Gian Luca Grazi presented a 20 minute presentation on indications and timing for resection of breast cancer liver metastases. He discussed recent literature reviews on the topic, comparative studies of resection versus other therapies, and cost utility analyses. Literature reviews showed resection can provide long term survival in selected patients. Comparative studies found resection was associated with improved overall and disease-free survival compared to ablation or chemotherapy alone. Resection was shown to provide a survival benefit even in some patients with controlled bone metastases. Patient selection factors like solitary metastases, response to pre-operative chemotherapy, and hormone receptor status were discussed.
This document summarizes a presentation on liver transplantation for cancer. It discusses evolving selection criteria and waiting list priorities for liver transplantation in patients with hepatocellular carcinoma (HCC). New endpoints such as cancer-specific survival are also examined. With reductions in liver transplantation for hepatitis C due to new direct-acting antiviral drugs, non-alcoholic steatohepatitis (NASH) related disease is expected to increase and criteria may need to expand to consider more carefully selected patients with non-resectable colorectal cancer metastases.
State of the art of robotic surgery in the liverGian Luca Grazi
1) Robotic liver surgery offers some technical advantages over laparoscopic liver surgery such as improved ergonomics and dexterity due to wristed instruments and 3D visualization, but is more costly.
2) Meta-analyses have found robotic liver resection has longer operating times but less blood loss compared to open surgery, and similar short-term outcomes as laparoscopic liver resection.
3) While not conclusively proven, robotic surgery may be particularly useful for complex resections such as those in the posterosuperior segments of the liver compared to the laparoscopic approach.
Surgical treatment of hepatocellular carcinomaGian Luca Grazi
This document summarizes surgical treatment options for hepatocellular carcinoma (HCC). Liver resection is the main treatment for early stage HCC within Milan criteria of 1-3 tumors less than 5 cm each. While guidelines recommend resection only for patients without portal hypertension or bilirubin over 1 mg/dL, many centers extend criteria to some with portal hypertension if liver function is preserved. Five-year survival after resection in selected patients exceeds 50%. For unresectable HCC, options include liver transplantation, which offers the best survival but limited availability, and locoregional therapies like radiofrequency ablation or transarterial chemoembolization. Ongoing research aims to further expand criteria for resection and transplantation.
Surgical treatment of colo rectal liver metastasesGian Luca Grazi
The document discusses guidelines for resection of liver metastases from colorectal cancer. It states that the aim of liver resection is to remove all visible cancer while leaving enough healthy liver tissue. Patients with solitary, multiple, or scattered tumors may be candidates for resection if the primary colorectal cancer has been treated. The surgeon should ensure clear margins and leave a minimum of one third of the standard liver volume to minimize risk of liver failure. Overall survival rates are improved with resection compared to chemotherapy alone.
This document summarizes a presentation on liver transplantation for cancer. It discusses evolving selection criteria and waiting list priorities for liver transplantation in patients with hepatocellular carcinoma (HCC). New endpoints such as cancer-specific survival are also examined. With reductions in liver transplantation for hepatitis C due to new direct-acting antiviral drugs, non-alcoholic steatohepatitis (NASH) related disease is expected to increase and criteria may need to expand to consider more carefully selected patients with non-resectable colorectal cancer metastases.
State of the art of robotic surgery in the liverGian Luca Grazi
1) Robotic liver surgery offers some technical advantages over laparoscopic liver surgery such as improved ergonomics and dexterity due to wristed instruments and 3D visualization, but is more costly.
2) Meta-analyses have found robotic liver resection has longer operating times but less blood loss compared to open surgery, and similar short-term outcomes as laparoscopic liver resection.
3) While not conclusively proven, robotic surgery may be particularly useful for complex resections such as those in the posterosuperior segments of the liver compared to the laparoscopic approach.
Surgical treatment of hepatocellular carcinomaGian Luca Grazi
This document summarizes surgical treatment options for hepatocellular carcinoma (HCC). Liver resection is the main treatment for early stage HCC within Milan criteria of 1-3 tumors less than 5 cm each. While guidelines recommend resection only for patients without portal hypertension or bilirubin over 1 mg/dL, many centers extend criteria to some with portal hypertension if liver function is preserved. Five-year survival after resection in selected patients exceeds 50%. For unresectable HCC, options include liver transplantation, which offers the best survival but limited availability, and locoregional therapies like radiofrequency ablation or transarterial chemoembolization. Ongoing research aims to further expand criteria for resection and transplantation.
Surgical treatment of colo rectal liver metastasesGian Luca Grazi
The document discusses guidelines for resection of liver metastases from colorectal cancer. It states that the aim of liver resection is to remove all visible cancer while leaving enough healthy liver tissue. Patients with solitary, multiple, or scattered tumors may be candidates for resection if the primary colorectal cancer has been treated. The surgeon should ensure clear margins and leave a minimum of one third of the standard liver volume to minimize risk of liver failure. Overall survival rates are improved with resection compared to chemotherapy alone.
1. Management of colorectal liver metastases involves various treatment strategies depending on the extent of disease including primary-first, simultaneous resection, liver-first, and two-stage hepatectomy approaches.
2. The optimal strategy aims to achieve an R0 resection of all metastases while preserving sufficient future liver remnant volume.
3. Preoperative chemotherapy can help downstage initially unresectable disease in select patients, allowing for potentially curative surgery.
Here are the main options for the timing of resection:
- Colon first (staged approach): Resect the primary colon tumor first, followed by chemotherapy, then resect the liver metastases at a later date if the patient responds well to chemotherapy.
- Colon and liver simultaneously: Resect both the primary colon tumor and liver metastases in one surgery. This is typically only done if the tumors are resectable upfront with low risk.
This document discusses colorectal liver metastases and treatments. It summarizes that complete surgical resection of metastases offers long term survival for some patients, but is only feasible in 20% of cases. Recent advances in chemotherapy and ablative techniques have increased resectability and reduced recurrence rates. While resection remains the best option when possible, other treatments like cryotherapy and radiofrequency ablation can treat previously unresectable tumors.
Staging and Surgical Management of Pancreatiic Canceru.surgery
This document discusses staging and surgical management of pancreatic cancer. It covers staging techniques like CT, endoscopic ultrasound, laparoscopy and biomarkers. CT is good for predicting resectability but not lymph node status. Endoscopic ultrasound is useful for diagnosis and staging. Laparoscopy can detect small volume disease and changes management in 10-15% of cases. Extended resections, portal vein resection and pylorus-preserving pancreaticoduodenectomy are discussed. Reconstruction techniques after resection include pancreaticojejunostomy. Drains and stents may not provide benefits while octreotide could help for high-risk anastomoses. Outcome depends on tumour type and quality of life is improved at high-volume
Surgical technique. New tendencies in perihilar cholangiocarcinomaGian Luca Grazi
This document discusses surgical techniques for perihilar cholangiocarcinoma (pCCA). It notes that radical resection often requires an extended hemihepatectomy while preserving sufficient future liver remnant. Traditionally a safe resection leaves 25-40% of the liver. Right trisectionectomy is described to allow for a longer stump of the left hepatic duct. En bloc resection of the caudate lobe with the tumor is recommended. Laparoscopic and minimally invasive approaches present technical challenges but may provide benefits like improved visualization. Close dissection is needed and conversion to open may be needed for complex cases or complications.
This document discusses current trends in the treatment of liver tumors. It covers various types of liver tumors including primary and secondary tumors. For hepatocellular carcinoma (HCC), the main treatment options discussed are surgical resection, liver transplantation, radiofrequency ablation, transarterial chemoembolization (TACE), radiotherapy, and targeted therapy. For colorectal liver metastases, surgical resection is the main treatment discussed along with ablation, liver directed therapies like TACE, and chemotherapy. The document provides details on patient selection criteria, techniques like portal vein embolization to improve outcomes of resection, and prognostic scoring systems for colorectal liver metastases.
