How to deal with synchronous primary and liver …...Watch-and-wait strategy can be a reasonable...

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How to deal with synchronous primary and liver metastases Dimitri Dorcaratto MD, PhD, FEBS Department of Surgery. Liver-Biliary and Pancreatic Unit Hospital Clínico. University of Valencia

Transcript of How to deal with synchronous primary and liver …...Watch-and-wait strategy can be a reasonable...

Page 1: How to deal with synchronous primary and liver …...Watch-and-wait strategy can be a reasonable alternative Adams RB et al. Selection for hepatic resection of colorectal liver metastases:

How to deal with synchronousprimary and liver metastases

Dimitri Dorcaratto MD, PhD, FEBSDepartment of Surgery. Liver-Biliary and Pancreatic UnitHospital Clínico. University of Valencia

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DISCLOSURE

Nothing to disclose

Page 3: How to deal with synchronous primary and liver …...Watch-and-wait strategy can be a reasonable alternative Adams RB et al. Selection for hepatic resection of colorectal liver metastases:

Definition

• Diagnosed at the same time as the CRC

Pre-operative stagingIntraoperative finding (urgent surgery CRC)

• 3-6 months after resection

Adam R et al. Managing synchronous liver metastases from colorectal cancer: A multidisciplinary internationalconsensus. Cancer Treat Review 2015.

Page 4: How to deal with synchronous primary and liver …...Watch-and-wait strategy can be a reasonable alternative Adams RB et al. Selection for hepatic resection of colorectal liver metastases:

Definition

• Diagnosed at the same time as the CRC

Pre-operative stagingIntraoperative finding (urgent surgery CRC)

• 3-6 months after resection

20-30% of patients with CRC

Adam R et al. Managing synchronous liver metastases from colorectal cancer: A multidisciplinary internationalconsensus. Cancer Treat Review 2015.

Page 5: How to deal with synchronous primary and liver …...Watch-and-wait strategy can be a reasonable alternative Adams RB et al. Selection for hepatic resection of colorectal liver metastases:

• Simultaneous: Liver metastases and the primary tumor are resected in the same operation (Vogt, 1991)

• Sequential bowel-first: First resection of the CRC and then the liver metastases.With or without Chemo during the interval

• Sequential liver first (reverse approach):Resection first of all liver metastases and later the CRC (Mentha G, 2006)

Definition

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Advantages Disadvantages

Avoid two operations Long surgical time

Shorter length hospital stay Specialised surgeons required

Lower costs Bacterial contamination

Resection of all disease, lower risk of dissemination

Safety of bowel anastomosis

Chemo starts early and in betteroncological conditions

The biological behaviour of the tumor is not observed

Simultaneous

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Simultaneous

Advantages Disadvantages

Avoid two operations Long surgical time

Shorter length hospital stay Specialised surgeons required

Lower costs Bacterial contamination

Resection of all disease, lower risk of dissemination

Safety of bowel anastomosis

Chemo starts early and in betteroncological conditions

The biological behaviour of the tumor is not observed

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Advantages DisadvantagesLess aggressive surgery Two surgical operations

Better management of complexsurgeries

Longer length of hospital stay

Evaluation of tumor behaviour If complications, delays liver surgery orChemo

Increase in global morbidity

Disease progression during postoperativeperiod

Higher costs

Sequential bowel-first

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Advantages DisadvantagesLess aggressive surgery Two surgical operations

Better management of complexsurgeries

Longer length of hospital stay

Evaluation of tumor behaviour If complications, delays liver surgery orchemo

Increase in global morbidity

Disease progression during postoperativeperiod

Higher costs

Sequential bowel-first

Page 10: How to deal with synchronous primary and liver …...Watch-and-wait strategy can be a reasonable alternative Adams RB et al. Selection for hepatic resection of colorectal liver metastases:

.Rationale1 : the lesion that kills the patient is the metastasis

Rationale 2: metastases usually determine resectability

Rationale 3: progression of the CRLM during treatment of the primary tumour

Sequential liver-first

Mentha G et al. Neoadjuvant chemotherapy and resection of advanced synchronous liver metastases before treatment of the colorectal primary. Br J Surg. 2006 Jul;93(7):872-8.

