Liver Metastases

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Liver Metastases

• Jean-Bernard Poulard MD, MBA, FACS
• Mount Sinai School of Medicine
• Queens Hospital Center
• Jamaica, NY

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Liver Metastases
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Liver Metastases

• 30 Years Ago, Considered Incurable

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Liver Metastasis

• Extent of the problem
• Primary Cancers and Mets
• Liver structure and function considerations
• Excision and its evolution
• Chemo as an adjunct
• Ablative Approaches
• Current Recommendations
• The Future

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Liver Metastases- Biology

• Fertile Circulation. Systemic and Portal
• Biliary Component
• Primary Drainage for GI Tract /Pancreas
• Functional Importance
• Regenerative Capacity
• Abused and Insult (alcohol and Viruses)

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Liver Mets- Extant of Problem

• Demographics of Colorectal Cancer
• Other Gastro-Intestinal Cancers
• Other Sites
• Sites Where Treatment Benefits
• Sites with No Benefit

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Liver MetastasesPractical Considerations

• Function
• Accessability
• Resectability
• Technical Considerations (Support)
• Equipment and Machinery
• Surgical and Interventional Expertise
• Critical Care

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Liver Mets -Metastasectomy

• Indications
• Tissue Diagnosis
• Size and Number and Lobes
• Timing
• Chemo Pre-Resection?
• Risks
• Morbidity and Mortality
• Outcome

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Liver Mets - Metastasectomy

• Extra-Hepatic Disease Containdication?
• Used to Be
• But if Extra-hepatic and Mets Resectable
• If R0 Possible 5 yr 29-38 (Elias et al, BJS
  2003 90 567-74)

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Liver Metastases-HAI

• Rationale for Hepatic Artery Infusion
• Not Amenable to Excision
• Technical Considerations
• Risks and Pitfalls (misperfusion, Art Injury)
• Evolution and Current Practice
• Chemo Agents 5-FUDR ( leucovorin and
  Dexamethasone),
• Results RR 78, Median Survival 25 mos
• Kemeny N. J Clin. Onc. 1994 232288

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Liver Metastases HAI 2

• Oxaliplatin and Irinotecan
• Scant Data but Safe via HA
• 28 Pts with Isolated Liver Mets
• Oxaliplatin Followed by IV 5-FU and Leucovorin
• Objective RR 64 Median Survival 28 Mos
• J. Clin. Onc. 2005 23275s

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Liver Metastases-Ablation 1

• Indications
• Modalities
• Intratumoral, Cryo, Radiation, Thermal
• Common Attributes
• Degree of Invasiveness

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Liver Metastases- Intratumoral

• Percutaneous Ethanol and Acetic Acid
• Used in small HCC (Japan)
• Difficult Access for Some Lesions
• Etoh not Effective in Other Histologies
• Consensus Etoh not Appropriate
• Acetic Acid

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Liver Metastasis - Cryoablation

• Techniques
• Failure Rate 10-44 (Most in Non-Frozen sites)
• Sometimes after Incomplete Excision
• Survival 24-38 5 year
• Drawback Requires Laparotomy
• Obsolescent?

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Liver Metastases- Radiation

• External Beam Therapy Limited
• Tolerance 35 Gy vs 70 Gy to Destroy CA
• Stereotactic for Small Tumors
• Brachytherapy I-125 Seeds Rarely used after
  Incomplete Excision
• Complex Logistics, Cryo Preferred
• Radioembolization
• Y-90 tagged Resin or Glass microspheres
• Used with HAI of FUDR (RR 44 vs 18)
• Similar Toxicity, No Signicant Survival Benefit
  (Xcptgt15)
• Ann. Onc. 2001 12 1711

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Liver Metastases Thermal Ablation 1

• Modalities
• Radiofrequency Ablation
• Laser and Microwaves (Europe)
• Limitations
• Control of Margin
• Specificity of Tissue Damage
• Advantage
• Percutaneous Approach

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Liver Metastases

• Radiofrequency Generator

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Liver Metastases -RFA

• Used in HCC and Liver Mets
• Open, Laparoscopic or Percutaneous
• Relation to Recurrences
• Experience, Type of Equipment
• Pitfalls Intestinal and Diaphragm Injuries
  Portal Vein Thrombosis
• Mortality 0-2 Major Complications 6-9
• Outcome Median Survival 24 Months

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Liver Metastases- Recommendations

• Resection for Cure is First Option
• Potentially Resectable if Lesions Smaller
• Systemic Chemo and Reevaluation
• Limited Number of Mets but Not Surgical
  Candidate
• Ablation (RFA Preferred)
• HAI

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Liver Metastases- The FutureCRC

• The M.D. Andersons Approach
• Up to 1992, 35 Survival for Stage 4 CRC
• Post 1992, Up to 58
• Anesthesia, Surgery, Hemostatics, Imaging,
  Intesive Care
• Surgical Excision as Primary Tx Better
• Chemo Alone or RFA lt20
• Solitary Met Excision 71 Survival 5 Yrs

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Liver Metastasis- The Future 2CRC

• Majority are Unresectable at Presentation
• Make Them Resectable?
• Prospective Trial
• Combination Chemotherapy
• Staged Hepatectomy
• Portal Vein Embolization
• Determine Remnant of Viable Liver
• Size and Number of Mets not Factor

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Liver Metastases The Future 3CRC

• Response Rate to Cytotoxic with Biologic
• Up to 50
• Portal Vein Embolization
• Induces Increase in Volume of the Liver
• Increases the Function
• Regeneration
• 2-4 Weeks in Normal Liver
• 6-8 Weeks for Diabetics and Cirrhotics

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Liver Metastases- The Future 4CRC

• Stage Resection
• For Bilateral Lobe Involvement
• Chemo- Excise From one Lobe
• PVE Liver Regenaration
• Resect from Other Lobe
• Survival 40
• 80 of Liver Volume can be Resected
• Use 3-D CT Volumetry
• Surgical Mortality .8

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Liver MetastasesPrevention?

• Stage 2 and 3 CRC
• Hepatic and Regional Chemo Before Surgery
• Randomized, No significant Morbidity
• Time to Liver Mets 16 vs 8 mos.
• Incidence 20.6 vs 28.3
• Disease Free Survival 74vs 58.1 (3 yr)
• Overall 87.7 vs 75.7
• No Benefit for Stage 2
• Xu et al. Ann Surg. 2007 245583-90

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Liver MetastasesGastric Cancer

• Hepatic Metasectomy done Rarely
• Isolated Liver Involvement Rare (.5)
• Long Term Survival is Rare
• Non-RandomIzed Series 37 patients -HAI
• 5 FU chemo
• Gastrectomy and HAI
• Better Response
• But No Increase Survival
• Ojima et Al. World J Surg. 2007 5 70

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Liver MetastasesFinal Word

• Screen, Screen, Screen for CRC
• Polypectomy may be Preventive
• Early Cancers are Curable
• Have you Had Your Colonoscopy?
• Thank You