Current evidence for laparoscopic surgery in colorectal cancersApollo Hospitals
This article reviews the current evidence for laparoscopic surgery in treating colorectal cancers. It discusses several large randomized controlled trials that compared short-term and long-term outcomes of laparoscopic versus open surgery. The trials found no significant differences in cancer recurrence rates, survival rates, or number of lymph nodes retrieved between the two surgical methods. Meta-analyses of the trials validated that laparoscopic surgery is as safe and effective as open surgery for treating colorectal cancer. While the laparoscopic approach has benefits like less blood loss and shorter hospital stays, long-term oncologic outcomes are comparable to open surgery.
Management of patients with primary colorectal cancer andYuvaraj Karthick
This document discusses the management of patients with primary colorectal cancer that has spread to the liver (synchronous liver metastasis). It notes that approximately 15% of colorectal cancer patients have synchronous liver metastasis at diagnosis. While sequential resection of the primary tumor and liver lesions is typically used, some patients may benefit from simultaneous or liver-first resection approaches. The selection of chemotherapy regimens and use of targeted therapies like monoclonal antibodies can help convert initially unresectable disease to resectable. With aggressive treatment including chemotherapy, targeted therapies, and surgical resection, long-term survival of over 30% is possible even in patients with initially extensive liver metastasis. Close postoperative surveillance is important to detect early recurrence that may be amenable to
This document discusses the management of colorectal liver metastases. It addresses topics such as:
- The role of PET-CT scans in assessing resectability and the limited impact they have on surgical management.
- Strategies to improve resectability for patients with multiple or bilobar tumors, including portal vein embolization, portal vein ligation, and ALPPS.
- The importance of volumetric assessment of the future liver remnant using CT or MRI to ensure sufficient functional liver remains post-resection.
- Approaches for synchronous and metachronous colorectal liver metastases, including primary-first, liver-first, and simultaneous resections.
- The role
Advanced and laparoscopic liver, bile duct and pancreatic surgeryhr77
The document discusses various topics related to hepatobiliary and pancreatic (HPB) surgery including:
1. The myth of Prometheus and the liver's ability to regenerate despite insult.
2. Advances in liver surgery over the last two decades for conditions like liver tumors, failure, transplantation, and portal hypertension.
3. Surgical management of diseases affecting the liver, pancreas, and biliary tract including resection, transplantation, and treatments for tumors, cirrhosis, portal hypertension, and pancreatitis.
Regional therapy options for tumors include embolization (bland, chemo, radio) and ablation (radiofrequency, cryo). Embolization is useful for colorectal cancer, hepatocellular carcinoma, cholangiocarcinoma, and neuroendocrine metastases. Chemoembolization is palliative for primary and metastatic liver cancer. It provides a survival benefit compared to best supportive care alone in salvage patients. Radioembolization also prolongs survival compared to supportive care. Transarterial chemoembolization improves survival for unresectable cholangiocarcinoma and hepatocellular carcinoma compared to systemic therapy or supportive care alone.
Il colangiocarcinoma: Epidemiologia, Fattori di rischio e patogenesi - Gastro...Gastrolearning
Gastrolearning II modulo/7a lezione
Il colangiocarcinoma: Epidemiologia, Fattori di rischio e patogenesi
Prof. D. Alvaro - Università di Roma La Sapienza
This document discusses the use of radiotherapy to treat biliary tract cancers. It begins by describing biliary tract anatomy and types of biliary cancers like cholangiocarcinoma. It then covers diagnosis, staging, surgical and non-surgical treatment options. It emphasizes that complete surgical resection offers the best chance of long-term survival. The document also discusses the role of radiotherapy as adjuvant or palliative treatment. Newer radiation techniques like IMRT allow safer delivery of higher radiation doses to tumors while minimizing doses to surrounding healthy organs.
The document provides an overview of the Egyptian HCC Guidelines presented by Mohamed A. Ezzel Arab MD. It summarizes the guidelines on primary, secondary, and tertiary prevention of HCC. It also outlines recommendations for screening, diagnosis, staging, treatment including surgical resection, locoregional therapies, transplantation, and systemic therapies. Post-treatment monitoring guidelines are also presented. The document aims to provide evidence-based guidelines tailored to factors in Egypt based on international guidelines and expert opinion.
The document discusses the management of liver metastases from colorectal cancer. It reports on a study that found perioperative chemotherapy with FOLFOX4 improved progression-free survival in patients with resectable liver metastases, especially in those whose metastases were resected. The study established perioperative chemotherapy as the new standard of care for these patients. It also discusses challenges in treating colorectal cancer patients with only liver metastases and strategies for increasing resection rates and long-term survival, including optimizing systemic therapies and utilizing a multidisciplinary team approach.
This study analyzed data from over 1,100 patients who underwent resection for intrahepatic cholangiocarcinoma (ICC) to evaluate the impact of lymph node metastasis (LNM) on outcomes. The results showed that patients with no LNM, 1-2 LNM, or 3 or more LNM had progressively worse survival. Examining at least 6 lymph nodes provided the best prognostic information. LNM beyond lymph node station 12 was associated with worse survival than LNM limited to station 12. The study concludes that routine lymph node dissection of at least 6 nodes including stations beyond 12 should be performed and that a new nodal staging system of N0, N1, and N2 based on number of positive
Difficulty scores for laparoscopic liver resectionsGian Luca Grazi
A critical analysis of the scores proposed to define the difficulty of performing laparoscopic liver resections. Four scores are too many. The information they offer differs in content.
The document provides an overview of genomics in breast cancer and summarizes the Oncotype DX genomic assay. It discusses how the assay analyzes the expression levels of 21 genes in breast tumor tissue to provide a Recurrence Score that quantifies a patient's risk of recurrence and predicts who will benefit from chemotherapy. Clinical studies have shown the assay stratifies patients into low, intermediate, and high risk groups and identifies those unlikely to benefit from chemotherapy while high risk patients see significant reduction in recurrence with chemotherapy. The assay is recommended in clinical guidelines and widely covered by insurance.
1. Management of colorectal liver metastases involves various treatment strategies depending on the extent of disease including primary-first, simultaneous resection, liver-first, and two-stage hepatectomy approaches.
2. The optimal strategy aims to achieve an R0 resection of all metastases while preserving sufficient future liver remnant volume.
3. Preoperative chemotherapy can help downstage initially unresectable disease in select patients, allowing for potentially curative surgery.
Here are the main options for the timing of resection:
- Colon first (staged approach): Resect the primary colon tumor first, followed by chemotherapy, then resect the liver metastases at a later date if the patient responds well to chemotherapy.
- Colon and liver simultaneously: Resect both the primary colon tumor and liver metastases in one surgery. This is typically only done if the tumors are resectable upfront with low risk.
This document discusses colorectal liver metastases and treatments. It summarizes that complete surgical resection of metastases offers long term survival for some patients, but is only feasible in 20% of cases. Recent advances in chemotherapy and ablative techniques have increased resectability and reduced recurrence rates. While resection remains the best option when possible, other treatments like cryotherapy and radiofrequency ablation can treat previously unresectable tumors.
Staging and Surgical Management of Pancreatiic Canceru.surgery
This document discusses staging and surgical management of pancreatic cancer. It covers staging techniques like CT, endoscopic ultrasound, laparoscopy and biomarkers. CT is good for predicting resectability but not lymph node status. Endoscopic ultrasound is useful for diagnosis and staging. Laparoscopy can detect small volume disease and changes management in 10-15% of cases. Extended resections, portal vein resection and pylorus-preserving pancreaticoduodenectomy are discussed. Reconstruction techniques after resection include pancreaticojejunostomy. Drains and stents may not provide benefits while octreotide could help for high-risk anastomoses. Outcome depends on tumour type and quality of life is improved at high-volume
Surgical technique. New tendencies in perihilar cholangiocarcinomaGian Luca Grazi
This document discusses surgical techniques for perihilar cholangiocarcinoma (pCCA). It notes that radical resection often requires an extended hemihepatectomy while preserving sufficient future liver remnant. Traditionally a safe resection leaves 25-40% of the liver. Right trisectionectomy is described to allow for a longer stump of the left hepatic duct. En bloc resection of the caudate lobe with the tumor is recommended. Laparoscopic and minimally invasive approaches present technical challenges but may provide benefits like improved visualization. Close dissection is needed and conversion to open may be needed for complex cases or complications.
