Presentation on theme: "Management of colorectal cancer with liver metastasis Dr. Vivian Lee Department of Surgery, UCH."— Presentation transcript:
Management of colorectal cancer with liver metastasis Dr. Vivian Lee Department of Surgery, UCH
Incidence UP to 70 % of patients with colorectal cancer develop liver metastasis during the course of their disease 50% are isolated liver metastasis 25% are synchronous 5-10% resectable Cady B, et al. Arch Surg 1992
Natural history Untreated patient open-and-close cases Median survival 6-12 months Bengmark S, et al. Cancer, 1969
Treatment Direct lesional approach Surgical Local ablative therapy Systemic approach Systemic chemotherapy Vascular approach Intraarterial infusion of chemotherapy
Surgical treatment is the gold standard for isolated liver metastasis !
Surgical treatment Prerequisites: Medical fittness for major surgery No sign on preoperative imaging of disseminated disease Tumors anatomically confined within liver such that adequate liver parenchyma could be preserved.
Surgical treatment 122 cases (74 metachronous lesions) over 8 years postoperative complication: 20 % pneumonia, pleural effusion hepatic insufficiency bile leak and biliary fistula Schlag P, et al. Eur J Surg Oncol, 1990
Operative mortality personal series 247 cases over 12 years operative mortality: < 5% Fortner JG, et al. Ann Surg. 1984
Surgical resection – early experience Multi-institutional review 859 patients of 24 centers 5-year survival 33% 5-year disease-free survival 21% Surgery 1998; 103: 278-288.
Major contraindications Positive perihepatic lymph nodes Presence of resectable extrahepatic metastasis Presence of 4 or more metastasis Surgery 1988; 103: 278-288.
Conditions with poor survival Margin of resection < 1 cm Positive mesenteric LN in primary tumor specimen Disease-free survival < 1 year NB. Presence of any one of these factors is not contraindication for surgery. Surgery 1988; 103: 278-288.
Predictors of poor long-term outcome 1001 consecutive cases from 1985 to 1998 multivariate analysis positive margin node-positive primary extrahepatic disease disease-free interval from primary to metastasis < 12 month number of hepatic tumor > 1 largest hepatic tumor > 5 cm CEA level > 200 ng/ml Fong Y, et al. Ann Surg, 1999
Recurrence after hepatectomy 50% develop another liver metastasis Half of them develop extrahepatic metastasis How could this be treated?
Repeat liver resection for recurrence ? 130 patients with 143 repeat liver resections (14 had both liver and extra-hepatic) Operative mortality 0.9% 3-year survival 33% 12 patients had the 3 rd liver resection → mean survival 12.5 months Nordlinger B, et al. J Clin Oncol 1994.
HAI after hepatectomy Memorial Sloan- Kettering Cancer Center Trial Intrahepatic chemotherapy verse systemic chemotherapy after surgery 2 years survival : 86% vs 72%(p=0.03) Hepatic 2 years disease free survival: 90% vs 60 %( p<0.001)
HAI after hepatectomy Southwest Oncology Group study Surgery vs HAI after surgery 4-yr hepatic disease-free survival 43% vs 66.9% ( p=0.03) 4-yr overall disease-free survival 25.2% vs 45.7% ( p=0.04) 4-yr overall survival 52.7% vs 61.5% ( p=0.06)
Radiofrequency ablation Several advantages over cryotherapy Can be performed percutaneously Evenly distributed heat, unlike the ice ball formation Local Ablative Therapy
RFA Disadvantage Limited by the size, up to 3 or 4cm only Complete ablation rate HCC: 86% Metastasis:11% T Kaneko, et al. HBP, 2003
Radiofrequency ablation Prospective non randomized trial 123 patient HCC:39.1% Colorectal liver metastasis:49.6% Only 1 patient with local recurrence Curley SA, Ann Surgery. 1999
RFA and HAI Prospective non randomized study 50 patient treated with RFA and HAI with or without resesction Follow up: 20 months 32% patient remained disease free 30% developed new liver metastasis 48% developed extrahepatic disease Curley SA, Ann Surg Oncol. 2003
How can we treat systemic spread after surgery?
Systemic Chemotherpy Treat the entire patient Low response rates with short duration of response
Treated with chemotherapy 64 cases I.A. or I.V. 5-fluorodeoxyuridine Median survival 12-18 months Chang AE, et al. Ann Surg, 1987
Chemotherapy for metastatic colorectal carcinoma
First line chemotherapy 5FU + Leucovorin meta-analysis: response rate 23% vs 11% for 5FU alone no impact on overall survival
Second line chemotherapy Irinotecan (CPT 11) inhibit topoisomerase I just completed phase II study tumor growth control: 60% Gil-Delgado MA, American Journal of Clinical Oncology, 2001
Summary Surgical resection is the gold standard. Survival improves by post-operative hepatic arterial chemotherapy. Post-operative systemic chemotherapy is needed to cover micro-metastasis.