Results of hepatic resection for sarcoma metastatic to liver

Long-term survival in metastasized leiomyosarcoma: a case report and review of the literature

BACKGROUND

Leiomyosarcoma of the mesosigma is a very rare entity, with low 5-year survival rates. Treatment consists of resection of the primary tumor and, if applicable, of synchronous or metachronous metastases. Local treatment options for metastatic disease should be exploited as long as possible, as response to chemotherapy is reportedly disappointing. Stereotactic radiotherapy is a fairly new locally effective treatment option which has been well established in stereotactic radiotherapy of lung tumors. Whether repeated stereotactic radiotherapy sessions for treatment of lung metastases can be safely and successfully performed over a long time period is not yet well documented.

CASE REPORT

We present the case of a 71-year-old female patient who had a primary diagnosis of lung metastases 12 years ago. Atypical resections of 4 lung metastases were performed in 2001 and 2002. Between 2004 and 2011, 7 sessions of stereotactic body irradiation of lung metastases were performed. All stereotactic treatment were tolerated well (no radiation pneumonitis, FEV1 was 1.3 L [67.8%] in 2004 and 0.99 L [56.3%] in 2011).

CONCLUSIONS

The present case could demonstrate that a repetitive treatment of lung metastases with multiple stereotactic radiotherapy sessions can lead to long-term survival with a good quality of life.

Liver metastases from non-gastrointestinal non-neuroendocrine tumours: review of the literature

Liver resection is integrated in the oncological surgical management of metastatic gastrointestinal and neuroendocrine tumours. However, the good prognosis reached in these cases has not been obtained for metastatic tumours of other histological types. In this review, we analysed the published case reports and series of hepatectomies in patients with metastatic breast cancer, melanoma, sarcoma, genitourinary tumours, pulmonary and adrenocortical tumours. From the reported data the surgical resection of oligometastases yields good results in terms of improved survival, in particular when the disease-free time period is longer than 1 year. Hepatic resection can be a valid surgical strategy to obtain a survival benefit in patients with liver metastases from non-gastrointestinal, non-neuroendocrine tumours. However, a careful patient selection is needed in order to obtain a real survival benefit; patients with a good performance status, with a disease-free period longer than 1 year and with oligometastases may obtain the best advantage from this approach.

Liver surgery in the multidisciplinary management of gastrointestinal stromal tumour

BACKGROUND

After the introduction of tyrosine kinase inhibitors (TKIs), the role of surgical resection in treating liver metastasis from gastrointestinal stromal tumour (GIST) is unclear. In this study, we evaluated the outcome of patients treated with TKIs followed by surgery for metastatic GIST.

METHODS

Eleven patients who underwent liver resection after downsizing TKIs therapy for metastatic GIST from 2006 until 2010 were reviewed.

RESULTS

One and 2-year overall survival (OS) rates were 80.8% and 70.7%. All patients with an initially resectable tumour were still alive without recurrence. Patients operated on clinical response had a better outcome (1-year and 2-year OS rate of 100%) than those operated on disease progression (1-year and 2-year OS rates of 60% and 40%; P = 0.043). No deaths were observed among patients who achieved an R0 resection (R0 versus R1/R2, P = 0.001).

CONCLUSION

R0 resection and clinical response to TKI are predictors of survival. Surgical resection should be performed as soon as feasible in responder patients. In poor responders, surgery may not add any survival benefit, except in localized progressive disease. In resectable metastatic liver disease, preoperative TKIs or upfront surgery followed by adjuvant therapy could be considered. Larger studies are needed to determine the optimum approach in patients with metastatic GIST.

Survival After Resection of Gastrointestinal Stromal Tumor and Sarcoma Liver Metastases in 146 Patients

BACKGROUND

We investigated outcomes by primary tumor type in patients who underwent resection of liver metastases from gastrointestinal stromal tumors (GIST), leiomyosarcomas, and other sarcomas.

METHOD

Our institutional liver database was used to identify patients who underwent resection from 1998 through 2013. Histopathological, clinical, and survival data were analyzed.

RESULTS

One hundred forty-six patients underwent resection of liver metastases from GIST (n = 49), leiomyosarcomas (n = 47), or other sarcomas (n = 50). The 5-year overall survival (OS) rates in patients with GIST, leiomyosarcomas, and other sarcomas were 55.3, 48.4, and 44.9%, respectively, and the 10-year OS rates were 52.5, 9.2, and 23.0%, respectively. The 5-year recurrence-free survival (RFS) rate was better for GIST (35.7%; p = 0.003) than for leiomyosarcomas (3.4%) and other sarcomas (21.4%). Lung recurrence was more common for leiomyosarcomas (36% of patients; p < 0.0001) than for other sarcomas (12%) and GIST (2%). For GIST, the findings support a benefit of imatinib regarding the 5-year RFS rate compared to resection alone (47.1 vs. 9.5%; p = 0.013). For leiomyosarcoma, primary tumor location did not affect the 5-year RFS rate (intraabdominal 14.5%; other location 0%; p = 0.182).

CONCLUSION

Liver metastases from GIST, leiomyosarcomas, and other sarcomas should be assessed separately as their survival and recurrence patterns are different. This is especially important for GIST, for which imatinib is now available.

Metastatic liver disease from non-colorectal, non-neuroendocrine, non-sarcoma cancers: a systematic review

BACKGROUND

Hepatic resection of liver metastases of non-colorectal, non-neuroendocrine, and non-sarcoma (NCNNNS) primary malignancies seems to improve survival in selected patients. The aims of the current review were to describe long-term results of surgery and to evaluate prognostic factors for survival in patients who underwent resection of NCNNNS liver metastases.

