How to integrate surgery in the treatment of patients with ... · Define the number and segmental...

How to integrate surgery in thetreatment

of patients with liver-onlymetastatic disease

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

DISCLOSURE

Nothing to disclose

Should we integrate surgery in the treatmentof patients with liver-only metastatic disease?

www.livermetsurvey-arcad.org

24,925 resected

1361 not resected

December 2016: 302 centers, 69 countries

p = < 0.001



Surgical resection

Chan et al. World Journal of Surgical Oncology 2014, 12:155 Tomlinson JS et al. Journal of Clinical Oncology 2007; 25: 4575

5-year Survival 10-year Survival

Keys • Primary tumour under control

• Complete resection (R0)

• Liver remnant– Normal liver ≥ 25 %

– Neoadjuvant Chemo ≥ 30 %

– Cirrhosis ≥ 40 %

Surgical resection offers a substantial chance of cure

1. Diagnosis and treatment: Multidisciplinary Board

2. Surgical techniques: Anatomy and Technology

3. New strategies and new therapies

Keys

Surgical resection offers a substantial chance of cure

MULTIDISCIPLINARY BOARD

• Diagnostic work-up• Best strategy discussion• Selection for surgical approach• Timing for surgery• Feed-back results

RADIOLOGY

GE

PATHOLOGY

ONCOLOGY

SURGERY

Adam R. et al. Cancer Treatment Reviews 41 (2015) 729–741

ESMO GUIDELINES, 2016

Integrating surgery and oncology

• R0 resection achievable

• Liver remnant adequate





• R0 resection achievable

• Liver remnant adequate

• N status of primary

• Disease free interval

• Number of lesions

• Diameter

• CEA

• Extrahepatic disease

• Biology

Goal of preoperative evaluation

Identify potencially resectable patients



Keys • Primary tumour under control

• Complete resection (R0)

• Liver remnant– Normal liver ≥ 25 %

– Neoadjuvant Chemo ≥ 30 %

– Cirrhosis ≥ 40 %











1. Define the number and segmental distribution of LM

2. Determine surgical resectability

3. Identify extra-hepatic disease

1. Computed tomography

2. Magnetic Resonance Imaging

3. FDG-Positron Emission Tomography

Stepwise imaging approach

1. Define the number and segmental distribution of LM

2. Determine surgical resectability

3. Identify extra-hepatic disease

PREOPERATORY IMAGING

• CT-scan

• MRI

INTRAOPERATORY IMAGING

• INTRA-OPERATIVE ULTRASONOGRAPHY

• FDG-PET

Determine surgical resectability

CT-scan

number and segmental distribution of LM

CT-scanContrast enhancementArterial and portal phases

CRCLM:HypovascularRim enhancement washed outon later phases

Limitations:Exposure to ionizing radiationReactions to iodinated contrastSub-centimetre lesions

7

8

4A 2

7

8

4A 2

8

4A 2/3

7

1

2/34A/B

7

8

34B

8/5

7/6

3

5

6

5

6

5

66

MRI

• No ionizing radiation• Higher contrast resolution• Better for lesions < 1cm• Better steatosis or changes due to chemotherapy

CRCLM:Hypointense T1Hyperintense T2Gadolinium hypovascular

enhancement pattern

Limitations:AvailabilityRadiology expertisePatient characteristics: claustrophobia, pacemaker…

INTRA-OPERATIVE ULTRASOUND

S-VII

S-VIII

S-IV

S-IIVHD

VC

VHM VHI

cortesy Dr. Andrés Valdivieso

IOUS + surgical exloration may changethe planned surgery up to 20 %

Preoperative evaluation and imaging

Surgical elegibility

1. Complete resection of all lesions

2. Free margin resection (R0)

3. Adequate functional liver remnant

4. Fitness for major abdominal surgery

Liver remnant

Normal liver ≥ 25 %

Neoadjuvant Chemo ≥ 30 %

Cirrhosis ≥ 40 %

Preserved inflow, outflow, biliarydrainage













Clinical Scenarios

Resectable M1and fit for surgery

Non-resectable M1 but fit for surgery Conversion surgery after combined therapies