This document discusses current trends in the treatment of liver tumors. It covers various types of liver tumors including primary and secondary tumors. For hepatocellular carcinoma (HCC), the main treatment options discussed are surgical resection, liver transplantation, radiofrequency ablation, transarterial chemoembolization (TACE), radiotherapy, and targeted therapy. For colorectal liver metastases, surgical resection is the main treatment discussed along with ablation, liver directed therapies like TACE, and chemotherapy. The document provides details on patient selection criteria, techniques like portal vein embolization to improve outcomes of resection, and prognostic scoring systems for colorectal liver metastases.
Current evidence for laparoscopic surgery in colorectal cancersApollo Hospitals
This article reviews the current evidence for laparoscopic surgery in treating colorectal cancers. It discusses several large randomized controlled trials that compared short-term and long-term outcomes of laparoscopic versus open surgery. The trials found no significant differences in cancer recurrence rates, survival rates, or number of lymph nodes retrieved between the two surgical methods. Meta-analyses of the trials validated that laparoscopic surgery is as safe and effective as open surgery for treating colorectal cancer. While the laparoscopic approach has benefits like less blood loss and shorter hospital stays, long-term oncologic outcomes are comparable to open surgery.
Management of patients with primary colorectal cancer andYuvaraj Karthick
This document discusses the management of patients with primary colorectal cancer that has spread to the liver (synchronous liver metastasis). It notes that approximately 15% of colorectal cancer patients have synchronous liver metastasis at diagnosis. While sequential resection of the primary tumor and liver lesions is typically used, some patients may benefit from simultaneous or liver-first resection approaches. The selection of chemotherapy regimens and use of targeted therapies like monoclonal antibodies can help convert initially unresectable disease to resectable. With aggressive treatment including chemotherapy, targeted therapies, and surgical resection, long-term survival of over 30% is possible even in patients with initially extensive liver metastasis. Close postoperative surveillance is important to detect early recurrence that may be amenable to
This document discusses the management of colorectal liver metastases. It addresses topics such as:
- The role of PET-CT scans in assessing resectability and the limited impact they have on surgical management.
- Strategies to improve resectability for patients with multiple or bilobar tumors, including portal vein embolization, portal vein ligation, and ALPPS.
- The importance of volumetric assessment of the future liver remnant using CT or MRI to ensure sufficient functional liver remains post-resection.
- Approaches for synchronous and metachronous colorectal liver metastases, including primary-first, liver-first, and simultaneous resections.
- The role
Advanced and laparoscopic liver, bile duct and pancreatic surgeryhr77
The document discusses various topics related to hepatobiliary and pancreatic (HPB) surgery including:
1. The myth of Prometheus and the liver's ability to regenerate despite insult.
2. Advances in liver surgery over the last two decades for conditions like liver tumors, failure, transplantation, and portal hypertension.
3. Surgical management of diseases affecting the liver, pancreas, and biliary tract including resection, transplantation, and treatments for tumors, cirrhosis, portal hypertension, and pancreatitis.
Regional therapy options for tumors include embolization (bland, chemo, radio) and ablation (radiofrequency, cryo). Embolization is useful for colorectal cancer, hepatocellular carcinoma, cholangiocarcinoma, and neuroendocrine metastases. Chemoembolization is palliative for primary and metastatic liver cancer. It provides a survival benefit compared to best supportive care alone in salvage patients. Radioembolization also prolongs survival compared to supportive care. Transarterial chemoembolization improves survival for unresectable cholangiocarcinoma and hepatocellular carcinoma compared to systemic therapy or supportive care alone.
Il colangiocarcinoma: Epidemiologia, Fattori di rischio e patogenesi - Gastro...Gastrolearning
Gastrolearning II modulo/7a lezione
Il colangiocarcinoma: Epidemiologia, Fattori di rischio e patogenesi
Prof. D. Alvaro - Università di Roma La Sapienza
This document discusses the use of radiotherapy to treat biliary tract cancers. It begins by describing biliary tract anatomy and types of biliary cancers like cholangiocarcinoma. It then covers diagnosis, staging, surgical and non-surgical treatment options. It emphasizes that complete surgical resection offers the best chance of long-term survival. The document also discusses the role of radiotherapy as adjuvant or palliative treatment. Newer radiation techniques like IMRT allow safer delivery of higher radiation doses to tumors while minimizing doses to surrounding healthy organs.
The document provides an overview of the Egyptian HCC Guidelines presented by Mohamed A. Ezzel Arab MD. It summarizes the guidelines on primary, secondary, and tertiary prevention of HCC. It also outlines recommendations for screening, diagnosis, staging, treatment including surgical resection, locoregional therapies, transplantation, and systemic therapies. Post-treatment monitoring guidelines are also presented. The document aims to provide evidence-based guidelines tailored to factors in Egypt based on international guidelines and expert opinion.
The document discusses the management of liver metastases from colorectal cancer. It reports on a study that found perioperative chemotherapy with FOLFOX4 improved progression-free survival in patients with resectable liver metastases, especially in those whose metastases were resected. The study established perioperative chemotherapy as the new standard of care for these patients. It also discusses challenges in treating colorectal cancer patients with only liver metastases and strategies for increasing resection rates and long-term survival, including optimizing systemic therapies and utilizing a multidisciplinary team approach.
This study analyzed data from over 1,100 patients who underwent resection for intrahepatic cholangiocarcinoma (ICC) to evaluate the impact of lymph node metastasis (LNM) on outcomes. The results showed that patients with no LNM, 1-2 LNM, or 3 or more LNM had progressively worse survival. Examining at least 6 lymph nodes provided the best prognostic information. LNM beyond lymph node station 12 was associated with worse survival than LNM limited to station 12. The study concludes that routine lymph node dissection of at least 6 nodes including stations beyond 12 should be performed and that a new nodal staging system of N0, N1, and N2 based on number of positive
Difficulty scores for laparoscopic liver resectionsGian Luca Grazi
A critical analysis of the scores proposed to define the difficulty of performing laparoscopic liver resections. Four scores are too many. The information they offer differs in content.
The document provides an overview of genomics in breast cancer and summarizes the Oncotype DX genomic assay. It discusses how the assay analyzes the expression levels of 21 genes in breast tumor tissue to provide a Recurrence Score that quantifies a patient's risk of recurrence and predicts who will benefit from chemotherapy. Clinical studies have shown the assay stratifies patients into low, intermediate, and high risk groups and identifies those unlikely to benefit from chemotherapy while high risk patients see significant reduction in recurrence with chemotherapy. The assay is recommended in clinical guidelines and widely covered by insurance.
Management of Advances Hepatocellular CarcinomaPratap Tiwari
Hepatocellular carcinoma (HCC) is a leading cause of cancer death worldwide. For advanced HCC that cannot be treated with surgery or transplantation, the standard of care has been sorafenib. Lenvatinib and cabozantinib have also shown efficacy in advanced HCC. Immunotherapy with nivolumab has shown promise based on phase II data. Combination therapies and future targeted agents may provide additional treatment options for this difficult to treat cancer.
Clinical value of circulating tumor cells in metastatic breast cancerNikos Xenidis
1) Circulating tumor cells (CTCs) in patients with metastatic breast cancer provide important clinical information and can help guide treatment decisions. The number of CTCs before and during therapy correlates with progression-free and overall survival.