METHODS

We identified 30 full texts (25 single-center and 5 multicenter studies) published after year 1995 and published in English with a total of 3849 patients. For NCNNNS liver metastases, 83.4 % of these subjects were resected.

RESULTS

No prior systematic reviews or meta-analyses on this topic were identified. All studies were case series without matching control groups. The most common primary sites were breast (23.8 %), genito-urinary (21.8 %), and gastrointestinal tract (19.8 %). The median 5- and 10-year overall survival were 32.3 % (range 19-42 %) and 24 % (indicated only in two studies, range 23-25 %), respectively, with 71 % of R0 resections.

CONCLUSIONS

There is evidence suggesting that surgery of NCNNNS metastases is safe, feasible, and effective if treatment is part of a multidisciplinary approach and if indication is based on the prognostic factors underlined in literature analysis.

Significance of local treatment in patients with metastatic soft tissue sarcoma

Metastatic soft tissue sarcomas (STS) represent enormous challenges to improve the low survival rate, which is almost the same as past 2 decades ago, although surgery, radiotherapy and radiofrequency ablation has been accepted in the treatment of metastatic STS. Moreover, STS varies between elderly and younger victims in the aspect of diagnoses, prognosis, and treatment strategies. In order to evaluate the role of local treatment in improving prognosis for patients with metastatic STS and select the proper candidates who will benefit from local therapy, a single-institution nearly 50-year experience were collected and reviewed. Finally, we found that local treatments could improve treatment response and survival, but overall survival advantage could not be seen in elderly patients. This conclusion from a single institution could serve as a basis for future prospective multi-institutional large-scale studies.

Contemporary management and classification of hepatic leiomyosarcoma

BACKGROUND

Hepatic leiomyosarcomas are rare soft-tissue tumours. The majority of lesions previously considered as leiomyosarcomas have been identified as gastrointestinal stromal tumours (GISTs). Consequently, understanding of the role of liver resection for true leiomyosarcoma is limited, a fact that is exacerbated by the increasing recognition of leiomyosarcoma subtypes. This study presents data on the outcomes of liver resection for leiomyosarcoma and suggests an algorithm for its pathological assessment and treatment.

METHODS

Patients were identified from a prospectively collected departmental database. All tumours were negative for c-kit expression. Immunohistochemistry was performed to identify the presence of oestrogen or progesterone receptor (OR/PR) expression or Epstein-Barr virus (EBV) and patients were stratified according to this profile.

RESULTS

Eight patients (of whom seven were female) underwent a total of 11 liver resections over a 12-year period. One patient had a primary hepatic leiomyosarcoma. Of those with metastatic leiomyosarcomas, the primary tumours were located in the mesentery, gynaecological organs and retroperitoneum in four, two and one patient, respectively. Both leiomyosarcomas of gynaecological origin stained positive for OR/PR expression. One patient had previously undergone renal transplantation; this leiomyosarcoma was associated with EBV expression. Median survival was 56 months (range: 22-132 months) and eight, six and four patients remained alive at 1, 3 and 5 years, respectively.

CONCLUSIONS

Hepatic resection for leiomyosarcoma is associated with encouraging rates of 5-year overall and disease-free survival. The worse outcome that had been expected based on data derived from historical cohorts (partly comprising subjects with GIST) was not observed. An algorithm for pathological classification and treatment is suggested.

The benefits of liver resection for non-colorectal, non-neuroendocrine liver metastases: a systematic review

PURPOSE

Defining the benefits of resection of isolated non-colorectal, non-neuroendocrine (NCRNNE) liver metastases is difficult. To better understand the survival benefit in this group of patients, we conducted a systematic review of the previous literature.

METHODS

Medline, Web of Knowledge, and manual searches were performed using search terms, such as "liver resection" and "primary tumor." Inclusion criteria were year>1990, >five patients, and median survival reported or derived. An expected median survival was calculated from weighted averages of median survivals, and differences were assessed using a permutation test.

RESULTS

A total of 7,857 references were identified. Overall 4,735 abstracts were reviewed; 120 manuscripts evaluated and of these, 73 met the study inclusion criteria. The final population consisted of 3,596 patients with renal (n=234), ovarian (n=119), testicular (n=153), adrenal (n=90), small bowel (n=28), gallbladder (n=21), duodenum (n=38), gastric (n=481), pancreatic (n=55), esophageal (n=23), head and neck (n=15), and lung (n=36) cancers, gastrointestinal stromal tumors (GISTs) (n=106), cholangiocarcinoma (n=13), sarcoma (n=189), and melanoma (n=643). The greatest expected median was 63 months for genitourinary (GU) primaries (n=549; range 5.4-142 months) followed by 44.4 months for breast cancer (n=1,013; range 8-74 months), 22.3 months for gastrointestinal cancer (n=549; range 5-58 months), and 23.7 months for other tumor types (n=1,082; range 10-72 months). Using a permutation test, we observed that survival was best for patients with GU primaries followed by that for breast cancer patients. Additionally, we also observed that survival was similar for those with cancer of the GI tract and other primary sites.

CONCLUSIONS

There appears to be a benefit to resection for patients with NCRNNE liver metastases. The degree of survival advantage is predicated by primary site.

Inflammatory pseudotumor of the liver diagnosed as metastatic liver tumor in a patient with a gastrointestinal stromal tumor of the rectum: report of a case

BACKGROUND

Inflammatory pseudotumor (IPT) of the liver is a rare benign lesion. A case of IPT of the liver found in association with a malignant gastrointestinal stromal tumor (GIST) is reported.

