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

Surgical Management of Genitourinary Cancer Liver Metastases

Genitourinary cancers are common. Liver metastases from genitourinary cancers are uncommon; isolated liver metastasis is rare. Liver resection in select patients with metastatic renal cell carcinoma can lead to prolonged survival. Patients with metachronous and low-burden disease are most likely to benefit. Chemotherapy is first-line treatment of metastatic germ cell tumors. Liver resection is dependent on germ cell lineage and initial response to chemotherapy. Prognosis with liver metastases from prostate cancer is poor; liver-only lesions are rare. Liver resection generally is not indicated. Cumulative experience with liver resection for metastatic bladder cancer is limited. Liver metastases are poor prognostic indicators for metastasectomy.

Is hepatic resection justified for non-colorectal non-neuroendocrine liver metastases? A systematic review and meta-analysis

BACKGROUND

Hepatic resection (HR) is effective for colorectal or neuroendocrine liver metastases. However, the role of HR for non-colorectal non-neuroendocrine liver metastases (NCNNLM) is unknown. This study aims to perform a systematic review and meta-analysis on long-term clinical outcomes after HR for NCNNLM.

METHODS

electronic search was performed to identify relevant publications using PRISMA and MOOSE guidelines. Primary outcomes were 3- and 5-year overall survival (OS) and disease-free survival (DFS). Secondary outcomes were post-operative morbidity and 30-day mortality.

RESULTS

There were 40 selected studies involving 5696 patients with NCNNLM undergone HR. Pooled data analyses showed that the 3- and 5-year OS were 40% (95% CI 0.35-0.46) and 32% (95% CI 0.29-0.36), whereas the 3- and 5-year DFS were 28% (95% CI 0.21-0.36) and 24% (95% CI 0.20-0.30), respectively. The postoperative morbidity rate was 28%, while the 30-day mortality was 2%. Subgroup analysis on HR for gastric cancer liver metastasis revealed the 3-year and 5-year OS of 39% and 25%, respectively.

CONCLUSIONS

HR for NCNNLM may achieve satisfactory survival outcome in selected patients with low morbidities and mortalities. However, more concrete evidence from prospective study is warrant in future.

Surgical Management of Genitourinary Cancer Liver Metastases

Genitourinary cancers are common. Liver metastases from genitourinary cancers are uncommon; isolated liver metastasis is rare. Liver resection in select patients with metastatic renal cell carcinoma can lead to prolonged survival. Patients with metachronous and low-burden disease are most likely to benefit. Chemotherapy is first-line treatment of metastatic germ cell tumors. Liver resection is dependent on germ cell lineage and initial response to chemotherapy. Prognosis with liver metastases from prostate cancer is poor; liver-only lesions are rare. Liver resection generally is not indicated. Cumulative experience with liver resection for metastatic bladder cancer is limited. Liver metastases are poor prognostic indicators for metastasectomy.

Extended hepatic metastasectomy for renal cell carcinoma-new aspects in times of targeted therapy: a single-center experience over three decades

Purpose

Despite the introduction of novel targeted therapies on patients with renal cell carcinoma, syn- and metachronous metastases (including hepatic lesions) are observed frequently and significantly influence patient survival. With introduction of targeted therapies as an effective alternative to surgery, therapeutical strategies in stage IV disease must be reevaluated.

Methods

This is a retrospective analysis of 40 patients undergoing hepatic resection of histologically confirmed RCC metastases at our institution between April 1993 and April 2017.

Results

The interval between nephrectomy for renal cell carcinoma and hepatic metastasectomy was 44.0 months (3.3–278.5). Liver resections of different extents were performed, including multivisceral resections. The median follow-up was 37.8 months (0.5–286.5). Tumor recurrence after resection of hepatic metastases occurred in 19 patients resulting in a median disease-free survival of 16.2 months (0.7–265.1) and a median overall survival of 37.8 months (0.5–286.5). Multivariable analysis identified multivisceral resection as an independent risk factor for disease-free and overall survival (p = 0.043 and p = 0.001, respectively). A longer interval between nephrectomy and hepatic metastasectomy was identified as an independent significant protective factor for overall survival (p < 0.001). Patients undergoing metastasectomy after introduction of sunitinib in Europe in 2006 (n = 15) showed a significantly longer overall survival (45.2 (9.1–111.0) versus 27.5 (0.5–286.52) months in the preceding era; p = 0.038).

Conclusion

Hepatic metastasectomy, including major and extended resections, on patients with metastasized renal cell carcinoma can be performed safely and may facilitate long-term survival. Due to significant morbidity and increased mortality, multivisceral resections must be weighed against other options, such as targeted therapy.

Electronic supplementary material

The online version of this article (10.1007/s00423-019-01852-4) contains supplementary material, which is available to authorized users.

