Hepatectomy for metastatic noncolorectal gastrointestinal, breast and testicular tumours

Time interval-based indication for liver resection of metastasis from pancreatic cancer

Background

Surgical indications for liver metastases from pancreatic ductal adenocarcinoma (PDAC) are lacking because outcomes are usually poor. However, liver resection and the recent progress in perioperative chemotherapy have been observed to improve survival.

Methods

We performed liver resection for liver metastases from PDAC only under the following criteria: (1) liver-only metastasis, (2) up to three tumors, and (3) no increase in the number of metastases during the 3-month observation period. No limitations were placed on the location or size of liver metastasis. In this study, we aimed to validate our surgical criteria and analyze factors affecting survival in patients with PDAC.

Results

Seventy-nine patients underwent curative resection for PDAC between 2005 and 2015. Seventy-one patients experienced recurrence, with liver-only recurrence in 17 patients. Among these, nine patients underwent liver resection and eight did not. The median survival time was significantly better for patients who underwent liver resection (55 months) than for those with other recurrences (17.5 months, p = 0.016). The median survival after liver recurrence was significantly better in the liver resection group (31 months) than in the non-liver resection group (7 months, p = 0.0008). The median disease-free interval (DFI) after pancreatectomy was significantly longer in the liver resection group (21 months; range, 3–44 months) than in the non-liver resection group (3 months; range, 2–7 months; p = 0.02).

Conclusion

Good indications for liver metastases from PDAC include solitary metachronous tumors and longer DFIs.

Liver resection for noncolorectal and nonneuroendocrine metastases: Results of a study on 56 patients at a single institution

The usefulness of surgical treatment for hepatic metastases of noncolorectal non-neuroendocrine (NCRNNE) tumors is not yet clear due to the natural history of these tumors, their frequent systemic dissemination and their histological heterogeneity. The aim of this study was to evaluate the long-term outcome of patients who underwent liver resection for NCRNNE metastases. For this purpose we retrospectively analyzed 202 patients who underwent liver resection for metastasis between January 1989 and December 2006 at the Department of Surgery of the University Hospital of Udine. Fifty-six patients underwent liver resection because of NCRNNE metastases. The preoperative assessment was based on hepatic ultrasonography and CT scan; PET was used in a few patients. All patients had intraoperative liver ultrasonography to evaluate the lesions and to define the resection. Gender, age, primary tumor site (gastrointestinal or nongastrointestinal), synchronous or metachronous metastasis, unilobar or bilobar localization, number and diameter of the lesion(s), type of resection, margin status, positive lymph nodes in the hepatoduodenal ligament, and time between surgery and diagnosis of liver metastases were evaluated as possible prognostic factors for survival. Univariate analysis showed that the location of the primary tumor and the disease-free interval since the treatment of the primary tumor were positive predictive factors for longer survival. Multivariate analysis showed that the only independent significant factor was gastrointestinal versus nongastrointestinal origin. Demographic data, the synchronous or metachronous appearance of metastases, their unilobar or bilobar location, number and size, the type of resection, the resection margin status and the involvement of lymph nodes did not prove to be prognostic factors.

Hepatic Resection or Ablation for Isolated Breast Cancer Liver Metastasis: A Case-control Study With Comparison to Medically Treated Patients. Ann Surg. 2016;264:147-154. [PMID: 26445472 DOI: 10.1097/sla.0000000000001371]

OBJECTIVE

To evaluate the efficacy of surgical treatment for patients with isolated breast cancer liver metastases (BCLM).

BACKGROUND

Single-arm retrospective studies have shown promising results associated with surgery for isolated BCLM; however, this treatment remains controversial and its role is not well-defined.

METHODS

A review of 2150 patients with BCLM who underwent treatment in a single institution was conducted, and 167 (8%) patients with isolated BCLM were identified. A case-control study was conducted to compare outcomes in patients with isolated BCLM who underwent surgery and/or ablation to patients who underwent conventional medical therapy.