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Advantages Disadvantages

To treat what determines resectabilityComplications of primary CRC requiringurgent or palliative surgery (5-11 %)

Avoids progression of livermetastases

CRC progression (rare)

Allows the most appropriatte timing of administration of pelvis Chemo-RDT

Small size liver M1 disappearance

Chemo treatment of liver metastases and the primary CRC

Two surgical operations

Increase OS if conversion of M1 to resectables

Sequential liver-first

Page 12: How to deal with synchronous primary and liver …...Watch-and-wait strategy can be a reasonable alternative Adams RB et al. Selection for hepatic resection of colorectal liver metastases:

Sequential liver-first

Advantages Disadvantages

To treat what determines resectability Complications of primary CRC requiringurgent or palliative surgery (5-11%)

Avoids progression of liver metastases CRC progression (rare)

Allows the most appropriatte timing of administration of pelvis Chemo-RDT

Small size liver M1 disappearance

Chemo treatment of liver metastases and the primary CRC

Two surgical operations

Increase OS if conversion of M1 to resectables

Page 13: How to deal with synchronous primary and liver …...Watch-and-wait strategy can be a reasonable alternative Adams RB et al. Selection for hepatic resection of colorectal liver metastases:

Summary Scientific Evidence

• No randomized (RCT) studies

• Important selection biases

• Sequential in patientes with greater liver disease

• Increased evidence on simultaneous resections

Scientific EvidenceSIMULTANEOUS vs Sequential BOWEL FIRST vs Sequential LIVER FIRST

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Brouquet A, Mortenson MM, Vauthey J-N et al. Surgical Strategies for Synchronous Colorectal Liver Metastases in 156 Consecutive Patients: Classic, Combined or Reverse Strategy?J Am Coll Surg 2010; 210: 934-941

Scientific Evidence

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Simultaneous resection

N=922

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N=922

Simultaneous resection

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N=922

Patients selection is crucial

Simultaneous resection

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135 HospitalsNew York State2005-14

Abelson JS et al. J Gastrointest Surg 2017

Simultaneous resection

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135 HospitalsNew York State2005-14

Abelson JS et al. J Gastrointest Surg 2017

Simultaneous resection

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Abelson JS et al. J Gastrointest Surg 2017

Simultaneous resection

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Abelson JS et al. J Gastrointest Surg 2017

Simultaneous resection

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5 years OS:Simultaneous: 38,5%Staged: 38,9%

N=429Simultaneous=320Staged=109

Simultaneous resection

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5 years DFS:Simultaneous: 24,3%Staged: 25,3%

N=429Simultaneous=320Staged=109

Simultaneous resection

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Gavriilidis et al. Simultaneous versus delayed hepatectomy for synchronous colorectal liver metastases: a systematic review and meta-analysis. HBP 2018.

30 studies5300 patients

Simultaneous resection

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Gavriilidis et al. Simultaneous versus delayed hepatectomy for synchronous colorectal liver metastases: a systematic review and meta-analysis. HBP 2018.

30 studies5300 patients Overall survival

Simultaneous resection

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Sturesson Ch et al. Liver-first strategy for synchronous colorectal liver metastases-an intention-to treat analysis. HBP 2017; 19: 52-58

Liver first strategy

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Classical30 %

Do not complete the plannedtreatment

(two surgeries)

Liver-first35 %

Do not complete the plannedtreatment

(two surgeries)

Sturesson Ch et al. Liver-first strategy for synchronous colorectal liver metastases-an intention-to treat analysis. HBP 2017; 19: 52-58