CASE REPORT

A 74-year-old man was admitted to our hospital for a liver tumor. He previously underwent rectal amputation for a malignant GIST. Computed tomography (CT) revealed a low-density area in the liver and dynamic contrast-enhanced MRI (EOB-MRI) showed that the tumor was completely washed out in the delayed phase. 18Fluorine-fluorodeoxyglucose positron emission tomography (FDG-PET) showed strong uptake in the liver. A diagnosis of liver metastasis was made and partial hepatectomy was performed. Microscopic examination showed that the tumor was an IPT.

CONCLUSION

Differential diagnosis between IPT and malignant neoplasms is difficult. Moreover, FDG-PET revealed strong uptake in the tumor. To our knowledge, this is the first patient reported to have an IPT in association with a rectal GIST. This patient is discussed along with a review of the literature.

Analysis of long-term survival after hepatectomy for isolated liver metastasis of gastrointestinal stromal tumour

BACKGROUND

In the treatment of liver metastasis of gastrointestinal stromal tumour (GIST), the role of hepatectomy is controversial. This study tried to identify such role by investigating the immediate and long-term surgical outcomes.

METHODS

Data of patients who underwent hepatectomy to treat their metastatic disease were reviewed. Patients whose liver tumours were confirmed to be metastatic GISTs were included for analysis. Clinicopathological characteristics of the primary disease, time of metastasis development and modes of treatment were recorded. Immediate outcome and long-term survival after hepatectomy were analysed.

RESULTS

Ten patients were confirmed to have isolated liver metastasis of GIST. Their median age was 61 (42-74) years. All of them had normal liver function and no cirrhosis. Seven patients received major hepatectomy and three patients received minor hepatectomy. The median operation time was 319.5 (122-735) min. The median tumor size was 5.5 (1.5-15) cm. No hospital death occurred. The 1-, 3- and 5-year overall survival rates were 100, 75 and 50%, respectively and the corresponding disease-free survival rates were 70, 42 and 14%, respectively.

CONCLUSION

Treating isolated liver metastasis of GIST with hepatectomy is effective and safe. Favourable long-term overall survival and disease-free survival can be achieved.

Liver surgery in the multidisciplinary management of gastrointestinal stromal tumour

INTRODUCTION

After the introduction of tyrosine kinase inhibitors (TKIs), the role of surgical resection in treating liver metastasis from gastrointestinal stromal tumour (GIST) is unclear. In this study, we evaluated the outcome of patients treated with TKIs followed by surgery for metastatic GIST.

METHODS

Eleven patients underwent liver resection after downsizing TKIs therapy for metastatic GIST from 2006 until 2010 were reviewed.

RESULTS

One and two-year overall survival rates were 80.8 and 70.7%. All patients with an initially resectable tumour were still alive without recurrence. Patients operated on clinical response had a better outcome (1- and 2-year overall survival (OS) rate 100%) than those operated on disease progression (1- and 2-year OS rates 60 and 40%; P = 0.043). No deaths were observed among patients who achieved an R0 resection (R0 versus R1/R2, P = 0.001).

DISCUSSION

R0 resection and clinical response to TKI are predictor of survival. Surgical resection should be performed as soon as feasible in responding patients. In poor responders, surgery may not add any survival benefit, except in localized progressive disease. In resectable metastatic liver disease, preoperative TKIs or upfront surgery followed by adjuvant therapy could be considered. Larger studies are needed to determine the optimum approach in patients with metastatic GIST.

Predictors of survival and recurrence in primary leiomyosarcoma

BACKGROUND

Leiomyosarcoma is a soft tissue sarcoma whose outcome has historically been confounded by the inclusion of gastrointestinal stromal tumors. Thus, we sought to determine the factors that predict survival and recurrence in patients with primary leiomyosarcoma alone.

METHODS

During 1982-2006, a total of 353 patients with primary resectable leiomyosarcoma were identified from a prospective database. Multivariate analysis was used to assess clinicopathologic factors for association with disease-specific survival (DSS). Competing risk survival analysis was used to determine factors predictive for local and distant recurrence.

RESULTS

Of 353 patients, 170 (48 %) presented with extremity, 144 (41 %) with abdominal/retroperitoneal, and 39 (11 %) with truncal tumors. Median age was 57 (range, 18-88) years, and median follow-up was 50 (range, 1-270) months. Most tumors were high grade (75 %), deep (73 %), and completely resected (97 %); median size was 6.0 (range, 0.3-45) cm. Abdominal/retroperitoneal location was associated with worse long-term DSS compared to extremity or trunk (P = 0.005). However, by multivariate analysis, only high grade and size were significant independent predictors of DSS. Overall, 139 patients (39 %) had recurrence: 51 % of those with abdominal/retroperitoneal, 33 % of extremity, and 26 % of truncal disease. Significant independent predictors for local recurrence were size and margin, whereas predictors for distant recurrence were size and grade. Site was not an independent predictor of recurrence; however, late recurrence (>5 years) occurred in 9 % of abdominal/retroperitoneal and 4 % of extremity lesions.

CONCLUSIONS

Grade and size are significant independent predictors of DSS and distant recurrence. Long-term follow-up in leiomyosarcoma is important, as late recurrence continues in 6-9 % patients.

Leiomyosarcoma of the sigmoid colon with multiple liver metastases and gastric cancer: a case report

Background

Leiomyosarcoma (LMS) of the gastrointestinal tract is an extremely rare high-grade neoplasm with poor prognosis. For advanced LMS with distant metastasis, the decision as to the choice of the most appropriate therapeutic strategy, including chemotherapy and surgery, is difficult. Here, we present an unusual case of LMS of the sigmoid colon with liver metastases and gastric cancer. The survival of this patient was prolonged by a combined modality therapy involving chemotherapy and surgery.