RESULTS

A total of 167 patients were included (surgery/ablation: 69; medical: 98), with a median follow-up for survivors of 73 months. Patients in the surgical cohort more frequently had estrogen receptor-positive tumors and received adjuvant chemotherapy and radiotherapy for their primary breast tumor. The hepatic tumor burden was less and the interval from breast cancer diagnosis to BCLM was significantly longer (53 vs 30 months) in the surgical cohort. Patients undergoing surgical treatment had a median recurrence-free interval of 28.5 months (95% confidence interval (CI): 19-38) with 10 patients (15%) recurrence free after 5 years. There was no significant difference in overall survival (OS) between the surgical and medical cohorts (median OS: 50 vs 45 months; 5-year OS: 38% vs 39%).

CONCLUSIONS

Hepatic resection and/or ablation was not associated with a survival advantage. However, significant recurrence-free intervals can be accomplished with surgical treatment. Surgical intervention might be considered in highly selected patients with the goal of providing time off of systemic chemotherapy.

Liver Resection for Non-colorectal Non-neuroendocrine Metastases: Where Do We Stand Today Compared to Colorectal Cancer?

The continuing controversy about surgery for non-colorectal non-neuroendocrine liver metastases (NCRNNE) necessitates identifying risk factors of worsened outcomes to improve patient selection and survival. Prospectively collected data of 167 patients undergoing hepatectomy for NCRNNE were analyzed, and a comparison to a matched population of colorectal liver metastases (CLM) was performed. Overall survival (OS) (35 vs. 54 months; P = 0.008) and recurrence-free survival (RFS) (15 vs. 29 months; P = 0.004) of NCRNNE patients were significantly shorter compared to those with CLM. The best survival was found in the genitourinary (GU; OS, 45 months; RFS, 21 months) NCRNNE subgroup, whereas survival for gastrointestinal (GI) metastases was low (OS, 8 months; RFS, 7 months). Patients with renal cell carcinoma (RCC) showed excellent outcomes when compared to CLM (OS, 50 vs. 51 months; P = 0.901). Extrahepatic disease (EHD) was identified as independent prognostic factor for reducing both RFS (P = 0.040) and OS (P = 0.046). The number of liver lesions (P = 0.024), residual tumor (P = 0.025), and major complications (P = 0.048) independently diminished OS. The degree of survival advantage by surgery is determined by the primary tumor site, EHD, the number of metastases, and residual tumor. Thus-even more than in CLM-these oncological selection criteria must prevail. GU metastases, especially RCC, represent a favorable subgroup.

Liver Resection for Non-Colorectal Liver Metastases - Standards and Extended Indications

Background

Due to the uncertain benefit of liver resection for non-colorectal liver metastases (NCLM), patient selection for surgery is generally difficult. Therefore, the aim of this article was to propose standard and extended indications for liver resection in this heterogeneous disease collective.

Methods

Review of the literature.

Results

The myriad of biologically different primary tumor entities as well as the mostly small and retrospective studies investigating the benefit of surgery for NCLM limits the proposal of general recommendations. Only resection of neuroendocrine liver metastases (NELM) appears to offer a clear benefit with a 5- and 10-year overall survival (OS) of 74 and 51%, respectively, in the largest series. Resection of liver metastases from genitourinary primaries might offer reasonable benefit in selected cases – with a 5-year OS of up to 61% for breast cancer and of 38% for renal cell cancer. The long-term outcome following surgery for other entities was remarkably poorer, e.g., gastric cancer, pancreatic cancer, and melanoma reached a 5-year OS of 20-42, 17-25, and about 20%, respectively.

Conclusion

Liver resection for NELM can be defined as a standard indication for the resection of NCLM while lesions of genitourinary origin might be defined as an extended indication.

