Met hepsarcoma pequim final

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Met hepsarcoma pequim final

  1. 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. 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. 3. www.CirurgiaOnline.com.brResections of Colorectal MetastasesWell EstablishedHepatic Metastases of Sarcomas?HEPATIC METASTASES OF SARCOMAINTRODUCTION
  4. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 15. www.CirurgiaOnline.com.brAngiomyosarcoma Leiomyosarcoma
  16. 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. 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. 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. 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. 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. 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. 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. 23. www.CirurgiaOnline.com.brResults• Tumour Grade:Analysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011P= 0.529
  24. 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. 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. 26. www.CirurgiaOnline.com.brRADIOFREQUENCYABLATION
  27. 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. 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. 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. 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. 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. 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. 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. 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. 35. www.CirurgiaOnline.com.brAnalysis of the hepatectomies forsarcoma metastases15 years experience of NCI Brazil 1996-2011P= 0.001
  36. 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. 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. 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. 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. 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. 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. 42. www.CirurgiaOnline.com.brGENERALIZED PROGRESSIONMetastasisSURGERY NOTRECOMMENDED
  43. 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. 44. www.CirurgiaOnline.com.brGood news Sir, We achieve a complete resection !
  45. 45. www.CirurgiaOnline.com.br

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