2) Molecular characterization of CTCs can reveal discordance between primary tumors and metastases, as well as heterogeneity within metastatic sites, helping to identify appropriate targeted therapies. Serial CTC analysis during treatment can detect emerging resistance mutations.
3) Monitoring changes in CTC counts during therapy provides an early indicator of treatment effectiveness compared to imaging, and may help determine when to switch treatments for better outcomes.
Scans and Ovarian Cancer: Everything You Want to Knowbkling
When you’re diagnosed with ovarian cancer, scans become an inevitable part of life. But what are the differences between the imaging tests? When should which scans be used? What about the pros and cons of each test? Join Dr. Kevin Holcomb, Vice-Chair of Gynecology and member of the Division of Gynecologic Oncology at Weill Cornell Medicine, and Dr. Elisabeth O’Dwyer, Instructor in Radiology at Weill Cornell Medicine and Assistant Attending Radiologist at NewYork-Presbyterian Hospital-Weill Cornell Campus, as they help make sense of it all.
MANAGEMENTOF METASTATIC OR ADVANCED GASTRIC CANCER : FIRST LINE OPTIONSMohamed Abdulla
1. The document discusses considerations for first-line therapy for gastric cancer, including various chemotherapy regimens and the role of targeted therapies like trastuzumab.
2. A network meta-analysis found that chemotherapy combinations including a fluoropyrimidine, platinum, and taxane or irinotecan provided the best outcomes for gastric cancer.
3. The TOGA trial established trastuzumab combined with chemotherapy as a standard first-line treatment for HER2-positive gastric cancer, improving overall survival.
RESEARCH & TREATMENT NEWS: Highlights from the 2014 GI Cancer SymposiumFight Colorectal Cancer
Each January, the brightest minds in colorectal cancer research meet at the Gastrointestinal Cancer Symposium.
Fight Colorectal Cancer and The Colon Cancer Alliance are partnering to bring you the big news in colorectal cancer from the symposium. Dr. Allyson Ocean will be presenting.
Get insights about new types of treatments on the horizon, diagnostic tests available, research for upcoming drugs/biomarkers and the way colorectal cancer is treated. We’ll take a look back and a look forward. You’re not going to want to miss it.
This document summarizes highlights from the Ohio Colorectal Cancer Prevention Initiative. The initiative screened over 3,300 colorectal cancer patients and found that 15.9% had defective DNA mismatch repair (dMMR). Further testing identified 4% as having Lynch syndrome (LS) and 2% as having double somatic mutations. Similar results were found in screening over 300 endometrial cancer patients. Cascade genetic testing of relatives identified over 180 additional individuals with LS. The initiative demonstrated the value of universal tumor screening in identifying hereditary cancer cases and facilitating prevention through genetic testing of relatives.
This document summarizes treatment options for ovarian cancer after diagnosis. It discusses that most cases are advanced at presentation and surgery is used to stage and debulk the cancer. Chemotherapy with a taxane and platinum agent is recommended for early and advanced stage disease. For advanced cancer, intraperitoneal chemotherapy may provide a survival benefit compared to intravenous treatment alone. Recurrent cancer can be treated with additional chemotherapy or surgery depending on factors like time since last treatment and extent of recurrence. Future research aims to improve treatment tolerability and identify new targeted therapies.
This document discusses the management of intermediate and high risk prostate cancer. It begins by providing background on prostate cancer epidemiology and risk stratification. It then covers various treatment options including observation, active surveillance, radical prostatectomy, radiotherapy, and androgen deprivation therapy. Several studies comparing the efficacy of radiotherapy alone versus radiotherapy with short or long-term ADT are summarized. For intermediate risk prostate cancer, the document recommends 4-6 months of ADT with radiotherapy based on trial results. For high risk prostate cancer, 2-3 years of ADT with radiotherapy is recommended.
Colon cancer is the second and third most common cancer in males and females. Screening programs have led to a reduction in late-stage diagnoses and mortality. Precise identification of prognostic patient groups allows for more targeted adjuvant therapy, improving disease-free and overall survival. Molecular markers of tumor aggressiveness aid in selecting optimal treatment approaches, increasing response rates, progression-free, and overall survival. A multidisciplinary team approach is essential for managing metastatic colon cancer with the goal of surgical cure in organ-limited disease.
1) Cancer screening aims to detect asymptomatic potentially curable disease earlier through screening tests to improve outcomes and reduce cancer mortality and morbidity in the screened population.
2) Randomized clinical trials have shown that screening for breast and colorectal cancers can reduce cancer mortality when screening finds cancer at an earlier stage.
3) Screening tests have limitations including false positives, overdiagnosis, costs, and psychological impacts of screening that must be considered.
This document summarizes screening guidelines for various gynecologic cancers including cervical, ovarian, endometrial, and vaginal/vulvar cancers at Shaukat Khanum Memorial Cancer Hospital and Research Centre. For cervical cancer, recommended screening includes Pap smear, liquid-based cytology, HPV testing, visual inspection with acetic acid, and colposcopy. HPV testing has higher sensitivity than Pap smear and different uses as a primary screening test, test of cure, or triage test. Guidelines for screening frequency are provided for different contexts. Biomarkers and imaging are discussed for ovarian cancer screening but no definitive screening test is recommended due to limitations.
This document discusses screening guidelines for various gynecologic cancers including cervical, ovarian, and endometrial cancers. For cervical cancer, recommended screening includes HPV testing, Pap smears, and visual inspection with acetic acid. No screening tests are recommended for ovarian cancer due to lack of specificity and no reduction in mortality seen in trials. Genetic testing is recommended for high risk patients. Endometrial cancer screening is also not recommended for average risk patients due to lack of cost effectiveness and evidence.
Original StudyType of Breast Cancer Diagnosis, Screening,a.docxvannagoforth
Original Study
Type of Breast Cancer Diagnosis, Screening,
and Survival
Carla Cedolini,1 Serena Bertozzi,1 Ambrogio P. Londero,2 Sergio Bernardi,3,4
Luca Seriau,1 Serena Concina,1 Federico Cattin,1 Andrea Risaliti1
Abstract
Organized, invitational breast cancer screening in our population succeeded in detecting early-stage tumors,
which have been consequently treated more frequently with breast and axillary conservative surgery, com-
plementary breast irradiation, and eventual hormonal therapy. The diagnosis of invasive cancer with screening
in our population resulted in a survival gain at 5 years from the diagnosis.
Introduction: Breast cancer screening is known to reduce mortality. In the present study, we analyzed the prevalence
of breast cancers detected through screening, before and after introduction of an organized screening, and we
evaluated the overall survival of these patients in comparison with women with an extrascreening imaging-detected
breast cancer or those with palpable breast cancers. Materials and Methods: We collected data about all women
who underwent a breast operation for cancer in our department between 2001 and 2008, focusing on type of tumor
diagnosis, tumor characteristics, therapies administered, and patient outcome in terms of overall survival, and re-
currences. Data was analyzed by R (version 2.15.2), and P < .05 was considered significant. Results: Among the 2070
cases of invasive breast cancer we considered, 157 were detected by regional mammographic screening (group A),
843 by extrascreening breast imaging (group B: 507 by mammography and 336 by ultrasound), and 1070 by extra-
screening breast objective examination (group C). The 5-year overall survival in groups A, B, and C were, respectively,
99% (95% CI, 98%-100%), 98% (95% CI, 97%-99%), and 91% (95% CI, 90%-93%), with a significant difference
between the first 2 groups and the third (P < .05) and a trend between groups A and B (P ¼ .081). Conclusion: The
diagnosis of invasive breast cancer with screening in our population resulted in a survival gain at 5 years from the
diagnosis, but a longer follow-up is necessary to confirm this data.