Predictive model for survival after liver resection for noncolorectal liver metastases in the modern era: a Japanese multicenter analysis

BACKGROUND

Survival benefit of liver resection for noncolorectal liver metastases (NCRLM) remains to be defined.

METHODS

This multicenter, retrospective cohort analysis included consecutive patients with NCRLM whose primary tumor and all metastases were treated with curative intent between 2000 and 2013. The primary endpoint was 5-year overall survival. Clinicopathological factors that affected prognoses were identified using multivariate Cox regression analyses and were included in a predictive model.

RESULTS

Data for 205 patients were analyzed. The three most common primary tumor sites were stomach (39%), pancreas (13%), and urinary tract (10%), with adenocarcinomas the main pathology (52%). R0 resection was achieved in 85%, and the overall survival at 5 years was 41%. In the multivariate analysis, synchronous liver metastases, R1/2 resection, and adenocarcinomas and other carcinomas (with gastrointestinal stromal tumors, neuroendocrine tumors G1/G2, and sarcomas set as the reference group) were independent negative indicators of overall survival. A predictive model effectively stratified the NCRLM patients into low-, intermediate-, and high-risk groups with overall 5-year survival rates of 63%, 38%, and 21%, respectively (P < 0.001).

CONCLUSIONS

Patients who underwent curative resection for metachronous disease and favorable tumor pathology are expected to have better survival in the NCRLM cohort.

Laparoscopic liver resection for non-colorectal non-neuroendocrine metastases: perioperative and oncologic outcomes

BACKGROUND

Liver resection is a treatment of choice for colorectal and neuroendocrine liver metastases, and laparoscopy is an accepted approach for surgical treatment of these patients. The role of liver resection for patients with non-colorectal non-neuroendocrine liver metastases (NCNNLM), however, is still disputable. Outcomes of laparoscopic liver resection for this group of patients have not been analyzed.

MATERIAL AND METHODS

In this retrospective study, patients who underwent laparoscopic liver resection for NCNNLM at Oslo University Hospital between April 2000 and January 2018 were analyzed. Perioperative and oncologic data of these patients were examined. Postoperative morbidity was classified using the Accordion classification. Kaplan-Meier method was used for survival analysis. Median follow-up was 26 (IQR, 12-41) months.

RESULTS

Fifty-one patients were identified from a prospectively collected database. The histology of primary tumors was classified as adenocarcinoma (n = 16), sarcoma (n = 4), squamous cell carcinoma (n = 4), melanoma (n = 16), gastrointestinal stromal tumor (n = 9), and adrenocortical carcinoma (n = 2). The median operative time was 147 (IQR, 95-225) min, while the median blood loss was 200 (IQR, 50-500) ml. Nine (18%) patients experienced postoperative complications. There was no 90-day mortality in this study. Thirty-five (68%) patients developed disease recurrence or progression. Seven (14%) patients underwent repeat surgical procedure for recurrent liver metastases. One-, three-, and five-year overall survival rates were 85%, 52%, and 38%, respectively. The median overall survival was 37 (95%CI, 25 to 49) months.

CONCLUSION

Laparoscopic liver resection for NCNNLM results in good outcomes and should be considered in patients selected for surgical treatment.

Surgical treatment of liver metastases from kidney cancer: a systematic review

BACKGROUND

Liver metastases are present in 20.3% of metastatic kidney cancers. The aim of this literature review was to assess the efficacy of surgical treatment for hepatic metastasis from kidney cancer.

METHODS

An extended web search of the literature was independently performed in March 2018 by two authors according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement.

RESULTS

Through electronic searches, we identified 935 potentially relevant citations. Thirteen articles were finally included in the systematic review. Median survival after resection ranged from 15 to 142 months while the 1-, 3- and 5-year overall survival ranged from 69% to 100%, 26% to 83.3% and 0% to 62%, respectively. Median disease-free survival ranged from 7.2 to 27 months.

CONCLUSION

Surgical treatment of hepatic metastases is performed in approximately 1% of patients with liver metastases and in select patients may be potentially curative. Surgical resection of liver metastases from kidney cancer represents a valid option for selected patients with metastatic renal cancer.

Surgical Management of Renal Cell Cancer Liver Metastases

BACKGROUND AND AIMS

There is an increasing trend toward performing liver resections in the setting of metastatic disease. Renal cell cancer liver metastases are associated with poor survival. The indications for and the short- and long-term outcomes of liver resection for renal cell cancer liver metastases remain not well defined.

MATERIAL AND METHODS

A focused, structured literature review on PubMed, EMBASE, and Google Scholar was performed to identify primary research articles, on short- and long-term outcomes and prognostic factors of patients undergoing liver resection for renal cell cancer liver metastases. Only studies with a sample size equal or larger than 10 patients were included.