Liver first strategy

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Liver first strategy

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54,0%

49,0%

Liver first strategy

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Vallance AE et al. The timing of liver resection in patients with colorectal cancer and synchronous liver metastases: a population-based study of current practice and survival. Colorectal Dis 2018

Synchronous primary CRC and liver metastases

Trends in surgical strategy

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Scientific EvidenceSIMULTANEOUS vs Sequential BOWEL FIRST vs Sequential LIVER FIRST

• No differences in survival... ... in selected cases

• No differences in complications… … in selectedcases

• Simultaneous: shorter length of hospital stay andlower costs

• Liver first approach: severe liver disease and asymptomatic primary tumour

Summary Scientific Evidence

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Indications and clinical recommendations

Primary tumor• Symptoms• Rectal vs colonic• Extent of the surgery

Liver mets• Resectability• Extent of the surgery/disease• Extrahepatic disease

• Fit for surgery?Patient

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Indications and clinical recommendations

Primary tumor• No symptoms• Colon• Easy

Liver mets• No extrahepatic disease• Easy• Limited disease

ChemotherapyCombined resection

Adam R et al. Managing synchronous liver metastases from colorectal cancer: A multidisciplinary internationalconsensus. Cancer Treat Review 2015.

1

Page 34: How to deal with synchronous primary and liver …...Watch-and-wait strategy can be a reasonable alternative Adams RB et al. Selection for hepatic resection of colorectal liver metastases:

Indications and clinical recommendations

Primary tumor• No symptoms• RECTAL• Easy

Liver mets• No extrahepatic disease• Easy• Limited disease

Chemotherapy+RT

Combined resection

Adam R et al. Managing synchronous liver metastases from colorectal cancer: A multidisciplinary internationalconsensus. Cancer Treat Review 2015.

2

Page 35: How to deal with synchronous primary and liver …...Watch-and-wait strategy can be a reasonable alternative Adams RB et al. Selection for hepatic resection of colorectal liver metastases:

Indications and clinical recommendations

Primary tumor• No symptoms• Colon• Easy

Liver mets• No extrahepatic disease• Extensive disease• Bilateral disease

ChemotherapyLiver first surgery

AAdam R et al. Managing synchronous liver metastases from colorectal cancer: A multidisciplinary internationalconsensus. Cancer Treat Review 2015.

3

Page 36: How to deal with synchronous primary and liver …...Watch-and-wait strategy can be a reasonable alternative Adams RB et al. Selection for hepatic resection of colorectal liver metastases:

Indications and clinical recommendations

Primary tumor• No symptoms• Colon• Easy

Liver mets• No extrahepatic disease• Extensive disease• Bilateral disease

ChemotherapyCombined

BSecond stage liver

PORTALEmbolization

3

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Indications and clinical recommendations

Primary tumor• No symptoms• Colon• Easy

Liver mets• No extrahepatic disease• Extensive disease• Bilateral disease

ChemotherapyCombined

BSecond stage liver

PORTALEmbolization

3

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Indications and clinical recommendations

Primary tumor• No symptoms• Colon• Easy

Liver mets• No extrahepatic disease• Extensive disease• Bilateral disease

ChemotherapyCombined

BSecond stage liver

PORTALEmbolization

3

Page 39: How to deal with synchronous primary and liver …...Watch-and-wait strategy can be a reasonable alternative Adams RB et al. Selection for hepatic resection of colorectal liver metastases:

Indications and clinical recommendations

Primary tumor• SYMPTOMS• Colon• Easy

Liver mets• No extrahepatic disease• Easy• Limited disease

Primary surgeryChemotherapy

Liver surgeryAdam R et al. Managing synchronous liver metastases from colorectal cancer: A multidisciplinary internationalconsensus. Cancer Treat Review 2015.