Case presentation

A 66-year-old woman who had been diagnosed with advanced gastric cancer and multiple liver metastases was referred to our hospital. The initial treatment with docetaxel and S-1 considerably reduced both the gastric cancer and liver tumors; consequently we performed surgical resection. Pathological examination revealed that no viable tumor cells remained in the stomach and chemotherapy resulted in complete remission of the gastric cancer. The liver tumors were immunohistochemically diagnosed as LMS. A tumor of the sigmoid colon was subsequently discovered and the liver tumors were found to have recurred. The surgically resected sigmoid colon and liver tumors were all immunohistochemically diagnosed as LMS. These findings indicated that the multiple liver metastases arose from the LMS in the sigmoid colon, and that they were accompanied by advanced gastric cancer. We performed another surgical resection and administered chemotherapy to treat the recurring liver metastases. The patient survived for 4 years and 10 months after initial presentation at our hospital.

Conclusion

Colonic LMS is rare and its joint occurrence with gastric cancer is extremely unusual. Although LMS is a high-grade neoplasm, a multimodal therapeutic approach can increase patient survival time even when multiple liver metastases are present.

A retrospective study of SBRT of metastases in patients with primary sarcoma

We retrospectively reviewed the results of stereotactic body radiotherapy (SBRT) in 46 patients with a total of 136 metastases from primary sarcoma. The purpose of this study was to evaluate the overall response rate and side effects of SBRT in metastatic sarcoma. The patients were treated at Karolinska University Hospital between 1994 and 2005, using 3D conformal multifield technique and a stereotactic body-frame. Prescribed doses ranged from 4 to 20 Gy per fraction in 1–5 fractions, with total doses of 10–48 Gy. All 46 patients were diagnosed with a primary sarcoma. The treated metastases were localized mainly in the lungs. A total number of 136 metastases were treated (1–14 per patient). Overall response rate (local control = CR, PR and SD) for each tumour was 88 % (119/135). Median follow-up was 21.8 months (range 2.7–112.8 months). Thirteen patients (31 %) were long-term survivors (>36 months), and 5 patients are still alive after last follow-up. Two cases of serious non-lethal side effects were seen, one patient had a colon perforation and another patient had contracture of the hip region. SBRT is a safe, convenient and effective non-invasive treatment with high local control for patients with metastatic sarcoma.

Hepatic resection for metastatic gastrointestinal stromal tumors in the tyrosine kinase inhibitor era

BACKGROUND

Before the advent of tyrosine kinase inhibitors (TKIs), surgical resection was the primary treatment for hepatic gastrointestinal stromal tumor (GIST) metastases. Although TKIs have improved survival in the metastatic setting, outcomes after multimodal therapy comprised of hepatectomy and TKIs for GIST are unknown. The objective of this study was to determine whether combination therapy for hepatic GIST metastases is associated with improved overall survival compared with reported outcomes from surgery or TKI therapy alone.

METHODS

Demographics, clinicopathologic tumor characteristics, treatments, and outcomes of patients who underwent hepatic resection at 3 high-volume centers from 1995 to 2010 were reviewed.

RESULTS

In total, 39 patients underwent hepatectomy for metastatic GISTs, and 27 patients received postoperative TKI therapy. At a median follow-up of 39.7 months, 23 patients (59%) experienced recurrence at a median of 18 months. The 1-year, 2-year, and 3-year overall survival rates were 96.7%, 76.8%, and 67.9%, respectively. Median survival was not reached at 5 years. The rates of severe complication and mortality were 10.2% (4 patients) and 2.5% (1 patient), respectively. When controlling for confounders, postoperative TKI therapy was associated with improved survival (hazard ratio, 0.04; 95% confidence interval, 0.01-0.50; P = .006), and extrahepatic disease was associated with worse survival (hazard ratio, 9.51; 95% confidence interval, 1.63-55.7; P = .012).

CONCLUSIONS

Overall survival after combination therapy exceeded previous reports for the treatment of metastatic GIST with hepatic resection or TKI therapy alone and was significantly enhanced by postoperative TKI therapy. The results from this study support findings that combination therapy for GIST liver metastases comprised of surgical resection and TKI therapy is more effective than surgery or TKI therapy alone.

Advances in the surgical management of gastrointestinal stromal tumor

Imatinib mesylate has revolutionized the treatment of GIST. Dramatic changes in clinical practice have been observed in the past decade. Nonetheless, time has also revealed the limitations of treating GIST with a single agent alone, as resistance to imatinib has become a significant clinical dilemma. Surgical resection still remains the only chance for a cure. However, it is clear that GIST is a complex disease and requires effective integration of surgery and targeted therapy to reduce recurrence after resection of primary GIST or to prolong survival in metastatic disease. Recent studies have begun to delineate the feasibility of multimodal treatment of this disease. Knowledge gained thus far, along with ongoing and future investigations of GIST, will be extremely relevant to the potential use of molecular targeted therapy for other solid neoplasms.

Outcomes of single-centre experience of hepatic resection and cryoablation of sarcoma liver metastases

BACKGROUND

Liver metastasis from sarcoma in metastatic disease is common and its effect on prognosis remains ill defined. Surgery remains paramount in sarcoma management; however, there is inadequate literature reporting the role of hepatic surgery as treatment for sarcoma liver metastases.

METHODS

Fifteen patients who underwent hepatic resection for metastatic sarcoma between January 1, 1995 and January 1, 2009 were identified from a prospective hepatobiliary database. Clinicopathologic, operative, recurrence, and long-term survival data are presented.

