6 segments) • Caution with pre op chemotherapy • Child-Pugh, ICG • CT scan-residual liver volume (>0.5%) COLORECTAL LIVER METASTASES Assessment for liver resection
  10. 10. Penna C. British Medical Bulletin 2002 Extrahepatic disease assessment • Primary tumor Rectal examination Colonoscopy MRI Endorectal US • Other metastatic sites Thorax Rx Brain CT Bone scintigraphy COLORECTAL LIVER METASTASES Assessment for liver resection
  11. 11. Penna C. British Medical Bulletin 2002 Hepatic involvement • Preoperative US Spiral CT scan MRI • Intraoperative Laparoscopy w/o lap-US Intraoperative US (IOUS) Radioguided surgery COLORECTAL LIVER METASTASES Assessment for liver resection
  12. 12. Spiral CT scan with portal phase COLORECTAL LIVER METASTASES Liver involvement and anatomy of Liver Metastases
  13. 13. IOUS mapping of the anatomical relations COLORECTAL LIVER METASTASES Anatomy of liver metastases
  14. 14. COLORECTAL LIVER METASTASES Surgical treament: types of liver resection Anatomy of the liver
  15. 15. Anatomy of the liver COLORECTAL LIVER METASTASES Surgical treament: types of liver resection
  16. 16. COLORECTAL LIVER METASTASES Advances in liver resection Technology:Diagnosis and resection
  17. 17. COLORECTAL LIVER METASTASES Liver resection Adam R. Arch Surg 2002 • The treatment of choice of LM • Feasible in < 30% of the cases • Goals of liver resection Remove all deposits Get clearance margins (> 1 cm) Preserve healthy parenchyma
  18. 18. COLORECTAL LIVER METASTASES Liver resection Adam R. Arch Surg 2002 • Contraindications for resection: Multifocal bilateral unresectable disease Major vascular/biliary structures involvement Inadequate liver reserve Unresectable extrahepatic disease
  19. 19. COLORECTAL LIVER METASTASES Liver resection Fong Y. J Clin Oncol 1997 Pichlmayr R. World J Surg 1982. Candidates for surgery • No non-resectable extrahepatic disease • Tumor free margins (all deposits) • Avoid postoperative liver failure
  20. 20. COLORECTAL LIVER METASTASES Liver resection Fong Y. J Clin Oncol 1997 Pichlmayr R. World J Surg 1982. Candidates for liver transplantation • Has been abandoned 2y survival: 14% 5y survival: 0% FIG. 1 End-to-end technique (group I) Coronary artery (Re) Common hepatic artery (Re) Celiac axis (Do) Splenic artery (Do) Coronary artery (Do) Gastroduodenal artery (Do) Proper hepatic artery (Do) Splenic artery (Re)
  21. 21. COLORECTAL LIVER METASTASES Results of liver resection for colorectal metastases Penna C. British Medical Bulletin 2002
  22. 22. COLORECTAL LIVER METASTASES Results of liver resection for colorectal metastases Penna C. British Medical Bulletin 2002
  23. 23. COLORECTAL LIVER METASTASES Results of liver resection for colorectal metastases Penna C. British Medical Bulletin 2002
  24. 24. COLORECTAL LIVER METASTASES Results of liver resection for colorectal metastases 100 Patients (1999-2001) 39% 61% MALE FEMALE Mean age: 56,5 ± 12,8 Moreno E at al. Cir Esp 2002
  25. 25. COLORECTAL LIVER METASTASES Results of liver resection for colorectal metastases Moreno E at al. Cir Esp 2002 40% 60% SYNCHRONIC METECHRONIC Mean interval for metachronic 6 ± 2,7 months
  26. 26. COLORECTAL LIVER METASTASES Results of liver resection for colorectal metastases Moreno E at al. Cir Esp 2002 3 4 % 6 6 % UNILOBAR BILOBAR 70%30%
  27. 27. COLORECTAL LIVER METASTASES Results of liver resection for colorectal metastases Moreno E at al. Cir Esp 2002 30 41,25 7,5 2,5 15 3,75 % 30 41,25 7,5 2,5 15 3,75 Rectum Sigmoid Left colon Transve rse Right colon Multifo cal
  28. 28. COLORECTAL LIVER METASTASES Results of liver resection for colorectal metastases Moreno E at al. Cir Esp 2002 73% 27%