RESULTS AND CONCLUSION

A total of 10 studies met inclusion criteria. Median overall survival ranged between 16 and 142 months. Major morbidity was rare while 30-day postoperative mortality was less than 5%. A disease-free interval of more than 2 years from nephrectomy to evidence of liver metastases and a radical, microscopically negative surgical resection (R0) were the most consistent prognostic factors that, in turn, could be used as potential selection criteria to identify patients who can benefit the most from liver-directed surgery. Liver surgery for renal cell cancer liver metastases can be performed with low mortality, acceptable morbidity, and promising survival benefit in carefully selected patients. Studies that can assess the impact of modern, targeted regimens in the preoperative setting and liver-directed surgery and in turn shape new selection criteria are warranted.

Hepatic resection of non-colorectal non-endocrine liver metastases

BACKGROUND

Hepatic resection is standard treatment for liver metastases from colorectal and neuroendocrine cancers as well as primary biliary and hepatic carcinomas. The role of hepatic resection in patients with non-colorectal non-endocrine liver metastases (NCNELM) is less defined. Overall survival in this group of patients is poor with few patients surviving beyond two years, even with modern chemotherapy.

METHODS

A prospective database of all liver resections performed by a single surgeon (KSH) from January 2007 to December 2014 was maintained. Patient demographics, surgical and pathological data were collected prospectively; survival data were updated retrospectively. Patients were grouped according to pathology and analysis was performed using SPSS (version 21).

RESULTS

A total of 48 patients underwent hepatic resection for NCNELM, of which 18 were major resections. Pathologies encountered included sarcoma in 8/48, both breast and ovarian in 6/48 each and renal cell carcinoma and melanoma, each representing 5/48. A result of 38/48 patients undertook chemotherapy prior to surgery. R0 margin was achieved in 96%. Seven patients suffered complications from surgery and one peri-operative mortality. Overall survival at 1, 3 and 5 years was 93%, 83% and 61%, respectively. Forty-four percent of patients developed disease recurrence, 29% at distant sites.

CONCLUSION

Hepatic resection can be achieved safely for NCNELM. Patient selection is key, along with a standardized surgical and anaesthetic technique. Patients should be rigorously investigated to exclude disseminated disease and multidisciplinary discussion must take place prior to surgery. Patients with NCNELM should not routinely be excluded from liver resection and selected patients may benefit from resection.

Hepatectomy for liver metastases in non-colorectal, non-neuroendocrine cancer patients. The survival benefit in primary unresectable cases

BACKGROUND

Although liver resection is widely accepted as a potentially curative treatment for colorectal liver metastases, there is an ongoing debate on the indications for hepatectomy for the treatment of liver metastases from non-colorectal primary tumors. The number of candidates for hepatectomy for non-colorectal liver metastases may increase due to advances in chemotherapy; however, the factors related to prognosis after hepatectomy for non-colorectal liver metastases have yet to be clearly elucidated.

METHODS

The clinical outcomes of 59 patients who underwent hepatectomy for non-colorectal liver metastases at a single institute were retrospectively analyzed.

RESULTS

The 5-year overall survival rate after hepatectomy for non-colorectal, non-neuroendocrine liver metastases was 30%, and 8 patients (gastric cancer (n = 2), ovarian cancer (n = 2), uterine cancer (n = 2) and breast cancer (n = 2)) survived for 5 years. The 5-year disease-free survival rate after hepatectomy was 28%. The postoperative morbidity rate was 25%; however, there were no cases of in-hospital mortality and no patients suffered liver failure. The presence of bilateral liver metastases was identified to be an independent predicting factor for poor prognosis by a multivariate analysis (P = 0.049). The survival rate of the conversion cases (initially unresectable and converted to resection after chemotherapy) was not inferior to that of primary resectable cases in terms of either overall survival or disease-free survival.

CONCLUSION

The present study demonstrates that hepatectomy for liver metastases from non-colorectal tumors is safe and that it may be a promising strategy for prolonging survival and achieving a cure.

Is Hepatic Resection for Non-colorectal, Non-neuroendocrine Liver Metastases Justified?

BACKGROUND

Discussions about the benefit of liver resection (LRx) for non-colorectal, non-neuroendocrine metastases are controversial. This study aimed to analyze the outcome of LRx for these patients and validate a previously published prognostic risk model.

METHODS

The study analyzed 150 patients who underwent LRx for non-colorectal non-neuroendocrine (NCNN) metastases. Patients' demographics, tumor characteristics, treatment options, and postoperative outcome were investigated. The Kaplan-Meier method and Cox regression models were used to assess survival and prognostic variables.