RESULTS

Three patients had synchronous liver metastases. The median time to developing liver metastasis was 26 (range, 0-206) months. The overall median survival from hepatic resection of liver metastasis was 103 (95% confidence interval, 6-200) months with a 5- and 10-year survival of 51% and 37%, respectively. The median disease-free survival from hepatic resection was 14 (95% confidence interval, 11-18) months. CD117 positive tumors was associated with an improved survival with a 3-year survival of 80% compared with 33% in CD117 negative tumors (P = 0.02).

CONCLUSIONS

Hepatic resection for sarcoma liver metastases with or without extrahepatic disease is a reasonable management strategy if a complete resection may be achieved. Concomitant treatment of CD117 positive tumors with imatinib leads to long-term survival.

Patient selection for surgical management of primary and metastatic liver cancers: current perspectives

The surgical management of liver malignancies remains a mainstay in the treatment of such patients, and has benefited from dramatic advancements over the last two decades. Improvements in surgical technique, better understanding of hepatic anatomy, and improvement in anesthesiological supportive care has resulted in a decline in perioperative morbidity and operative mortality. Proper patient selection for surgical and nonsurgical treatment currently employs a multidisciplinary approach in our institution. This review will focus on the surgical treatment options for both primary and secondary liver cancers.

Surgery for liver metastases originating from sarcoma-case series

INTRODUCTION

Liver metastases originating from various types of sarcoma are a rare reason for hepatic resection. So far, even multicentre studies do hardly provide statistically relevant sample sizes. Thus, review of available data can provide surgeons with useful information in similar cases. Therefore, this study can be regarded more as a contribution to this pool of data than as a stand-alone paper.

PATIENTS AND METHODS

The study includes 10 women and five men who underwent subtotal hepatic resection for solitary (n = 4) and multiple (n = 11) liver metastases originating from sarcoma. The median tumour diameter was 60 mm (range 20-200 mm).

RESULTS

Morbidity was 33%. One patient died within 30 days after surgery. Resection was complete (R0) in 67%. Median overall survival was 33.6 months, 5-year survival 27%. The use of Pringle manoeuvre was significantly associated with poorer outcome (p = 0.014) and shorter period of recurrence-free survival (p = 0.012). Diameter of liver lesion over 50 mm showed significantly shorter recurrence-free survival (p = 0.042).

CONCLUSION

Hepatic resection may be beneficial in patients with isolated sarcoma metastasis in the liver.

Hepatic resection for non-colorectal, non-neuroendocrine, non-sarcoma metastasis: a single-centre experience

BACKGROUND

The aim of the present study was to analyse the outcome after hepatic resection for non-colorectal, non-neuroendocrine, non-sarcomatous (NCNNNS) metastatic tumours and to identify the factors predicting survival.

METHODS

All patients who underwent hepatic resection for NCNNNS metastatic tumours between September 1996 and June 2009 were included. Patients' demographics, clinical and histopathological parameters, overall survival and the factors predicting survival were analysed.

RESULTS

In all, 65 patients underwent hepatic resection for metastasis. The most common site of a primary tumour was the kidney (24 patients). Fifteen patients had synchronous tumours. Fifty patients had major liver resections and 22 patients had bilobar disease. The median number of liver lesions resected was 1 and the median maximum diameter of the metastasis was 6 cm. A R0 resection was performed in 51 patients. The 1-, 3- and 5-year overall survival from the time of metastasectomy was 72.9%, 47.9% and 25.6%, respectively, with a median survival of 19 months. The presence of a tumour of greater than 6 cm (P= 0.048) and a positive resection margin (P= 0.04) were associated with poor survival.

CONCLUSION

Hepatic resection for metastasis from NCNNNS tumours can offer acceptable long-term survival in selected patients. To offer a chance of a cure a R0 resection must be performed.

Liver transplantation for metastasized extragastrointestinal stromal tumor: a case report and an overview of literature

A 63-year-old woman underwent living donor liver transplantation for hepatic metastases of an extragastrointestinal stromal tumor (EGIST) originating from the rectovaginal space. Due to a multifocal extrahepatic tumor recurrence, treatment with imatinib mesylate was started after extensive pharmacokinetic studies to rule out possible interactions with immunosuppressives. We performed several re- resections for EGIST recurrence thereafter. At the last follow-up, 17 years after primary tumor resection and 10 years after living donor liver transplantation, the patient is symptom-free under immunosuppressive and imatinib mesylate treatments with a 2-cm stable recurrent pararectal EGIST. To our knowledge, this is the only report published on a patient who underwent transplantation for hepatic EGIST metastases with a posttransplantation follow-up of 10 years and the first report on living donor liver transplantation for metastasized EGIST. This is the first description of pharmacokinetics of imatinib and its main active metabolite CGP74588 in a liver transplant recipient.

A long-term follow-up of the imatinib mesylate treatment for the patients with recurrent gastrointestinal stromal tumor (GIST): the liver metastasis and the outcome

Background

About 80% of patients with GIST would experience tumor recurrence or metastasis after radical resection. The most common site of the metastasis is the liver. Imatinib mesylate has been proved effective for advanced GIST. The present study was designed to further observe the effectiveness of the imatinib mesylate treatment on the recurrent GIST and the correlation between the liver metastasis and the outcome.

Methods

Forty-two patients who had recurrent GIST after the first radical resection were enrolled. According to the recurrent sites, the patients were divided into 3 groups: group LG (recurrent liver GISTs), group AG (recurrent abdominal GISTs) and group ALG (recurrent abdominal and liver GISTs). All the patients were given imatinib mesylate at an initial dose of 400 mg per day. Their clinical data was prospectively collected. A follow-up over 3 years was conducted. Tumor response, time to progression and survival were evaluated.