Clinical Breast Cancer, Vol. 14, No. 4, 235-40 ª 2014 Elsevier Inc. All rights reserved.
Keywords: Breast cancer, Breast cancer screening, Invasive breast cancer, Mammographic screening, Overall survival
Introduction
Because of the detection of early-stage tumors, breast cancer
screening reduced breast cancer mortality in Europe by 25%-31%
in patients who were invited for screening and by 38%-48% in
those who were actually screened during the last decade of the
twentieth century and the first decade of the twenty-first.1 In our
region of Italy, an organized breast cancer screening was firstly intro-
duced in 2005, but despite the high compliance of invited women
1Clinic of Surgery
2Clinic of Obstetrics and Gynecology
University of Udine, Udine, Italy
3Department of Surgery, Ospedale Civile di Latisana, Udine, Italy
4 ...
Indocyanine green (ICG) in liver surgery.pptxGian Luca Grazi
The use of indocyanine green has now become common practice during liver and biliary tract surgery. This dye helps in defining the anatomy of the liver segments and is able to provide data on the course of the biliary tract. Furthermore, it can detect the presence of small superficial tumors, increasing the cure potential of liver resections in the treatment of liver tumors.
This reading reviews the main uses of indocyanine green in liver surgery, in particular for laparoscopic and robotic surgery, and opens a window on the future clinical developments of indocyanine green in the treatment of liver tumors.
Parenchyma-sparing surgery in the resective treatment of liver metastases, particularly for those originating from colon and rectal tumors, is an approach that has gained great appreciation in recent years. Parenchyma sparing must not be understood only as the sole execution of operations limited to the removal of metastases, but as a real operating strategy aimed at more conservative interventions, which preserve the vascular and iliar structure of the liver itself. For example, the resection of two contiguous segments, despite being an anatomical surgery, can and must still be considered as a liver parenchyma-sparing surgery compared to a major hepatectomy. This presentation retraces the history of liver resections performed for liver metastases and revisits the evolution of surgery that has led to parenchyma-sparing liver surgery being defined as the golden standard.
Liver resections after iatrogenic vasculobiliary lesions or for post traumati...Gian Luca Grazi
Liver trauma is still a condition burdened by significant mortality and high morbidity. Although today the treatment of patients who have suffered liver trauma is essentially conservative, there is still a certain number of patients who require liver resection surgery. The indication in these cases may be due either to the presence of a major lesion of the vascular or biliary pedicles, or to the onset of major phenomena of necrosis of the liver parenchyma (MHN). In this presentation the main aspects of the surgical treatment of these patients are taken into consideration and the indications for performing a hepatectomy are critically revisited.
Cholangiocarcinoma Risk stratification - Prognostic factors related to the pa...Gian Luca Grazi
The prognosis of patients with cholangiocarcinoma generally remains very low. However, patients who manage to have an indication to perform liver resection surgery can hope for a certain increase in survival. In this context, one of the most important problems is the definition of prognostic factors for survival after hepatectomy, in order to avoid useless if not harmful interventions. This presentation revisits the main prognosis systems published in the scientific literature regarding cholangiocarcinoma and performs a critical evaluation of them.
Pancreatic surgery has now established as the only potentially curative therapy for pancreatic adenocarcinoma. However, 3-year survival after radical oncological surgery remains limited to 30-40% and between 20 and 30% after 5 years. To date, there are no aids that have substantially improved these results. This presentation addresses the most debated topics on the subject. The first is related to the pre-operative management of patients. There are now definite scientific evidences that show how the placement of biliary drainages inevitably lead to an increase in post-operative infectious complications. For this reason, if possible, it is now preferable to perform pancreatic resections even in the presence of jaundice. The second argument concerns the role of neo-adjuvant therapy. There is growing data indicating an improvement in results in patients who have performed this therapy, even if the number of patients who do not then undergo surgery remains substantial. Finally, the presentation talks about the centralization of pancreatic surgery, with a marked improvement in the results for patients who are operated on in high-volume centres.
Minimally invasive liver surgery now allows almost all liver resection operations to be performed safely. The advent of robotic surgery has allowed further development of these surgeries. In this field, any artifice that can further benefit the surgeon in performing these particular hepatic resections is certainly desired. Indocyanine green has shown to be extremely useful in verifying the anatomy of the liver and biliary tract, in the discovery of small tumor nodules located in the more peripheral areas of the liver and in the intraoperative definition of liver segmentation.
Liver failure after major hepatic resection.pptxGian Luca Grazi
Liver failure after hepatic resection has a multifactorial origin. However, the volume of the removed liver, technical problems during the procedure and the development of infections in the post-operative period certainly play a primary role.
The surgeon plays an important role in implementing all those surgical and radiological procedures to prevent the onset of this severe complication.
However, the treatment of liver failure that occurs after a hepatectomy requires multidisciplinary management, including intensive care physicians, neurologists, nephrologists, and others.
In order not to incur in the failure to recognize the complication and to avoid not implementing all the therapeutic measures necessary for the treatment of post-resection liver failure, it is essential that the hospital where the operation is performed is equipped with all professionalism and all the necessary technological tools.
These are the characteristics needed to define where liver surgery can be performed safely.
Hepatobiliary surgery - role in liver diseases.pptxGian Luca Grazi
Over the past 40 years, liver surgery has become an independent branch of general surgery and abdominal surgery. Liver resections are now well-coded procedures that require sophisticated planning. There are many diseases that can be treated with surgery in the context of liver diseases. This presentation reviews the indications for surgery in the field of primary liver tumors (mainly hepatocellular carcinoma), in the field of benign hepatic tumors, in the field of acute and chronic biliary diseases.
Performing vascular resections during a liver resection is a complex procedure, that is often carried out for advanced tumor diseases. Certainly, the removal of a tumor recurrence or a residual disease that has infiltrated one of the liver vessels (hepatic artery, portal vein, hepatic vein or inferior vena cava) can allow the patient to enjoy a further period of well-being, independently to the possibility of being able to perform adjuvant chemotherapy. However, in most cases, performing a vascular resection involves an increased risk of mortality and morbidity. Furthermore, the results in terms of long-term survival are often discouraging.
Minimally invasive liver surgery has recently acquired the surgical robot among the available weapons. In particular, the “Da Vinci” Robot currently represents the operative standard. Liver resections are now increasingly performed robotically. The increased experience has made these robotic procedures ever simpler and safer to perform. In this presentation, we review the basic steps for dealing with a robotic liver resection. The tools available to perform a robotic hepatectomy also occur. However, at the present time, the robotic surgical instruments completely studied and realized for their application on the liver are very few.
Treatment of metachronous liver metastases from colorectal cancer sees surgery as the primary therapy. However, in recent years, several factors have emerged that have led to considering liver resection as an increasingly personalized practice. Liver resections are now placed within the "precision surgery". Even if in the presence of different guidelines published in the scientific literature, very often the attitude of the various hepatobiliary surgery centers, and even of the individual surgeons, is not homogeneous and different (sometimes very different) are the attitudes that direct towards the 'one or the other surgery.
Conversion from laparoscopy to open technique during laparoscopic liver resections. Which are the causes and how it might be possible to avoid them. Presented at the Palermo meeting of the Italian register "I Go Mils" on liver resections carried out by a mini-invasive approach (both laparoscopic and robotic)
Minimally invasive pancreatic surgery has led to the identification of new technical challenges.
An important aspect is to verify the possibility of performing vascular resections during pancreatic resection procedures for cancer.
Chemotherapy for liver metastases from colorectal cancer now makes it possible to reduce their size. Sometimes these metastases can even disappear. This does not mean that the metastases are cured and surgical removal is always advisable. The main problem is how to identify these "vanishing" metastases during liver resection and how to perform truly effective interventions from an oncological point of view.