RESULTS

After a median follow-up period of 61 months, 39 % of the patients were alive. The 30-day mortality rate was 0.7 %. The overall, disease-free, and intrahepatic recurrence-free survival rates were respectively 42, 29, and 51 % at 5 years and 28, 23, and 47 % at 10 years. The negative prognostic factors identified in the multivariate analysis were melanoma (p = 0.04), squamous tumors (p = 0.01), and a primary tumor liver metastasis, with an interval shorter than 2 years (p = 0.02), whereas the predictive prognostic factors identified were breast cancer (p = 0.04), stromal tumors (p = 0.03), and major LRx (p = 0.04). The prognostic risk score stratified patients into low risk (0-3 points: n = 50; 5-year overall survival [OS] 58 %), medium risk (4-6 points: n = 91; 5-year OS 35 %), and high risk (≥7 points: n = 9; 5-year OS, 33 %) groups (p = 0.01).

CONCLUSION

Liver resection for patients with NCNN metastases is a safe treatment option. More than 25 % of patients can achieve a long-term survival of 10 years when the histology of the primary tumor and the surrogates for the individual biologic tumor behavior are taken into account. Exclusion of patients with NCNN liver metastases from surgical therapy is no longer justified.

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.

A systematic review of the role of hepatectomy in the management of metastatic renal cell carcinoma

AIM

This review sought to systematically appraise the literature to establish the role of hepatectomy in treating renal cell carcinoma hepatic metastases.

METHOD

Medline and EMBASE were systematically searched for papers reporting survival of patients who underwent hepatectomy for metastatic renal cell carcinoma.

RESULTS

Six studies containing 140 patients were included. There were no randomised controlled trials. Perioperative mortality was 4.3%, with reported morbidity between 13 and 30%. Patients with metachronous presentation, and a greater time interval between resection of primary tumour and development of metachronous metastases, appeared to have better survival. There was no difference in survival between patients with solitary and multiple metastases.

CONCLUSION

Few patients with hepatic metastases from renal cell carcinoma are suitable for hepatectomy as metastatic disease is usually widespread. Selected patients may experience a survival benefit, but identifying these patients remains difficult.

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.

Prognostic factors related to surgical outcome of liver metastases of breast cancer

PURPOSE

The role of hepatectomy for patients with liver metastases of breast cancer (LMBC) remains controversial. The purpose of this study is to share our experience with hepatic resection in a relatively unselected group of patients with LMBC and analyse the prognostic factors and indications for surgery.

METHODS

In 2000 to 2006, 42 female patients with a mean age of 58.2 years (range, 39 to 69 years) with LMBC diagnosed by means of abdominal ultrasound, computed tomography and/or magnetic resonance imaging in the hospital. They were considered for surgery because of limited comorbidities, presence of seven or fewer liver tumors and absence of (or limited and stable) extrahepatic disease on preoperative imaging. Patients' demographics, metastatic characteristics as well as clinical and operative parameters were being studied. Overall actuarial 1-, 3-, and 5-year survival rates were calculated since the hepatic resection onwards using the Kaplan-Meier method.

RESULTS

Metastatic tumor size of ≤4 cm (p=0.03), R0 resection (p=0.02), negative portal lymph nodes (p=0.01), response to chemotherapy (p=0.02), and positive hormone receptor status (p=0.03) were associated with better survival outcomes on univariate analysis. However, it did not show survival benefits on multivariate analysis. The disease-free survival and overall survival are 29.40 and 43 months, respectively. The 1-, 3- and 5-year survival rates were 84.61%, 64.11%, and 38.45%, respectively.

CONCLUSION

Selected patients with isolated LMBC may benefit from surgical management; although, indications remain unclear and the risks may outweigh the benefits in patients with a generally poor prognosis. Improvements in preoperative staging and progressive application of new multimodality treatments will be the key to improved survival rates in this severe disease. The careful selection of patients is associated with a satisfactory long-term survival rate.

[Surgical treatment of melanoma liver metastases]

The appearance of liver metastases during the follow-up of a patient with a skin melanoma has classically been considered a sign of a very poor prognosis. There are limited therapeutic options, since these lesions are non-resectable and form part of a disseminated disease in several organs. In certain cases, in those where the disease is restricted to the liver or accompanied by a resectable extra-hepatic disease, hepatectomy can be useful, obtaining acceptable survivals of about 25% at 5 years, although hepatic or skin recurrence is usually early. The limited number of patient cases published, the absence of randomised studies, and the heterogeneity of the series, makes it difficult to reach conclusions to be able to recommend which patients may benefit from liver resection, with an acceptable level of scientific evidence, and thus define its real usefulness. There are also no action plans defined as to when and what type of adjuvant therapy we should use.