Results

The long-term Imatinib mesylate treatment was safe and well tolerated. At a median follow-up time for 39.5 months, the 3-year survival rate was 66.7%. Median TTP and OS were 37 months (95% CI: 28.2~45.8 months) and 48 months (95% CI: 37.0~58.9 months), respectively. There was no statistical difference in tumor response among the 3 groups. The similar TTP (P = 0.291) and OS (P = 0.160) were observed in the 3 groups.

Conclusions

The imatinib mesylate treatment could prolong the survival of the patients who have recurrent GIST after the radical surgery in spite of an existence of the liver metastasis. Survival was not significantly affected by liver metastasis when imatinib mesylate was warranted.

[Primary pancreatic sarcoma with liver metastases: is there a place for radical surgery?]

Pancreatic leiomyosarcomas are a rare neoplasm that accounts for 1/1000 of pancreatic cancers. In the literature, 23 cases of pancreatic leiomyosarcoma have been reported and the majority being diagnosed on autopsy. It has never been reported any radical curative surgery in presence of synchronous hepatic metastasis. We reported a case of a patient affected by a primitive pancreatic leiomyosarcoma with bilobar hepatic metastasis, who underwent distal splenopancreatectomy associated with the resection of multiple liver metastases.

Non-colorectal, non-neuroendocrine, and non-sarcoma metastases of the liver: resection as a promising tool in the palliative management

PURPOSE

Hepatic resection is established as a safe procedure for colorectal, neuroendocrine, and sarcoma liver metastases. The present study evaluates whether liver resection is an option for patients with non-colorectal, non-neuroendocrine, and non-sarcoma metastases of the liver.

METHODS

According to data from our prospective clinical tumor registry, we reviewed the medical records of 44 consecutive patients with non-colorectal, non-neuroendocrine, and non-sarcoma liver metastases, who underwent hepatic resection from January 2000 to December 2008. Univariate Kaplan-Meier analysis and a stepwise multivariable Cox regression model were applied.

RESULTS

Following hepatic resection, mean overall survival was 21 months, and 5-year survival was 20%. Following hepatic resection, gender, histology, and chemotherapy were of prognostic value in our patient cohort in univariate analysis (p < 0.05). Multivariate survival analysis confirmed chemotherapy (p = 0.002) as an independent prognostic variable. Following initial resection of the primary tumor, synchrone occurrence of metastases, histology, localization of primary, perioperative complications, interval between initial resection of the primary tumor and resection of the metastases, and metastases in follow-up after hepatic resection were of prognostic value in univariate analysis (p < 0.05). Histology (p = 0.017) and interval between resection of the primary and resection of the metastases (p = 0.030) were confirmed as independent prognostic variables in multivariate survival analysis.

CONCLUSIONS

Hepatic resection seems to be a safe and promising additive for a selective group of patients with non-colorectal, non-neuroendocrine, and non-sarcoma metastases of the liver.

[Surgical therapy of abdominal and trunk soft tissue sarcomas]

Soft tissue sarcomas are rare tumours of mesenchymal cells which can arise in all parts of the body. Sarcomas of the trunk and abdominal cavity are a very heterogeneous group of tumours. This review focuses on retroperitoneal sarcomas, which tend to be asymptomatic for a long time, resulting in an advanced stage at presentation in most patients. Surgical resection is the basis for cure in these patients, possibly combined with radiation. In contrast to extremity sarcomas, the majority of patients with retroperitoneal sarcomas succumb to an isolated local recurrence of the disease. In case of local recurrence or distant metastases, surgical resection should again be contemplated.

Fluorodeoxyglucose positron emission tomography in leiomyosarcoma: imaging characteristics

OBJECTIVE

Leiomyosarcoma, a malignant neoplasm of smooth muscle, accounts for 7% of the sarcomas. Patients with leiomyosarcoma tumors have an average survival of 5 years. These tumors, which are derived from mesenchymal tissues, are difficult to diagnose, and treatment options remain controversial. The relatively rare incidence of this soft tissue sarcoma subtype has limited the number of patients available for studies and research. This study examines whether the imaging characteristics of positron emission tomography (PET) with radiolabeled fluorodeoxyglucose (FDG) provide a reliable, noninvasive means to predict tumor behavior in patients with leiomyosarcomas.

METHODS

[18F]-FDG-PET was performed on the tumors of participating patients before the neoadjuvant chemotherapy or resection, and a maximum tumor standard uptake value (SUVmax) was calculated.

RESULTS

The SUVmax was correlated with tumor grade (P=0.001) and tumor size as greatest dimension (P=0.004). Analysis of these data indicated the potential effectiveness of FDG-PET imaging in predicting tumor grade.

CONCLUSION

In leiomyosarcoma, the SUVmax from FDG-PET is a likely predictor of tumor behavior. The results of this study suggest that a large (by greatest dimension) intermediate grade tumor is expected to have the same predicted outcome as a high-grade tumor and should be treated in the same manner, as they share the same prognosis by definition of tumor grade. Improvements made in the clinical treatment of leiomyosarcomas by use of FDG-PET imaging data may lead to an increase in patient survival.

Hepatic metastasectomy for soft-tissue sarcomas: is it justified?

BACKGROUND

Except for patients with gastrointestinal stromal tumors (GIST), systemic chemotherapy in patients with liver metastasis of soft-tissue sarcoma (STS) is not effective. Therefore, all patients with resectable liver metastases underwent surgical therapy. We present our experience with this approach during the last 13 years.

METHODS

All patients (n=45) with liver metastasis of STS undergoing surgical therapy were prospectively analyzed. Clinical and histopathological parameters as well as the postoperative course were recorded. Survival data were analyzed by using the Kaplan-Meier method and the log-rank test.