  29. 29. • Operative mortality • Inhospital mortality • Complications • Liver failure • Reoperations • Mean PRC transfusion • No transfusionç • Median stay 0% 3% 11% 7% 0% 702 ml (1200 SD) 65% 10.5 days COLORECTAL LIVER METASTASES Results of liver resection for colorectal metastases Moreno E at al. Cir Esp 2002
  30. 30. COLORECTAL LIVER METASTASES Results of liver resection for colorectal metastases Moreno E at al. Cir Esp 2002 Survival Function superv tras metastasectomía(meses) 100806040200 PorcentajePacientes 1,0 ,9 ,8 ,7 ,6 ,5 ,4 ,3 ,2 ,1 ,0 Survival Function Censored 5ys 47% 3ys 70% Mean survival 61 months (95%IC: 50-73
  31. 31. COLORECTAL LIVER METASTASES Results of liver resection for colorectal metastases Moreno E at al. Cir Esp 2002 superv tras reresección(meses) 100806040200 Porcentajepacientes 1,0 ,9 ,8 ,7 ,6 ,5 ,4 ,3 ,2 ,1 ,0 Survival Function Censored Mean survival after repeated resection 50 months (95%IC: 30-70) 5ys 37% 3ys 47%
  32. 32. Midgley R. Lancet 1999 • Liver resection is safe and effective • Distant metastases does not preclude curative treatment • Liver resection can ensure Long term survival Cure • A minority will benefit from resection COLORECTAL LIVER METASTASES Liver resection
  33. 33. COLORECTAL LIVER METASTASES How to increase resectability? Adam R. Annals of Surgery 2002 Preoperative chemotherapy (Two-stage hepatectomy)
  34. 34. COLORECTAL LIVER METASTASES How to increase resectability? Adam R. Annals of Surgery 2002 Acchieved in 16% of previously considered unresectable Similar 3 and 5 years survival rate to initially resectable tumors (81% and 67% vs 88% and 61%)
  35. 35. COLORECTAL LIVER METASTASES How to increase resectability? KodamaY. JVIR 2002 Preoperative portal vein embolization
  36. 36. COLORECTAL LIVER METASTASES How to increase resectability? Azoulay D. Ann Surg 2000 Resection feasible in 60% of the cases Comparable survival rate at 1 and 3 years
  37. 37. COLORECTAL LIVER METASTASES How to treat unresectable tumors? Adam R. Arch Surg 2002
  38. 38. Midgley R. Lancet 1999 Criotherapy • Low temperature (-196ºC) • Cyclic aplication • Liquid nitrogen/argon • Effects: Cellular dehydration Protein denaturalization Microcirculatory failure COLORECTAL LIVER METASTASES How to treat unresectable tumors?
  39. 39. Midgley R. Lancet 1999 Radiofrequency • High temperature (> 50ºC) • 460-500kHz • Effects: Cellular dehydration Protein denaturalization Coagulation necrosis COLORECTAL LIVER METASTASES How to treat unresectable tumors?
  40. 40. COLORECTAL LIVER METASTASES How to treat unresectable tumors? Adam R. Arch Surg 2002
  41. 41. COLORECTAL LIVER METASTASES How to treat unresectable tumors? Adam R. Arch Surg 2002
  42. 42. COLORECTAL LIVER METASTASES How to treat unresectable tumors? Adam R. Arch Surg 2002
  43. 43. COLORECTAL LIVER METASTASES How to treat unresectable tumors? Kerr DJ, The Lancet 2003
  44. 44. • Complete surgical resection Low mortality(<2%) Long term survival (>40% at 5 years) • However: feasible in 20% of the cases • Best candidates No extrahepatic disease More than 2 years of interval CEA levels < 5 ng/ml COLORECTAL LIVER METASTASES Summary and conclusions
  45. 45. • Recent progress Chemotherapy Ablative techniques • Increase resectability? • Reduces recurrence? COLORECTAL LIVER METASTASES Summary and conclusions
  46. 46. IX WOR LD CONGR E SS OF T HE IS DE Madrid, 2004 May 27th-29th Preparation s tatus for the Meeting E. Moreno-Gonzalez Professor and Chairman Department of Surgery And Organ Transplantation “Doce de Octubre” Hospital - Complutensis University Department of Surgery And Organ Transplantation “Doce de Octubre” Hospital - Complutensis University THANK YOU FOR YOUR ATTENTION

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