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En pratique : Hépatectomie majeure ou "economique" quand les deux sont possibles? - Pr René Adam

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Journées de Chirurgie 2016
En pratique : Hépatectomie majeure ou "economique" quand les deux sont possibles?

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En pratique : Hépatectomie majeure ou "economique" quand les deux sont possibles? - Pr René Adam

  1. 1. Métastase colorectale unique ≤ 3 cm Hépatectomie droite ou Résection limitée ? Une étude LiverMetSurvey Isamu HOSOKAWA, René ADAM
  2. 2. • 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
  3. 3. 25,868 Pts , Dec. 2015
  4. 4. • 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
  5. 5. Study Population Solitary, ≤ 30 mm tumor in histology n=3890 PH group n=1478 (86%) RH group n=242 (14%) Segment 5, 6, 7, 8 n=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 population n=1720
  6. 6. 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 0.62 Primary 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 0.76 CLM 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 0.03 Periopearative 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
  7. 7. 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
  8. 8. 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 874 543 361 255 194 131 RH 242 144 98 65 53 34 21 PH 1478 967 662 472 328 245 162 RH 242 158 116 83 65 42 25
  9. 9. 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 781 571 398 291 184 RH 242 178 135 101 80 54 34
  10. 10. 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 0.71 Primary 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 1.00 CLM 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 1.00 Periopearative 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
  11. 11. 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 0.63 Recurrence 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
  12. 12. 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
  13. 13. 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
  14. 14. 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 3 RH 35 21 9 3 0 0 0 PH 172 134 86 67 44 33 21 RH 35 27 15 8 4 2 1 PH group (n=172) RH group (n=35) Time to last unresectable recurrenceRFS
  15. 15. Univariate and Multivariate Analysis of Survival in Patients with Liver-Only Recurrence Variables n 5-yr OS (%) Univariate p Multivariate p RR 95% CI Patients 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 37 Primary 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 64 CLM 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
  16. 16. 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
  17. 17. 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…
  18. 18. • 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
  19. 19. Conclusions Une hépatectomie limitée en cas de métastase unique du foie droit doit etre considérée comme la procédure standard lorsqu’elle est techniquement réalisable.

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