RESULTS

Twenty-seven of 45 patients with liver metastasis underwent hepatic resection; 59% of these patients had a solitary metastasis, 22% had two metastases, and 18% had three or more metastatic nodules. The surgical perioperative mortality was 7%. The median survival was 44 (range, 1-123) months, and the 5-year survival was 49%. Repeated resection for recurrent tumor was performed in eight patients, which yielded a median survival of 76 months.

CONCLUSIONS

Patients who have hepatic metastases that are functionally and technically resectable should be considered for surgery because this treatment offers the chance for long-term survival (>5 years).

[Uterine sarcoma treatment]

There are many common features between uterine sarcomas - leiomyosarcoma, endometrial stromal sarcoma, undifferentiated endometrial sarcoma and adenosarcoma -with regards to course, therapy and follow-up, such as post-menopausal bleeding or additional premenopausal bleeding, as well as rapid growth. There is a new staging system according to FIGO and new therapy recommendations according to NCCN. Prior to therapy, imaging staging of the pelvis, abdomen and chest should be carried out due to the frequency with which metastases are found at the time of diagnosis. In the case of disease spread in uterine sarcomas and malignant mixed tumors, good supportive therapy is a possible therapy option instead of chemo- or radiotherapy. The approach - observation, surgery, lymphonodectomy, mono- or polychemotherapy, radiotherapy, hormone therapy - is chosen according to the extent of spread and the resection status. Neoadjuvant therapies are not as yet established.

Developments in the Management of Extremity Soft Tissue Sarcomas

Soft tissue sarcomas, a rare and extremely low prevalence tumor, has no uniform treatment recommendation because there have been few randomized prospective trials to guide management. Recently, there have been surgical, medical, biologic, and genetic advances toward improved treatment. A multidisciplinary approach at specialized treatment centers should be sought because the skill set necessary to implement these advances can be provided and outcomes improved. Centralized care will be crucial to improving survival and functional outcome because it will allow for patients to be effectively entered into prospective randomized trials and create regional and national tissue banks to generate meaningful data.

Hepatectomia para o tratamento de metástases colorretais e não-colorretais: análise comparativa em 30 casos operados

RACIONAL: Hepatectomia é a melhor opção terapêutica curativa para metástases hepáticas de origem colorretal. Mais recentemente, ressecção hepática também tem sido realizada para metástases de etiologia não-colorretal. OBJETIVO: Comparar os resultados em curto e longo prazo de uma série de hepatectomias para 20 doentes com metástase colorretal com uma série de 10 doentes com metástase não-colorretal realizadas pelo Serviço de Cirurgia Geral (Disciplina de Cirurgia do Aparelho Digestivo) da Faculdade Medicina do ABC (Santo André - Brasil). MÉTODOS: Os dados completos de 30 doentes submetidos à hepatectomia por metástase metacrônica entre o período de Janeiro de 2001 e Setembro de 2007 foram avaliados. Vinte com metástase colorretal (Grupo 1) foram comparados com dez com metástase não-colorretal (Grupo 2). Foi realizada análise multivariada dos fatores prognósticos com o programa Epi-Info para Windows. RESULTADOS: Foram realizadas vinte hepatectomias maiores e dez hepatectomias menores. A morbidade foi similar entre os grupos (p >0,05). A mortalidade cirúrgica foi maior no Grupo 1 do que no Grupo 2 (5 % X 0 %), mas não houve significância estatística (p>0,05). Os índices de sobrevida global em 3 e 5 anos foram comparáveis entre os dois grupos (p>0,05). CONCLUSÃO: Nessa amostra, a ressecção hepática para metástase de etiologia não-colorretal apresenta resultados similares aos da metástase colorretal com sobrevida em cinco anos de 20 %. Foram fatores prognósticos adversos: mais que uma metástase e linfonodo positivo.

Hepatic resection for gastrointestinal stromal tumor liver metastases

Liver resection is the preferred treatment for gastrointestinal stromal tumor liver metastases (GIST LMs) when complete resection can be achieved. Major and extended hepatic resections can be safely performed, and using modern techniques, an increasing proportion of patients with GIST LMs are candidates for potentially curative therapy. The combination of tyrosine kinase inhibitor therapy (eg, imatinib) with surgery seems to improve outcome, and although prospective data are lacking, a short neoadjuvant course (6 months) of imatinib therapy followed by resection may improve patient selection for surgery and outcome from treatment. Postoperative therapy with imatinib is generally advised, although the duration of such therapy is not yet clearly defined. These questions may formulate the basis for future prospective studies of imatinib with complete resection of GIST LMs.

Management of resectable gastrointestinal stromal tumor

Gastrointestinal stromal tumor (GIST) is a rare neoplasm that recently has become an intense focus of scientific investigation, as it serves as a model for the molecular therapy for cancer. Although surgery remains the principle treatment of primary localized GIST, imatinib mesylate, a selective inhibitor of KIT protein, achieves dramatic responses in metastatic GIST. Multimodality therapy integrating surgery and molecular therapy has shown promise. This article summarizes the epidemiology, clinicopathologic features, natural history, and clinical management of GIST.

Multidisciplinary treatment of gastrointestinal stromal tumors

Gastrointestinal stromal tumor (GIST) has been recognized as a unique tumor only in the last decade. Although rare as a clinical entity, there is much interest in the pathology and treatment because the KIT protooncogene mutation common to most GISTs can be inhibited by imatinib mesylate. Diagnosing and treating GIST requires a multidisciplinary approach, given the combination of pathologic and radiographic evaluation, surgical treatment, and oncologic care required to successfully treat patients with GIST.