The document discusses surgical treatment options for cholangiocarcinoma. It describes several prognostic nomograms that can help estimate patient prognosis and determine if adjuvant therapy is needed after liver resection. The nomogram by Wang et al. was found to have the best accuracy but requires additional preoperative variables. High volume surgical centers that perform over 40 resections have better outcomes than low volume centers. Surgical resection remains a challenge due to the risk of complications, especially when combined with arterial resection or for perihilar lesions.
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
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Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
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How STIs Influence the Development of Pelvic Inflammatory Disease.pptx
Grazi breast cancer final
1. Gian Luca Grazi
Hepato-Biliary-Pancreatic Surgery
National Cancer Institute Regina Elena
Rome
Breast Cancer Liver Metastases:
Indications and Timing for Resection
20 minute presentation followed by 10 minutes for questions and answers
1
2. Breast Cancer Liver Mets: Indications & Timing for Resection
Introduction
Literature reviews
Comparative studies
Cost utility analysis
AGENDA
2
3. Breast Cancer Liver Mets: Indications & Timing for Resection
• In 2012, the estimated age-adjusted annual incidence of breast
cancer in 40 European countries was 94.2/100,000 and the
mortality 23.1/100,000.
• The incidence increased after the introduction of mammography
screening, and continues to grow with the ageing of the
population.
INTRODUCTION (1)
Primary breast cancer: ESMO Clinical Practice, Ann Oncol 2015; 26 (Supp 5): v8–v303
4. Breast Cancer Liver Mets: Indications & Timing for Resection
• The estimated 5-year prevalence of breast cancer in Europe in
2012 was 1,814,572 cases.
• Prevalence is increasing, as a consequence of increased
incidence and due to improvements in treatment outcomes.
• In most Western countries, the mortality rate has decreased in
recent years, especially in younger age groups, because of
improved treatment and earlier detection.
• However, breast cancer is still the leading cause of cancer-
related deaths in European women.
INTRODUCTION (2)
Primary breast cancer: ESMO Clinical Practice, Ann Oncol 2015; 26 (Supp 5): v8–v304
5. Breast Cancer Liver Mets: Indications & Timing for Resection
• The leading cause of these deaths was metastatic spread.
• The timing and distribution of breast-cancer metastases
vary considerably.
• In approximately 5% of women with breast cancer,
metastases are clinically evident at the time of diagnosis.
• In other women, metastases become apparent years or
even decades after the initial diagnosis.
• Moreover, the number of metastases varies considerably.
INTRODUCTION (3)
Schwartz RS, New Engl J Med 2017, 376(25): 2486-24885
6. Breast Cancer Liver Mets: Indications & Timing for Resection
• Regular history, physical examination, and mammography are
recommended
• Examinations should be performed every 3 to 6 months for the first
3 years, every 6 to 12 months for years 4 and 5, and annually
thereafter
• Use of CBCs, chemistry panels, bone scans, chest radiography, liver
ultrasounds, CT scans, [18F] fluorodeoxyglucose-PET scanning, MRI,
or tumor markers (CEA, CA 15-3, and CA 27.29) is not
recommended for routine breast cancer follow-up in an otherwise
asymptomatic patient with no specific findings on clinical
examination
Khatcheressian JL, J Clin Oncol 2012, 31: 961-9656
7. Breast Cancer Liver Mets: Indications & Timing for Resection
Skeletal system Other sites
Median survival 48 months 17 months p<0.01
First hormonal therapy effective 87% (56/64)
(median 10 months)
Initial CHT effective 93% (43/46)
(median 11 months)
Metastatic breast cancer confined to the skeletal system.
An indolent disease.
Sherry MM, Am J Med 1986, 81(3): 381-3867
8. Breast Cancer Liver Mets: Indications & Timing for Resection
• Approximately 30% of patients with breast cancer will develop
distant metastases at some point during their disease course.
• While liver is the third most frequent site of metastatic spread
(after lymph nodes and lung), only 5–25% of patients will have
isolated breast cancer liver metastases (BCLM) and will, in turn,
be eligible for liver directed surgery.
INTRODUCTION (4)
Margonis GA, HPB 2016, 18: 700–7058
9. Breast Cancer Liver Mets: Indications & Timing for Resection
Mariani P, EJSO 2013, 39: 1377–1383
LIVER METS FROM
BREAST CANCER
LIVER METS FROM
COLON CANCER
Effective chemotherapy Established long Established recently
Role of liver surgery Even if disease readily
resectable, always
treated by first-line CHT
Only effective first-line
treatment
Surgical treatment Excessively invasive
9
10. Breast Cancer Liver Mets: Indications & Timing for Resection
Margonis G et al
(HPB 2016, 18: 700-705)
8 International Centers
5 United States
2 Italy
1 Portugal
over 24 years
In the same period in the United
States:
approximately 5.5 million new cases
(230,000 x 24 years)
Approximately 10% of the
patients with metastatic
disease limited to the liver
96,000 cases of BCLM
119 cases of liver
resections for BCLM
D’Angelica M, HPB 2016, 18: 631–63210
11. Breast Cancer Liver Mets: Indications & Timing for Resection
Annual number of hepatic resections for patients
with noncolorectal nonendocrine liver metastases
at 41 centers from 1983 to 2004.
11
12. Breast Cancer Liver Mets: Indications & Timing for Resection
Groeschl RT, J Am Coll Surg 2012, 214: 769–77712
13. Breast Cancer Liver Mets: Indications & Timing for Resection
Variable Points
Extrahepatic metastases present prior
to or at the time of hepatectomy
Yes 1
No 0
Major Hepatectomy
(>2 segments)
Yes 1
No 0
R2 resection
Yes 1
No 0
Patient age Less than 30 years 0
30–60 years 1
Greater than 60 years 2
Patient with a disease-free interval Greater than 24 months 0
12–24 months 1
Less than 12 months 2
Primary cancer Breast primary tumor 0
Squamous primary tumor histology 2
Choroids melanoma primary tumor 3
All other primary tumor sites and histologies 1
Adam R, Ann Surg 2006, 244: 524–53513
14. Breast Cancer Liver Mets: Indications & Timing for Resection
Analysis of survivals based on a risk model for patients
with noncolorectal nonendocrine liver metastases.
Adam R, Ann Surg 2006, 244: 524–53514
15. Breast Cancer Liver Mets: Indications & Timing for Resection
The principal question relative to liver resections
for LMBC remains proof of their usefulness
Elias D, Lasser P, Spielmann M, May-Levin F, el Malt O, Thomas H, Mouriesse H.
Surgical and chemotherapeutic treatment of hepatic metastases from carcinoma
of the breast.
Surg Gynecol Obstet. 1991 Jun;172(6):461-4.
Institut Gustave-Roussy, Villejuif, France.