4

Page 40: How to deal with synchronous primary and liver …...Watch-and-wait strategy can be a reasonable alternative Adams RB et al. Selection for hepatic resection of colorectal liver metastases:

Indications and clinical recommendations

Primary tumor• SYMPTOMS• Colon• Easy

Liver mets• No extrahepatic disease• Extensive disease• Bilateral disease

Primary surgeryChemotherapy

Liver surgeryAdam R et al. Managing synchronous liver metastases from colorectal cancer: A multidisciplinary internationalconsensus. Cancer Treat Review 2015.

5

Page 41: How to deal with synchronous primary and liver …...Watch-and-wait strategy can be a reasonable alternative Adams RB et al. Selection for hepatic resection of colorectal liver metastases:

SIMULTANEOUS Surgery

Indications and clinical recommendations

• Patients fit for surgery

• “Easy” hepatic resection

• Uncomplicated primary tumor

• Specialized surgeons

Adam R et al. Managing synchronous liver metastases from colorectal cancer: A multidisciplinary internationalconsensus. Cancer Treat Review 2015.

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SEQUENTIAL COLON FIRST Surgery

Indications and clinical recommendations

• Symptomatic CRC

• Patient not fit for simultaneous

• Surgeon not an expert in liver surgery

• Doubtful resectability of CCR

• Complex surgery of the CRC and the M1

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SEQUENTIAL LIVER FIRST Surgery

Indications and clinical recommendations

• Asymptomatic primary tumor

• Unresectable or borderline resectable liver M1

• Risk of M1 progression during treatment of the primary

Page 44: How to deal with synchronous primary and liver …...Watch-and-wait strategy can be a reasonable alternative Adams RB et al. Selection for hepatic resection of colorectal liver metastases:

Management of the disappearing metastases

Incidence: 5-38 %

Try to avoid this problem• Early involvement of surgeon: Multidisciplinary board

• Limit the duration of chemo

• Coils to mark M1 if risk of disapearing

Adams RB et al. Selection for hepatic resection of colorectal liver metastases: expert consensus statement. HBP 2013; 15: 91-103Lucidi V et al. Missing metastases as a model to challenge current therapeutic algorithms in colorectal liver metastases. World J Gastroenterol2016; 22: 3937-3944

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1. M Karoui, et al. Ann Surg vol 243, Number 1; January 20062. Folprecht G. Eur J Cancer. 2011 Sep;47 Suppl 3:S52-60.

Incidence: 5-38 %

Try to avoid this problem• Early involvement of surgeon: Multidisciplinary board

• Limit the duration of chemo

• Coils to mark M1 if risk of disapearing

Management of the disappearing metastases

Page 46: How to deal with synchronous primary and liver …...Watch-and-wait strategy can be a reasonable alternative Adams RB et al. Selection for hepatic resection of colorectal liver metastases:

Surgical resection should include all original sites of M1…when feasible

Complete radiological response IS NOT EQUIVALENT to complete pathological response

Watch-and-wait strategy can be a reasonable alternative

Adams RB et al. Selection for hepatic resection of colorectal liver metastases: expert consensus statement. HBP 2013; 15: 91-103Lucidi V et al. Missing metastases as a model to challenge current therapeutic algorithms in colorectal liver metastases. World J Gastroenterol2016; 22: 3937-3944

Management of the disappearing metastases

Recurrence in 30-70%

Page 47: How to deal with synchronous primary and liver …...Watch-and-wait strategy can be a reasonable alternative Adams RB et al. Selection for hepatic resection of colorectal liver metastases:

Summary

• Multidisciplinary treatmnent strategies

• Selection of patients

• Planification for an appropriate timing

• Complex surgical procedures requiring surgical expertise

Synchronous primaryand liver metastases

Page 48: How to deal with synchronous primary and liver …...Watch-and-wait strategy can be a reasonable alternative Adams RB et al. Selection for hepatic resection of colorectal liver metastases:

Painting: Sandra Villa LagoPhotograph: David Gimeno VesesSchool of Medicine. Universitat de Valencia

Thank you!


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