Yttrium-90 radioembolization stops progression of targeted breast cancer liver metastases after failed chemotherapy. J Vasc Interv Radiol. 2014;25:1523-1532, 1532.e1-1532.e2. [PMID: 25156827 DOI: 10.1016/j.jvir.2014.07.007]

PURPOSE

To determine, in an open-label, retrospective report, the safety and effectiveness of locoregional therapy with yttrium-90 ((90)Y) radioembolization for patients with progressing breast cancer liver metastases (BCLMs) despite multi-agent chemotherapy.

MATERIALS AND METHODS

Seventy-five patients with progressing BCLMs and stable extrahepatic disease were treated with radioembolization at a single institution. Retrospective review of a prospectively collected database was performed to evaluate clinical and biochemical toxicities, tumor response, overall survival (OS), and time to progression. Radiologic response assessments included Response Evaluation Criteria In Solid Tumors in primary index lesions and metabolic activity on positron emission tomography (PET). Univariate and multivariate analyses were performed.

RESULTS

The mortality rate at 30 days was 4% (n = 3). Clinical toxicity and hyperbilirubinemia of grade 3 or worse occurred in 7.6% (n = 5) and 5.9% of patients (n = 4), respectively. Partial response (PR) was seen in 35.3% of patients (n = 24), stable disease (SD) in 63.2% (n = 43), and progressive disease in 1.5% (n = 1). PET imaging was available in 25 patients, and 21 (84%) had a complete response, PR, or SD. The median OS was 6.6 months (95% confidence interval [CI], 5.0-9.2 mo). The hazard ratio (HR) for OS on multivariate analysis was 0.39 (95% CI, 0.23-0.66) for tumor burden less than 25% compared with greater burden. Elevated bilirubin levels were shown to reduce OS. The HR for hepatic progression was 0.22 (95% CI, 0.05-0.98) for solitary versus multifocal disease.

CONCLUSIONS

Locoregional therapy with (90)Y radioembolization is safe and stops or delays the progression of targeted chemorefractory BCLMs. Adverse prognosticators were identified.

Liver resections of isolated liver metastasis in breast cancer: results and possible prognostic factors

Background. Breast cancer liver metastasis is a hematogenous spread of the primary tumour. It can, however, be the expression of an isolated recurrence. Surgical resection is often possible but controversial. Methods. We report on 29 female patients treated operatively due to isolated breast cancer liver metastasis over a period of six years. Prior to surgery all metastases appeared resectable. Liver metastasis had been diagnosed 55 (median, range 1–177) months after primary surgery. Results. Complete resection of the metastases was performed in 21 cases. The intraoperative staging did not confirm the preoperative radiological findings in 14 cases, which did not generally lead to inoperability. One-year survival rate was 86% in resected patients and 37.5% in nonresected patients. Significant prognostic factors were R0 resection, low T- and N-stages as well as a low-grade histopathology of the primary tumour, lower number of liver metastases, and a longer time interval between primary surgery and the occurrence of liver metastasis. Conclusions. Complete resection of metastases was possible in three-quarters of the patients. Some of the studied factors showed a prognostic value and therefore might influence indication for resection in the future.

Prognostic factors and 10-year survival in patients with hepatocellular carcinoma after curative hepatectomy

PURPOSE

There were contrary results about the effects of hepatitis B e antigen (HBeAg) positivity on the long-term survival in patients with hepatocellular carcinoma (HCC) after curative resection.

PATIENTS AND METHODS

Medical records of 170 HCC patients who underwent curative liver resections were retrospectively reviewed. The 10-year survival rate and correlations among clinical, laboratory, and pathological data, especially HBeAg, were analyzed.

RESULTS

Fifty-two patients survived more than 10 years. The 10-year actual overall survival (OS) rate was 30.6%, and the actual disease-free survival (DFS) rate was 24.1%. The median OS and DFS were 76 and 35 months, respectively. In multivariate analysis, HBeAg positivity (P = 0.032; hazard ratio [HR], 3.041), presence of a satellite nodule (P = 0.007; HR, 4.166), and elevated ICG R15 (P = 0.003; HR, 4.915) had a significant negative correlation with the 10-year DFS rate. In addition, HBeAg positivity (P = 0.044; HR, 3.725) and recurrence (recur within 1 year, P < 0.001; HR, 41.296; recur after 1 year, P = 0.03; HR, 4.848) were found as independent factors which were negatively correlated to the 10-year OS.