15
16. Breast Cancer Liver Mets: Indications & Timing for Resection
Introduction
Literature reviews
Comparative studies
Cost utility analysis
16
17. Author Year Journal # of studies Therapy Minimun # pts
Elias 2006 HPB 9 Resection > 10
Howlader 2011 Int J Surg 11 Resection ≥ 9
Chua 2011 Eur J Cancer 19 Resection > 10
Vogl 2013 Eur Radiol 8 Thermal ablation
Vertriest 2015 Dig Surg 17 Resection
Fairhurst 2016 The Breast 33 Resection > 5
Golse 2017 Clin Breast Cancer 18 Resection Principal series
published
since 2000
Yoo 2017 The Breast 43 Resection
Ercolani 2017 Dig Surg 10 Resection > 40
Tasleem 2018 Irish J Med Sci 25 Resection
Breast Cancer Liver Mets: Indications & Timing for Resection
Recent reviews appeared in the literature
17
18. Breast Cancer Liver Mets: Indications & Timing for Resection
Golse N, Clin Breast Cancer 2017, 17(4): 256–26518
19. Breast Cancer Liver Mets: Indications & Timing for Resection
Golse N, Clin Breast Cancer 2017, 17(4): 256–26519
20. Breast Cancer Liver Mets: Indications & Timing for Resection
Golse N, Clin Breast Cancer 2017, 17(4): 256–26520
22. Breast Cancer Liver Mets: Indications & Timing for Resection
Yoo TG, The Breast 2017, 32: 162–17222
23. Breast Cancer Liver Mets: Indications & Timing for Resection
Yoo TG, The Breast 2017, 32: 162–172
Some patients characteristics
Median time between breast surgery and diagnosis BCLM 35 months 11-71 months
Synchronous 13% 123/412 pts
Solitary 55% 503/913 pts
Unilobar 64% 263/412 pts
CHT prior to LR 74% 523/705 pts
CHT after LR 66% 486/733 pts
30 day mortality 0.7% 6/918
Median 3- and 5-year survival 56% - 37%
Recurrence 62% 325/523 pts
Liver 61% 197/325 pts
Skeletal 11% 36/325 pts
Lungs 7% 24/325 pts
Brain 5% 17/325 pts
Pleura 2% 6/325 pts
23
24. Breast Cancer Liver Mets: Indications & Timing for Resection
Yoo TG, The Breast 2017, 32: 162–172
Quality of the reported and included 43 studies 1686 pts
Systematic criteria to select patients 21 studies
More than 50 patients 6 studies
Extrahepatic as an exclusion criteria 7 studies 150 pts
Potentially curative 8 studies 207 pts
Extent of BCLM 7 studies
Response to pre-hepatectomy CHT 2 studies 154 pts
In combining the articles with small sample sizes, there is a
significant heterogeneity between the
• selection criteria,
• disease stage and
• treatment characteristics.
24
25. Breast Cancer Liver Mets: Indications & Timing for Resection
Yoo TG, The Breast 2017, 32: 162–172
Reported analysis included 43 studies 1686 pts
Analysis done 22 studies 826 pts
Age irrelevant 12/15 123/412 pts
Better for pts aged ↑ 50 years 2/15 503/913 pts
Better for pts aged ↓ 50 years 1/15 263/412 pts
Primary tumor histology grade irrelevant 3
Grade irrelevant 12
Lymph node status irrelevant 7
Type of breast surgery irrelevant 2
Positive hormone receptor status at primary BC 6 341 pts
Absent hormone receptor status at primary BC 1 486/733 pts
Hormone receptor status at primary BC irrelevant 8 325/523 pts
Extrahepatic metastases worse 5 205 pts
Extrahepatic metastases irrelevant 5 154 pts
25
26. Breast Cancer Liver Mets: Indications & Timing for Resection
Yoo TG, The Breast 2017, 32: 162–172
Positive factors Irrelevant
Prolonged interval between breast
cancer treatment and diagnosis of BCLM
Timing
(synchronous/methachronous)
Solitary
Unilobar
Small tumor size
Extent of resection
Hormonal status
Grade of the tumor
26
27. Breast Cancer Liver Mets: Indications & Timing for Resection
Period: 1/1985 – 12/2012
139 consecutive female
162 hepatectomies
27
28. Breast Cancer Liver Mets: Indications & Timing for Resection
Ruiz A, Ann Surg Oncol 2017, 24: 535–545
Negative predictors of survival Positive predictors of survival
> 1 liver metastasis Negative resection margin
Max tumor size ≥ 20 mm at diagnosis Administration of hormonal therapy
before and after hepatectomy
Negative receptor status for estrogen,
progesterone, and HER2/Neu receptor
(triple negative)
Targeted therapy after hepatectomy
Microscopic vascular invasion Performance of repeated hepatectomy
28
29. Breast Cancer Liver Mets: Indications & Timing for Resection
Ruiz A, Ann Surg Oncol 2017, 24: 535–54529
30. Breast Cancer Liver Mets: Indications & Timing for Resection
Ruiz A, Ann Surg Oncol 2017, 24: 535–545
Calibration plot for the probability of survival at 3 and 5
years, demonstrating good calibration between the
prediction by the normogram and the actual observation.
30
31. Breast Cancer Liver Mets: Indications & Timing for Resection
Ruiz A, Ann Surg Oncol 2017, 24: 535–545
Hepatectomy should be considered for all patients with
BCLM responding to systemic treatment when
technically feasible.
Liver resection provides a chance of long-term survival
for selected patients with an acceptable risk of
morbidity and mortality.
Accurate selection of patients for hepatectomy remains
crucial.
A nomogram can help to identify patients who may
benefit most from hepatic resection and can help
clinicians and patients to make a more informed decision
when advocating for resection.
31
32. Breast Cancer Liver Mets: Indications & Timing for Resection
Introduction
Literature reviews
Comparative studies
Cost utility analysis
32
34. Breast Cancer Liver Mets: Indications & Timing for Resection
Mariani P, EJSO 2013, 39: 1377–138334
35. Breast Cancer Liver Mets: Indications & Timing for Resection
Mariani P, EJSO 2013, 39: 1377–138335
36. Breast Cancer Liver Mets: Indications & Timing for Resection
Mariani P, EJSO 2013, 39: 1377–1383
Patients were candidates for surgical resection if they had
• resectable liver metastases (≤4 metastases),
• had stable disease or disease responding to
chemotherapy and/or hormone therapy, and
• achieved a performance status of 0-1.
The only extra-hepatic site metastases allowed were bone
metastases if they were not growing during treatment.
36
37. Breast Cancer Liver Mets: Indications & Timing for Resection
Mariani P, EJSO 2013, 39: 1377–138337
38. Breast Cancer Liver Mets: Indications & Timing for Resection
Mariani P, EJSO 2013, 39: 1377–138338
39. Breast Cancer Liver Mets: Indications & Timing for Resection
Mariani P, EJSO 2013, 39: 1377–1383
• In select patients, the resection of liver metastases from
primary breast cancer is associated with a genuine survival
benefit.
• An aggressive and multidisciplinary approach, including
surgery of metastases, should be considered even if
patients had bone metastases controlled by medical
treatment.
39
40. Breast Cancer Liver Mets: Indications & Timing for Resection
Period May 2004 – May 2011
26 patients with BCLM
Cancer confined to one
lobe regardless of the
number of lesion
12
Liver resections
Bilobar distribution and
no lesions greater than 6
cm in maximum diameter
14
RFA
38 patients with BCLM
treated with CHT during the
same time period
(no brain metastases or visceral
metastatic spread)
40
41. Breast Cancer Liver Mets: Indications & Timing for Resection
Treated Liver
resections
RFA Control group
Overall survival from
the BC diagnosis
47.69 ± 22.25
(median 45.5)
52.25 ± 14.57
(median 48.5)
43.79 ± 27.14
(median 39)
Overall survival from
BCLM treatment
21.12 ± 12.78
(median 15.5)
29.42 ± 14.53
(median 29.5)
14 ± 4.45
(median 13.5)
(median 9.7)
Overall disease-free
survival from BCLM
15.96 ± 13.15
(median 12)
23.22 ± 16.2
(median 18.5)
9.64 ± 4.22
(median 9)
Overall 1-, 2- and 5-
year actuarial survival
80.7, 57, 31% 100, 66.6, 34% 64.2, 21.4,
11.5%
5.2, 0, 0
Polistina F, World J Surg 2013; 37: 1322–1332
Overall survivals and median survivals are expressed in months
41
42. Breast Cancer Liver Mets: Indications & Timing for Resection
• A retrospective review of consecutive patients with isolated BCLM (167/2150 patients,
7,7%) from January 1991 to January 2014 treated at Memorial Sloan Kettering Cancer
Center (MSKCC)
• Surgical cases were discussed on a case-by-case basis at a multidisciplinary meeting
where consensus concerning resectability and appropriateness of liver resection were
determined.
• Patients with isolated BCLM treated with liver resection and/or ablation (surgical cohort:
69 patients, 41%) and those receiving medical therapy alone (medical cohort: 98
patients, 59%) were analyzed and compared.