Surgical management of gastrointestinal stromal tumors: analysis of outcome with respect to surgical margins and technique

This report reviews the methods and goals of treatment of gastrointestinal stromal tumor (GIST), the most common mesenchymal tumor of the gastrointestinal tract. GISTs express CD117, which serves as an immunohistochemical diagnostic marker. Surgical excision is the definitive treatment for all primary GISTs greater than 2 cm without evidence of peritoneal seeding or metastasis. Preoperative or intraoperative biopsy is not indicated except when the differential diagnosis includes another type of malignancy. Resection may be performed by traditional open surgery or by laparoscopic or laparoscopy-assisted procedures. Regardless of the approach, oncological precautions must be strictly observed. Tumor disruption is to be avoided at all costs; tumor enucleation leaves a tumor-seeded pseudocapsule behind and is considered insufficient. Because GISTs rarely metastasize through the lymphatics, routine lymphadenectomy is not indicated. The importance of achieving negative microscopic margins is controversial, although patients who undergo incomplete microscopic resection may be at greater risk of locoregional recurrence. Other factors, such as tumor grade and size, may play a more significant role in predicting recurrence. Cases of advanced disease or involvement of adjacent structures should be evaluated on an individual basis by a multidisciplinary team.

Patient selection and outcome of hepatectomy for noncolorectal non-neuroendocrine liver metastases

Improved patient selection, introduction of more effective systemic treatments including targeted biologic and combined therapies, and the low morbidity and mortality rates of hepatobiliary surgery in centers of excellence are likely to provide continued improvements in outcomes for patients with noncolorectal non-neuroendocrine liver metastases. Further advances in treatment may emerge from better understanding of the underlying tumor biology for each cancer type and application of individualized care to each patient.

Pathologic complete response confirmed by surgical resection for liver metastases of gastrointestinal stromal tumor after treatment with imatinib mesylate

A 39-year-old male underwent distal gastrectomy for a high grade gastrointestinal stromal tumor (GIST). Computed tomography (CT) and magnetic resonance imaging (MRI) 107 mo after the operation, revealed a cystic mass (14 cm in diameter) and a solid mass (9 cm in diameter) in the right and left lobes of the liver, respectively. A biopsy specimen of the solid mass showed a liver metastasis of GIST. The patient received imatinib mesylate (IM) treatment, 400 mg/day orally. Following the IM treatment for a period of 35 mo, the patient underwent partial hepatectomy (S4 + S5). The effect of IM on the metastatic lesions was interpreted as pathologic complete response (CR). Pathologically verified cases showing therapeutic efficacy of IM have been rarely reported.

Gastrointestinal stromal tumors and leiomyosarcomas

Only recently has gastrointestinal stromal tumor (GIST) been recognized as the most frequent GI mesenchymal neoplasm. Prior to the use of KIT staining, most GI stromal tumors were identified as leiomyosarcoma (LMS). For primary GIST, surgery remains the principal treatment and adjuvant imatinib may improve outcomes. Multimodality therapy may also be effective in patients with metastatic GIST. In this review, we summarize the epidemiology, clinicopathologic features, natural history, and clinical management of LMS and GIST.

Diagnosis and treatment of metastatic disease to the liver

A number of cancers present with synchronous or metachronous hepatic metastases. Historically, many of these patients were considered unresectable and were treated with either systemic chemotherapy or supportive care. Today, a variety of options exist for the management of hepatic metastases. Newer agents for systemic therapy continue to be introduced and are providing improved progression-free and overall survival and increased resectability of liver metastases. However, complete surgical resection of isolated hepatic metastases remains the optimal management for these patients. Surgical interventions can be offered to patients with hepatic-only metastases. Hepatic artery chemotherapy represents an adjunct for those patients undergoing resection and can improve survival. This benefit may be even more pronounced when combined with systemic chemotherapy. Newer generation biologic agents can improve results. New therapeutic modalities to treat lesions that are unresectable include ablative techniques such as radiofrequency ablation (RFA) and cryoablation. This article will examine modalities of diagnosis of hepatic metastases and highlight the data regarding hepatic resection for metastases of several types of primary cancers, the rationale for, and efficacy of, hepatic arterial chemotherapy, in both the postoperative adjuvant setting and in unresectable liver disease, and review the current literature for ablative techniques in the treatment of liver metastases.

Effect of loss of heterozygosity of the c-kit gene on prognosis after hepatectomy for metastatic liver gastrointestinal stromal tumors

The authors have previously reported that loss of heterozygosity (LOH) of the c-kit gene could be responsible for the gain in high proliferative activity in some gastrointestinal stromal tumors (GIST), resulting in enhanced metastatic potential. In the present study, an attempt was made to identify the factors that might predict the postoperative prognosis of patients with metastatic liver GIST. The clinicopathologic or genetic features of resected liver GIST in 14 patients who had undergone a hepatectomy for metachronous liver metastases and who had not received adjuvant imatinib treatment were examined. LOH of the c-kit gene was observed in seven of 12 metastatic liver GIST (58.3%), of which DNA suitable for testing could be extracted. Ten patients had recurrence after hepatectomy and four had none. The median post-recurrent disease-free survival (PRDFS) after hepatectomy was 27.5 months (range 8-104). The tumor-specific PRDFS was examined using clinicopathologic features, c-kit mutation and LOH of the c-kit gene. No single clinicopathologic or genetic finding was significantly associated with PRDFS. However, patients with 'Ki67 labeling index <5% and LOH(-)' had a significantly longer PRDFS than those with 'Ki67 >/=5% or LOH(+)' (P = 0.032), and there was no correlation between the presence of LOH of the c-kit gene and the Ki67 labeling index. LOH of the c-kit gene in metastatic liver seems to be a common event, and LOH of the c-kit gene in resected liver GIST may be a helpful factor in the prediction of the post-recurrent prognosis of patients with liver metastasis.