CONCLUSIONS

The presence of HBeAg was significantly correlated to DFS and OS after curative resection for HCC. Active treatment of B viral hepatitis before and after surgery should be provided to prolong survival in patients with 5-10-cm HCC.

Surgical treatment for liver cancer

Primary liver cancer is amongst the commonest tumors worldwide, particularly in parts of the developing world, and is increasing in incidence. Over the past three decades, surgical hepatic resection has evolved from a high risk, resource intensive procedure with limited application, to a safe and commonly performed operation with a range of indications. This article reviews the approach to surgical resection for malignancies such as hepatocellular cancer, metastatic liver deposits and neuroendocrine tumors. Survival data after resection is also reviewed, as well as indications for curative resection.

Transarterial chemoembolization (TACE) with mitomycin C and gemcitabine for liver metastases in breast cancer

The purpose of this study was to evaluate the efficacy of transarterial chemoembolization (TACE) using different drug combinations in the treatment of breast cancer liver metastases in terms of local tumor control and survival rate. A total of 208 patients (mean age 56.4 years, range 29-81) with unresectable hepatic metastases of breast cancer were repeatedly treated with TACE at 4-week intervals. In total, 1,068 chemoembolizations were performed (mean 5.1 sessions/patient, range 3-25). The chemotherapy protocol consisted of mitomycin-C only (8 mg/m(2); n = 76), mitomycin-C with gemcitabine (n = 111), and gemcitabine only (1,000 mg/m(2); n = 21). Embolization was performed with lipiodol and starch microspheres. Tumor response was evaluated by MRI according to RECIST criteria. Survival rates were calculated using Kaplan-Meier method. For all protocols, local tumor control was partial response 13% (27/208), stable disease 50.5% (105/208), and progressive disease 36.5% (76/208). The 1-, 2-, and 3-year survival rates after TACE were 69, 40, and 33%. Median and mean survival times from the start of TACE were 18.5 and 30.7 months. Treatment with mitomycin-C only showed median and mean survival times of 13.3 and 24 months, with gemcitabine only they were 11 and 22.3 months, and with a combination of mitomycin-C and gemcitabine 24.8 and 35.5 months. TACE is an optional therapy for treatment of liver metastases in breast cancer patients with better results from the combined chemotherapy protocol.

Long-term results of liver resection for non-colorectal, non-neuroendocrine metastases

INTRODUCTION

The safety and efficacy of liver resection for colorectal and neuroendocrine liver metastases is well established. However, there is lack of consensus regarding long-term effectiveness of hepatic resection for non-colorectal, non-neuroendocrine (NCNN) liver metastases.

METHODS

A review of prospectively collected data of patients undergoing hepatic resection for NCNN liver metastases at two tertiary referral centres in the UK and Australia was undertaken. Survival analysis was used to evaluate the clinical, demographic and operative factors associated with long-term survival.

RESULTS

A total of 114 hepatic resections in 102 patients were performed between 1986 and 2006. Postoperative mortality and morbidity was 0.8% and 21.1%, respectively. At 3 and 5 years overall survival was 56.1% and 38.5%, whereas disease-free survival was 37.2% and 26.5%, respectively. On multivariate analysis, factors associated with poor overall survival were diameter of liver metastasis [<5 cm versus >5 cm: hazard ratio (HR) = 2.83, p = 0.001] and the presence of extrahepatic nodal disease (HR = 3.58, p = 0.001). The type of tumor, the presence of distant extra-hepatic metastases, tumor-free interval, number and distribution of metastases did not effect long-term survival.

CONCLUSION

These results of the present study suggest that liver resection is an effective management option in selected patients with NCNN metastases confined to the liver.