• A propensity score analysis was used to control for selection bias, which resulted in
uneven distribution of covariates among the surgical and medical cohorts.
42
43. Breast Cancer Liver Mets: Indications & Timing for Resection
Sadot E, Ann Surg 2016, 264: 147–15443
44. Breast Cancer Liver Mets: Indications & Timing for Resection
Sadot E, Ann Surg 2016, 264: 147–154
Overall survival of the low
propensity score subgroup
stratified by surgical intervention
Overall survival of the intermediate
propensity score subgroup stratified
by surgical intervention
Overall survival of the high
propensity score subgroup
stratified by surgical intervention
44
45. Breast Cancer Liver Mets: Indications & Timing for Resection
Sadot E, Ann Surg 2016, 264: 147–154
Surgical therapy for BCLM is safe and, in a subset of carefully
selected cases, may provide a substantial period of time free of
recurrent disease during which systemic chemotherapy might
be avoided.
This does not appear to compromise OS.
At the same time, there are no associated OS benefits in these
selected patients when compared to patients receiving standard
medical care.
Surgical intervention should only be considered in highly
selected patients with the goal of providing time off systemic
therapy, and this may be most appropriate for patients requiring
cytotoxic chemotherapy.
45
46. Breast Cancer Liver Mets: Indications & Timing for Resection
Abbas H, Int J Surg 2017, 44: 152–15946
47. Breast Cancer Liver Mets: Indications & Timing for Resection
Abbas H, Int J Surg 2017, 44: 152–15947
48. Breast Cancer Liver Mets: Indications & Timing for Resection
Abbas H, Int J Surg 2017, 44: 152–15948
49. Breast Cancer Liver Mets: Indications & Timing for Resection
Abbas H, Int J Surg 2017, 44: 152–15949
50. Mariani Polistina Sadot Abbas
Year 2013 2013 2016 2017
Nature of the
study
Retrospective Retrospective Retrospective Retrospective
(report of UK tertiary center
tumor board meeting)
Medical cohort Medical therapy
alone
Medical therapy
alone
Medical therapy
alone
Medical therapy
alone
Inclusion
criteria for
medical cohort
≤ 4 liver mets
With/without bone
mets
No other mets
Not reported Not reported Not reported
Surgical cohort Resection only Resection or
ablation
Resection and/or
ablation
Resection and/or
ablation
Inclusion
criteria for
surgical cohort
≤ 4 liver mets
Stable disease at CT
With/without
stable bone mets
PS 0-1
Stable liver disease
Karnofsky > 80
No general
contraindication
No underlying CLD
Non reported Resectable
Statistics Case control study Analysis of survival Propensity score
analysis
Analysis of survival
(Mariani and Polistina’s
studies not cited)
(Mariani and Polistina’s
studies not cited)
Breast Cancer Liver Mets: Indications & Timing for Resection
50
51. Breast Cancer Liver Mets: Indications & Timing for Resection
Introduction
Literature reviews
Comparative studies
Cost utility analysis
51
53. Breast Cancer Liver Mets: Indications & Timing for Resection
Spolverato G, Ann Surg 2017, 265: 792–799
Scenario 1 Strategy A Liver Resection Postoperative
conventional systemic
therapy
Letrozole for hormone estrogen
receptor-positive [ER+] patients;
Docetaxel + trastuzumab for human
epidermal growth factor receptor 2
[HER2+] positive patients
Strategy B Conventional systemic
therapy
Scenario 2 Strategy A Liver Resection Postoperative
conventional systemic
therapy
Strategy C Newer systemic
therapy alone
Letrozole + palbociclib for ER+
patients;
Docetaxel + trastuzumab +
pertuzumab for HER2+ patients
53
54. Breast Cancer Liver Mets: Indications & Timing for Resection
Spolverato G, Ann Surg 2017, 265: 792–799
Patients with ER+: unadjusted
survival curves of strategy A vs.
strategy B or C in patients with
BCLM.
Patients with HER2+: unadjusted
survival curves of strategy A vs.
strategy B or C in patients with
BCLM.
54
55. Breast Cancer Liver Mets: Indications & Timing for Resection
Spolverato G, Ann Surg 2017, 265: 792–79955
56. Breast Cancer Liver Mets: Indications & Timing for Resection
Spolverato G, Ann Surg 2017, 265: 792–79956
57. Breast Cancer Liver Mets: Indications & Timing for Resection
Spolverato G, Ann Surg 2017, 265: 792–799
Strategy A: LR + letrozole
Strategy A:
LR + docetaxel + trastuzumab
Strategy A:
LR + letrozole
Strategy B: letrozole alone Strategy B:
Docetaxel + trastuzumab alone
Strategy B:
Letrozole + palbociclib
Strategy A:
LR + docetaxel + trastuzumab
Strategy B:
Docetaxel + trastuzumab + pertuzumab
ER+
ER+
HER2+
HER2+
57
58. Breast Cancer Liver Mets: Indications & Timing for Resection
Spolverato G, Ann Surg 2017, 265: 792–799
Liver resection plus conventional systemic therapy was more
cost-effective for patients with ER+ tumors than systemic
therapy alone.
For patients with HER2+ tumors, LR plus systemic therapy that
included trastuzumab had a cost-effectiveness that was
comparable to conventional systemic therapy alone.
The use of newer systemic chemotherapeutic agents such as
palbociclib and pertuzumab for patients with resectable BCLM
was not cost-effective.
Although certain therapies may have a clinical effect, the cost-
effectiveness of these agents may not justify their use
compared with other therapies such as surgical resection and
standard systemic chemotherapy.
58
59. Breast Cancer Liver Mets: Indications & Timing for Resection
Up to now, metastatic disease from
breast cancer should be controlled by
systemic therapy.
TAKE HOME MESSAGE (1)
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60. Breast Cancer Liver Mets: Indications & Timing for Resection
Liver resection is an effective treatment for some
liver metastases from breast cancer
We have not been able to define solid prognostic
factors
• Systemic reviews on BCLM suffer of the significant
heterogeneity between the selection criteria, disease stage
and treatment characteristics
• Papers included in systemic reviews usually describe liver
resection performed over very long periods and report
limited number of cases
It is unlike that a prospective single center trial is
feasible
TAKE HOME MESSAGE (2)
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61. Breast Cancer Liver Mets: Indications & Timing for Resection
Evaluation for surgery should include:
the presence of isolated liver metastases (their
survival is improved compared to CHT alone) which
respond or are stable with chemotherapy
(≤ 4 ??)
the interval between breast cancer treatment and
diagnosis of BCLM
(the longest, the better ?)
The feasibility of an oncologically correct liver
resection
(free margins, adequate remnant liver)
Skeletal metastases are not an absolute contraindication
TAKE HOME MESSAGE (3)
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62. Breast Cancer Liver Mets: Indications & Timing for Resection
No teams has reported unresectable LMBC that
became secondarily resectable.
Resection could also:
• decrease the need for repetitive cycles of cytotoxic
chemotherapy;
• reduce the tumor burden potentially providing an
immunologic benefit;
• at least allow time off cytotoxic chemotherapy during
the disease-free period («treatment-free holiday»).
TAKE HOME MESSAGE (4)
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63. Breast Cancer Liver Mets: Indications & Timing for Resection
The selection of patients with LMBC for
surgery should be performed only in
tertiary centers that can offer the best
short-term (low morbidity, nil postoperative
mortality) and long-term outcomes.
TAKE HOME MESSAGE (5)
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65. Gian Luca Grazi
Hepato Biliary Pancreatic Surgery
National Cancer Institute “Regina Elena”, Rome, Italy
gianluca.grazi@ifo.gov.it
www.chirurgiadelfegato.it
Breast Cancer Liver Mets: Indications & Timing for Resection
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