1. No category

Strategy in CRC stage IV –
-TitelThe liver surgeon´s
view
Hauke Lang
Klinik für Allgemein, Viszeral- und Transplantationschirurgie
Case report MHH 1991
rectal cancer
synchronous
• large liver metastases
• Infiltration of diaphragm
•
rectal exstirpation;
simultaneous extended right hepatectomy
•
postoperative chemotherapy; 5-FU
•
died of disease 1 year postop.
Strategy in CRC stage IV (liver only)
• R0-resection of both primary tumor and liver metastases offers the only
chance for cure!
Therapeutic strategies aim at:
• in curative situations:
resection and potential cure, lowering the risk for recurrence
• In potentially curative situations
increasing resectability
lowering the risk for local and systemic recurrence
• in case of noncurable disease:
prolongation of survival
optimizing quality of life
no randomized studies!
Strategy in CRC stage IV (liver only)
treatment in former times?
is there a benefit due to
• resection of primary tumor in case
of irresectable liver metastases?
current strategy?
Stage IV colorectal carcinoma (liver only)
Rational for traditional approach (primary first)
•
•
•
•
resection of
primary tumor
Treatment of tumor related symptoms
Prevention of tumor related symptoms
Primary tumor is „motor“ of metastases
Recovery time after resection of primary tumor:
resection of liver
metastases
– „selection period“ (to avoid unneccessary liver resections)
Rational for liver first
• liver metastses determine prognosis
• „better“ condition for RCTx (rectal cancer)
• Recovery time after liver resection:
– Selection period (to avoid unneccessary colorectal resections)
additional
treatment
Stage IV colorectal carcinoma (liver only)
Colorectal carcinoma with synchronous liver metastases
Colon carcinoma
Rectal carcinoma
Strategy in Colon carcinoma stage IV (liver only)
Colon carcinoma with synchronous liver metastases
Small asymptomatic carcinoma
Liver metastases resectable
minor liver
involvement
major liver
involvement
Liver metastases
primarily not
resectable
CTx;
if second. resect.
CTx?
simultaneous
resection
one stage
hepatect. possible
if right colon Ca:
simult. resection;
left colon: probably
two-step; liver first
two stage
hepatect.
two-steps:
colon first plus
minor liver resect.,
major hepatect. sec.
Large or symptomatic carcinoma
Liver metastases
resectable
Liver metastases
primarily not resectable
Liver resection for CRLM
- neoadjuvant CTx• 38-year-old female; synchronous liver metastases
adenocarcinoma of sigmoid (15-20cm ab ano) (ED 06/2011)
Chemotherapy with Folfiri + Cetuximab from 06/2011 to 12/2011
Liver resection for CRLM
- neoadjuvant CTxCT after 3 cycles Folfiri + Cetuximab
significant regress !!
Liver resection for CRLM
- neoadjuvant CTxOperation 02.02.2012:
•
Extended right hepatectomy (Seg. I, V-VIII, partially IVa und II)
•
wedge excisions segment II and III
•
Reconstruction of left hepatic vein
Operation 26.03.2012:
•
ant. rectal resection; (ypT3N0; G2; R0)
R0-resection
prognostic factors
Comparison of 15 scoring systems of prognosis (1996 -2009)
Spelt L; EJSO 2012
Liver resection for CRLM
- neoadjuvant CTxOperation 02.02.2012:
•
Extended right hepatectomy (Seg. I, V-VIII, partially IVa und II)
•
wedge excisions segment II and III
•
of left (RFA)
hepatic
vein
- Reconstruction
intrahep. recurrence
and
pulmonary mets (CTx)
Operation 26.03.2012:
•
-
again intrahep. recurrence (repeated liver resection; R0)
ant. rectal resection; (ypT3N0; G2; R0)
- pulmonary metastasectomy
-
Now probably again repeated hepatectomy
in very good condition
R0-resection
and 37 months after liver resection
44 months after diagnosis
Case report
Strategy in Colon carcinoma stage IV (liver only)
Colon carcinoma with synchronous liver metastases
Small asymptomatic carcinoma
Liver metastases resectable
minor liver
involvement
major liver
involvement
Liver metastases
primarily not
resectable
CTx;
if second. resect.
Large or symptomatic carcinoma
Liver metastases
resectable
minor liver
involvement
Liver metastases
primarily not resectable
major liver
involvement
CTx???
simultaneous
resection
one stage
hepatect. possible
If right colon Ca:
simult. resection;
left colon: probably
two-step; liver first
two stage
hepatect.