WITHDRAWN: Resection versus no intervention or other surgical interventions for colorectal cancer liver metastases

BACKGROUND

About one in four of patients with metastatic colorectal cancer have metastases isolated to the liver, of which 10-25% are eligible for ablation of the liver metastases, improving the 5-year survival rate. Treatments include hepatic resection and non-surgical tumor ablation using cryosurgery and radiofrequency thermal ablation. Although new modalities allow safe ablation of liver metastases without the need for surgical intervention, there are still no clear guidelines on the appropriate management of patients with colorectal cancer and hepatic metastases.

OBJECTIVES

The primary objectives were to compare resection of liver metastases to no intervention and other modalities of intervention (including cryosurgery and radiofrequency ablation), in terms of the benefits and harms for each intervention.

SEARCH STRATEGY

We identified randomized controlled trials from MEDLINE, Embase, and the Cochrane Controlled Trials Register up to October 2006, based upon the search strategy developed for MEDLINE, and revised appropriately for each database. In addition, references were scrutinized in identified eligible trials.

SELECTION CRITERIA

We only considered randomized controlled trials reporting patients of any age and sex, who have had curative surgery for adenocarcinoma of the colon or rectum, diagnosed with liver metastases that are candidates for liver resection, i.e., with no evidence of primary or metastatic cancer elsewhere.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality using a data-extraction form designed for this review. Discrepancies were resolved in consensus.

MAIN RESULTS

Only one trial fulfilled our inclusion criteria. The data of this 10-year prospective, randomized clinical trial suggest that hepatic cryosurgery is effective in the treatment of resectable and non-resectable liver metastases. The results show intra-operative tumor reduction (> or = 90% < or = 97%) and extended higher survival in these patients. The study indicated a 5-year and 10-year survival rate of 44% and 19% after cryosurgery, respectively. However, it was not possible to separate out and unravel the outcomes data that related only to the participants (66.6%) with liver metastases from colorectal cancer as opposed to those with liver metastases from other primary tumors.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to support a single approach, either surgical or non-surgical for the management of colorectal liver metastases. Therefore, treatment decisions should continue to be based on individual circumstances and clinician's experience. We concede that local ablative therapies are probably useful, but they need to be further evaluated in a randomized controlled trial.

Liver resection for non-colorectal, non-neuroendocrine metastases: analysis of a multicenter study from Argentina

BACKGROUND AND AIM

Resection of colorectal liver metastases has become a standard of care, although the value of this procedure in non-colorectal non-neuroendocrine (NCRNNE) metastases remains controversial and is still a matter of debate. The aim of the study was to determine the utility of liver resection in the long-term outcome of patients with NCRNNE metastases.

MATERIAL AND METHODS

The records of 106 patients who underwent liver resection for NCRNNE metastases in the period 1989 to 2006 at 5 HPB Centers in Argentina were analyzed. Patient demographics, tumor characteristics, type of resection, long-term outcome and prognostic factors were analyzed. Depending on primary tumor sites, a comparative analysis of survival was performed.

RESULTS

Mean age was 54 (17-76). Hepatic metastases were solitary in 62.3% and unilateral in 85.6%. Primary tumor sites: Urogenital (37.7%), sarcomas (21.7%), breast (17.9%), gastrointestinal (6.6%), melanoma (5.7%), and others (10.4%). Fifty-one major hepatectomies and 55 minor resections were performed. Twenty patients underwent synchronous resections. An R0 resection could be achieved in 89.6%. Perioperative mortality was 1.8%. Overall, 1-year, 3-year, and 5-year survival rates were 67%, 34%, and 19%, respectively. Survival was significantly longer for metastases of urogenital (p=0.0001) and breast (p=0.003) origin. Curative resections (p=0.04) and metachronous disease (p=0.0001) were predictors of better survival.

CONCLUSIONS

Liver resection is an effective treatment for NCRNNE liver metastases; it gives satisfactory long-term survival especially in metachronous disease, in patients with metastases from urogenital and breast tumors and when R0 procedures can be performed.