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Liver MetastasesLiver Metastases
Jean-Bernard Poulard MD, MBA, FACSJean-Bernard Poulard MD, MBA, FACSMount Sinai School of MedicineMount Sinai School of Medicine
Queens Hospital CenterQueens Hospital CenterJamaica, NYJamaica, NY
Liver MetastasesLiver Metastases
Liver MetastasesLiver Metastases
• 30 Years Ago, Considered Incurable
Liver MetastasisLiver Metastasis
• Extent of the problem• Primary Cancers and Mets• Liver structure and function considerations• Excision and its evolution• Chemo as an adjunct• Ablative Approaches• Current Recommendations• The Future
Liver Metastases- BiologyLiver Metastases- Biology
• Fertile Circulation. Systemic and Portal
• Biliary Component
• Primary Drainage for GI Tract /Pancreas
• Functional Importance
• Regenerative Capacity
• Abused and Insult (alcohol and Viruses)
Liver Mets- Extant of ProblemLiver Mets- Extant of Problem
• Demographics of Colorectal Cancer
• Other Gastro-Intestinal Cancers
• Other Sites
• Sites Where Treatment Benefits
• Sites with No Benefit
Liver MetastasesLiver MetastasesPractical ConsiderationsPractical Considerations
• Function
• Accessability
• Resectability
• Technical Considerations (Support)
• Equipment and Machinery
• Surgical and Interventional Expertise
• Critical Care
Liver Mets -MetastasectomyLiver Mets -Metastasectomy
• Indications• Tissue Diagnosis• Size and Number and Lobes• Timing• Chemo Pre-Resection?• Risks• Morbidity and Mortality• Outcome
Liver Mets - MetastasectomyLiver Mets - Metastasectomy
• Extra-Hepatic Disease: Containdication?
• Used to Be
• But if Extra-hepatic and Mets Resectable
• If R0 Possible – 5 yr 29-38% (Elias et al, BJS 2003; 90: 567-74)
Liver Metastases-HAILiver Metastases-HAI
• Rationale for Hepatic Artery Infusion– Not Amenable to Excision
• Technical Considerations• Risks and Pitfalls (misperfusion, Art Injury)• Evolution and Current Practice• Chemo Agents: 5-FUDR (+ leucovorin and
Dexamethasone), – Results: RR 78%, Median Survival 25 mos
Kemeny N. J Clin. Onc. 1994; 23:2288
Liver Metastases HAI 2Liver Metastases HAI 2
• Oxaliplatin and Irinotecan– Scant Data but Safe via HA– 28 Pts with Isolated Liver Mets– Oxaliplatin Followed by IV 5-FU and
Leucovorin– Objective RR 64% Median Survival 28 Mos
J. Clin. Onc. 2005; 23:275s
Liver Metastases-Ablation 1Liver Metastases-Ablation 1
• Indications
• Modalities– Intratumoral, Cryo, Radiation, Thermal
• Common Attributes
• Degree of Invasiveness
Liver Metastases- IntratumoralLiver Metastases- Intratumoral
• Percutaneous Ethanol and Acetic Acid
• Used in small HCC (Japan)
• Difficult Access for Some Lesions
• Etoh not Effective in Other Histologies
• Consensus: Etoh not Appropriate
• Acetic Acid
Liver Metastasis - CryoablationLiver Metastasis - Cryoablation
• Techniques
• Failure Rate: 10-44% (Most in Non-Frozen sites)
• Sometimes after Incomplete Excision
• Survival 24-38% 5 year
• Drawback: Requires Laparotomy
• Obsolescent?
