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Metastatic Liver Disease Indications and Limitations

N.J.LygidakisN.J.Lygidakis MD FACS, FRCST (Hon) MD FACS, FRCST (Hon)

“HENRY DYNANT” Hospital Dept. of Surgical Oncology

LimitationsAbsolute Contraindications:

(1) Decompensated liver function(2) > 70% of liver surface covered by tumor(3) Presence of primary malignant tumor(4) Locoregional anatomical peculiarities(5) Multiple metastatic disease


Indications• Colorectal• Gastric• Breast• Renal• Melanoma• Pancreas


Carcinomas…

Indications

• Unilobular localisation• Bilobular localisation• Solitary• Multiple


Therapeutical strategies:Surgery combined with neo and adjuvant

regional chemo–immuno therapy

Surgery combined with neo and adjuvant chemo–immuno therapy and

• ablation therapy• two stage surgery



From From November 1991 to May 2002, , 183 patients with metastatic liver disease of colorectal origin with metastatic liver disease of colorectal origin were assigned in three groups according to the were assigned in three groups according to the

therapeutical strategy: therapeutical strategy:

1. Surgery combined with neo and adjuvant regional chemo–immuno therapy (n=60 patients)

2. Surgery combined with neo and adjuvant chemo–immuno therapy and ablation therapy (n=61 patients)

3. Two stage Surgery combined with neo and adjuvant chemo–immuno therapy (n=62 patients)


Surgery combined with neo and adjuvant regional chemo–immuno therapy

From Nov. 1991 to May 2002, all patients with

liver metastases of colorectal origin (n=61) were

considered for adjuvant locoregional immuno-chemotherapy following liver

resection


Procedure No. of Pts n=60

right hemihepatectomy

26

extended right trisegmentectomy

12

left hemihepatectomy

14

segmentectomy 8


…survival time: 79 months

…survival free of hepatic progression: 75 months …

survival of disease free – progression: 45.5 months

Median….


Cumulative proportion surviving

1 year 95

2 year 92

3 year 80

4 year 78

5 year 73


Cumulative proportion surviving free of hepatic progression

1 year 97

2 year 95

3 year 86

4 year 85

5 year 82


Cumulative proportion surviving of disease free progression

1 year 84

2 year 69

3 year 62

4 year 59

5 year 58

Liver metastasis from a Liver metastasis from a colon primary …a right colon primary …a right hepatectomy was done hepatectomy was done

… … an extendedan extendedright hepatectomy was right hepatectomy was done done

Liver metastasis from a Liver metastasis from a rectal primary …a right rectal primary …a right hepatectomy was done hepatectomy was done

Surgery combined with ablation therapyand Neo and adjuvant locoregional

chemo-immunotherapy

From Nov. 1991 to May 2002, sixty one

patients (n=61) with liver metastases of

colorectal origin were considered for Surgery combined with neo and adjuvant chemo–

immuno therapy and ablation therapy

Procedure No. of Pts n=61

right hepatectomyPlus ablation

27

left hepatectomy Plus ablation

13

Segmentectomy Plus ablation

21


chemo-immunotherapy


Median….


chemo-immunotherapy


chemo-immunotherapy

1 year 87

2 year 70

3 year 50

4 year 18

5 year 0


chemo-immunotherapy

Metastatic liver disease from colon cancer

Patient underwent Right hepatectomy catheter to the hepatic artery and Microwave coagulation of a solitary lesion in the left liver lobe


Patient underwent Right hepatectomy catheter to the hepatic artery and Microwave coagulation of a solitary lesion in the lesion of segment IV


Patient underwent Liver segmentectomy and Microwave

coagulation of a solitary lesion in the left lobe

Two stage surgery


From From November 1991 to May 2002, 62 , 62 patients with metastatic liver disease patients with metastatic liver disease of colorectal originof colorectal origin underwent underwent main portal branch transection combined

with liver resection and neo- and adjuvant transarterial immuno-

chemotherapy.

Age Median 6262Range 25-8025-80

Sex Male 3030Female 3232

Karnofski score Median 9090Range 70-10070-100

Liver involvement Median 45%45%Rage 30-7030-70

No of liver metastases

3 10104-6 3030>6 2222

Type of disease Synchronous 1515metachronous 4747

Prior treatmentNone 1818

Adjuvant chemotherapy 2222Chemotherapy for metastases 2222

Clinicopathological characteristics

Phase I surgery

• Main Portal branch ligation • Locoregional chemo-immunotherapy

catheter insertion in the gastroduodenal artery

Two stage surgery


Main Portal branch ligation

Locoregional chemo-immunotherapy catheter insertion in the gastroduodenal artery

Chemotherapy

11stst Day Day Oxaliplatin 150 mg per m2 of bs

2nd Day2nd Day Mitomycin 20 mg per m2 of bs5 FU 750 mg per m2 of bs Leucovorin 200 mg per m2 of bs Irinotecan 2 mg per m2 of bs

3rd, 4th, 5th day3rd, 4th, 5th day 5-FU 750 mg per m2 of bsLeucovorin 200 mg per m2 of bsIrinotecan 2 mg per m2 of bs

Immunotherapy

The next day and for (10) consecutive days

1ml of Proleukin

Two stage surgery

LFT’s at admission

LFT’s 40 days following main portal branch

transection

Albumin 30 g/l 45g/l

Alkaline Phosphatase

450 iu/l 270 iu/l

SGOT 68 iu/l 35 iu/l

SGPT 62 iu/l 32 iu/l

Bilirubin 2.8 mg/100ml 1.5 mg/100ml

γ-GT 220 iu/l 95 iu/l

INR 2 1.2

Two stage surgery

Procedure No. of Patients

right hemihepatectomy

28

extended right trisegmentectomy

12

left hemihepatectomy

14

segmentectomy 8

Phase II surgery - Liver resection

Two stage surgery

Phase II surgery - Liver resection

Video


…survival free of hepatic progression: 43 months

…survival of disease free – progression: 19 months

Median….

Two stage surgery


Cumulative proportion surviving was:

1 year ….87 % 2 year ….73 % 3 year ….69 % 4 year ….64 % 5 year ….59 %.

Disease free of hepatic progression survival was:

1 year….74% 2 year….61% 3 year….60% 4 year….53% 5 year….48%.

Disease free progression survival

1 year….69% 2 year….48% 3 year….41% 4 year….40% 5 year….38%.

Lipiodol-Urografin emulsion, Lipiodol-Urografin emulsion, selectively retained in the selectively retained in the

tumor bearing area.tumor bearing area. Left liver Left liver lobe hypertrophy. lobe hypertrophy.

Hepatectomy was possible one Hepatectomy was possible one month latermonth later

Two months later after tumor reduction the patient

underwent right hepatectomy

CT scan after right hepatectomy

Patient with right liver Patient with right liver metastasis underwent two-metastasis underwent two-

stage liver surgerystage liver surgery

Patient with large right Patient with large right liver HCC underwent two-liver HCC underwent two-


Patient with left liver Patient with left liver metastasis underwent two-metastasis underwent two-


Patient with right liver Patient with right liver metastases underwent two-metastases underwent two-


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