Two-step:
colon first plus
minor liver,
major hepatect. sec.
good PS, ColonCa right:
simultaneous
Colon first
Colon first;
rarely only
enterostomy
CTx;
if secondarily
resectable
reduced PS;
Colon-Ca left:
probably twostep; colon first
liver resection
Strategy in rectal carcinoma stage IV (liver only)
rectal carcinoma with synchronous liver metastases
Small asymptomatic carcinoma
Liver metastases resectable
minor liver
involvement
probably
simultaneous
resection
major liver
involvement
CTx
Liver first
Large or symptomatic carcinoma
Liver metastases
primarily not
resectable
CTx;
if secondarily
resectable
Liver metastases
resectable
Liver metastases
primarily not resectable
Liver first
- case report I• 51year-old female patient
• 04/10 diagnosis of non-obstructing adeno-carcinoma of upper rectum
• synchronous liver metastses in segments I and IV-VIII
Liver first
- case report I29.04.2010
extended right hepatectomy
(R0-resection)
01.07.2010
ant. rectal resection with partial adnexectomy right,
partial peritonectomy in pelvis; loop ileostomy
pT4a pN2b (11/16) G3 R0
28.07.2010
closure of ileostomy
adjuvant chemotherapy: FOLFOX
Strategy in rectal carcinoma stage IV (liver only)
rectal carcinoma with synchronous liver metastases
Small asymptomatic carcinoma
Liver metastases resectable
Large or symptomatic carcinoma
Liver metastases
primarily not
resectable
Liver metastases
resectable
?
Liver metastases
primarily not resectable
Neoadjuvant RCT
RCTx in rectal carcinoma
• 5-Fu/Oxaliplatin; 50,4 Gy
• undertreatment of liver metastases
• German rectal cancer study:
• only about 50% of patients received adjuvant
therapy after rectal resection
improvement of
survival by
intensifying
systemic therapy !
Strategy in rectal carcinoma stage IV (liver only)
rectal carcinoma with synchronous liver metastases
Small asymptomatic carcinoma
Liver metastases resectable
Large or symptomatic carcinoma
Liver metastases
primarily not resectable
Liver metastases
resectable
minor liver involvement
Liver metastases
primarily not resectable
major liver involvement:
neoadjuvant CTx; probably stoma
if secondarily
resectable:
Liver first
Neoadjuvante RCT
- Case report III• 47 – year-old male
• adenocarcinoma of rectum
• primary tumor circular growth, exophytic; no stenosis
uT3 uN1; M1 (hep)
• Procedere:
1. liver resection (bisegmentectomy)
2. RCTx
3. two-stage: resection of rectal cancer
Strategy in rectal carcinoma stage IV (liver only)
rectal carcinoma with synchronous liver metastases
Small asymptomatic carcinoma
Liver metastases resectable
minor liver
involvement
Liver metastases
primarily not
resectable
major liver
involvement
CTx;
Large or symptomatic carcinoma
Liver metastases
resectable
minor liver
involvement
falls sekundär
resektabel
CTx
probably
simultaneous
resection
Liver first
Liver metastases
primarily not resectable
major liver
involvement
neoadjuvant CTx;
probably stoma;
two step procedure
Liver first
Liver first
Neoadjuvant RCT
CTx;
probably
Stoma
if secondarily
resectable:
Liver first
Liver first - literature
Author/year
patients
rectal/
colon
Liver resection
n (%)
completed
sequence
prognoses
Mentha /
2008
n = 35
13/17
31 (89%)
30 / 85%
med. survival: 44 months;
1-, 2-, 3-, 4-, 5J-OS resect pat.:
100%, 89%, 66%, 44%, 30%
Verhoef /
2009
n = 23
23/0
20 (87%)
17 / 73%
Median survival : 19 (7–56)
months
n = 41
28/13
27 (66%)
27 / 66%
4-year: 52%
n = 22
19/3
21 (95%)
16 / 73%
3-year.: 41%
1-year-OS: 66%
3-year-OS: 30%
Brouquet /
2010
De Jong /
2011
Rosa /
2013
n = 37
25/12
30 (81%)
24 / 65%.
158
108/45
129 (82%)
114 (72%)
Liver first - summary
- no evidence based data!
- usually CTx first!
- disadvantage:
prognoses related factors of primary tumor remain unknown
- advantage:
treatment of „prognostic most relevant“ tumor
-
Indication for liver first:
- if there is a risk for irresectability in case of further progression
- if the risk of simultaneous operation is too high
- in case of minor liver involvement but planned RCTx for rectal cancer
Thank you!