Liver Metastases- RadiationLiver Metastases- Radiation
• External Beam Therapy Limited– Tolerance 35 Gy vs 70 Gy to Destroy CA
• Stereotactic for Small Tumors• Brachytherapy : I-125 Seeds Rarely used after
Incomplete Excision– Complex Logistics, Cryo Preferred
• Radioembolization• Y-90 tagged Resin or Glass microspheres• Used with HAI of FUDR (RR 44 vs 18) • Similar Toxicity, No Signicant Survival Benefit (Xcpt>15)Ann. Onc. 2001; 12: 1711
Liver Metastases Liver Metastases Thermal Ablation 1Thermal Ablation 1
• Modalities– Radiofrequency Ablation– Laser and Microwaves (Europe)
• Limitations– Control of Margin– Specificity of Tissue Damage
• Advantage– Percutaneous Approach
Liver MetastasesLiver Metastases
• Radiofrequency Generator
Liver Metastases -RFALiver Metastases -RFA
• Used in HCC and Liver Mets
• Open, Laparoscopic or Percutaneous– Relation to Recurrences– Experience, Type of Equipment
• Pitfalls: Intestinal and Diaphragm Injuries Portal Vein Thrombosis
• Mortality 0-2% Major Complications 6-9%
• Outcome: Median Survival 24 Months
Liver Metastases- Liver Metastases- RecommendationsRecommendations
• Resection for Cure is First Option
• Potentially Resectable if Lesions Smaller– Systemic Chemo and Reevaluation
• Limited Number of Mets but Not Surgical Candidate:– Ablation (RFA Preferred)– HAI
Liver Metastases- The FutureLiver Metastases- The FutureCRCCRC
• The M.D. Anderson’s Approach
• Up to 1992, 35% Survival for Stage 4 CRC
• Post 1992, Up to 58%– Anesthesia, Surgery, Hemostatics, Imaging,
Intesive Care
• Surgical Excision as Primary Tx –Better
• Chemo Alone or RFA <20%
• Solitary Met Excision 71% Survival 5 Yrs
Liver Metastasis- The Future 2Liver Metastasis- The Future 2CRCCRC
• Majority are Unresectable at Presentation
• Make Them Resectable?
• Prospective Trial– Combination Chemotherapy– Staged Hepatectomy– Portal Vein Embolization
• Determine Remnant of Viable Liver
• Size and Number of Mets not Factor
Liver Metastases – The Future 3Liver Metastases – The Future 3CRCCRC
• Response Rate to Cytotoxic with Biologic – Up to 50%
• Portal Vein Embolization– Induces Increase in Volume of the Liver– Increases the Function
• Regeneration – 2-4 Weeks in Normal Liver– 6-8 Weeks for Diabetics and Cirrhotics
Liver Metastases- The Future 4Liver Metastases- The Future 4CRCCRC
• Stage Resection• For Bilateral Lobe Involvement• Chemo- Excise From one Lobe• PVE – Liver Regenaration• Resect from Other Lobe• Survival 40% • 80% of Liver Volume can be Resected• Use 3-D CT Volumetry• Surgical Mortality .8%
Liver MetastasesLiver MetastasesPrevention?Prevention?
• Stage 2 and 3 CRC• Hepatic and Regional Chemo Before Surgery• Randomized, No significant Morbidity• Time to Liver Mets 16 vs 8 mos.• Incidence 20.6 vs 28.3• Disease Free Survival 74vs 58.1 (3 yr)• Overall 87.7 vs 75.7• No Benefit for Stage 2Xu et al. Ann Surg. 2007; 245:583-90
Liver MetastasesLiver MetastasesGastric CancerGastric Cancer
• Hepatic Metasectomy done Rarely• Isolated Liver Involvement Rare (.5%)• Long Term Survival is Rare• Non-RandomIzed Series 37 patients -HAI
– 5 FU chemo– Gastrectomy and HAI– Better Response– But No Increase SurvivalOjima et Al. World J Surg. 2007; 5: 70
Liver MetastasesLiver MetastasesFinal WordFinal Word
• Screen, Screen, Screen for CRC
• Polypectomy may be Preventive
• Early Cancers are Curable
• Have you Had Your Colonoscopy?
• Thank You