Unresectable M1 or unfit for surgery

Resectable M1 in patients

fit for surgery

Surgical technique

ANATOMY

and

TECHNOLOGY

Management of colorectal cancer presenting with synchronous liver metastasesSiriwardena AK et al. Nature Reviews Clinical Oncology 2014; 11: 446–459

The Brisbane 2000 terminology of hepatic anatomy and resections.The terminology committee of the IHPBA.Journal: HPB 2000;2:333-339 http://www.ahpba.org/liverterms.php

Liver anatomy

Retractor Kent / Makuuchii

Argon Beam Coagulator

Intra-operativeultrasonography

CUSA

Tissuelink®

CUSA

Open approach

Laparoscopic approach

Laparoscopic approach

Surgical standards

MORBIDITY < 30 %

MORTALITY < 5 %

Goal anatomical knowledge and technology

Non-resectable M1 in patients fit

for surgery

Strategies

✓Neoadjuvant Chemotherapy

✓Radiofrequency ablation

✓Portal embolization

✓Two-stage hepatectomy

✓Combinations

M1 UNRESECTABLE M1 RESECTABLE

Chemo

NEOADJUVANT CHEMOTHERAPY

Conversion is the goal

M1 UNRESECTABLE M1 RESECTABLE

Chemo

NEOADJUVANT CHEMOTHERAPY

Conversion is the goal

M Karoui, et al. Ann Surg vol 243, Number 1; January 2006 and Folprecht G. Eur J Cancer. 2011 Sep;47 Suppl 3:S52-60.

RADIOFREQUENCY ABLATION




PORTAL EMBOLIZATION

A B

TWO STAGE HEPATECTOMY

± portal embolization

5-Year S32-64 %

Median survival

24-44 m

Drop-out35 %

Torzilli G et al. Liver Cancer 2017

Fernando A. Alvarez, Jose Iniesta, Jose Lastiri, Marina Ulla, Fernando Bonadeo Lassalle y Eduardo de Santibañes. Cir Esp 2011; 89 (10):645-649

Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS)

• Two-stage hepatectomy with very short interval • Minimizes the drop-out risk• Extraordinarily rapid hypertrophy of the FRL (10 days) • Rescue in patients with portal embolization failure

Clearance of the FRL+ portal vein ligation+ liver parenchyma division

Hepatectomy when the FRLis considered to be large enough

Stage 1 Stage 2

TWO STAGE HEPATECTOMY

LiverMetastases

Resectables

Non-Resectables

LiverMetastases

Resectables

Non-Resectables

Prognosis factors*Low risk

Prognosis factors*High risk

*Nordlinger (96), Fong (99)…Konopke (09)Number, Size, Lymph node-status,Margin, CEA, Extrahepatic disease,Synchonous…

LiverMetastases

Resectables

Non-Resectables


Prognosis factors*High risk Surgery + Adjuvant therapy


LiverMetastases

Resectables

Non-Resectables


Prognosis factors*High risk Surgery + Adjuvant therapyNeoadjuvant therapy


LiverMetastases

Resectables

Non-Resectables



Stable or Responder

Progression

Change strategy Chemo


LiverMetastases

Resectables

Non-Resectables



Stable or Responder

Progression

Change strategy Chemo PalliativeProgression


LiverMetastases

Resectables

Non-Resectables



Stable or Responder

Progression


Neoadjuvant therapy


LiverMetastases

Resectables

Non-Resectables



Stable or Responder

Progression


Neoadjuvant therapy

Resectable

Surgery + Adjuvant therapy


LiverMetastases

Resectables

Non-Resectables



Stable or Responder

Progression


Neoadjuvant therapy

Resectable


Resectablewith combined

strategies

Portal EmbolizationRadiofrequency Two-stage Hepatectomy


LiverMetastases

Resectables

Non-Resectables



Stable or Responder

Progression


Neoadjuvant therapy

Resectable



strategies


Progression

Change strategy Chemo


LiverMetastases

Resectables

Non-Resectables



Stable or Responder

Progression


Neoadjuvant therapy

Resectable



strategies


Progression

Change strategy Chemo PalliativeNon-Responderor Progression


Summary

Multidisciplinary Treatment

Appropriate selection for the best treatment

Oncological and surgical strategies

Complex surgical techniques in specialized centres

Liver metastases colorectal cancer

Thank you!!

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