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Transcript of Met hepsarcoma pequim final
www.CirurgiaOnline.com.br
OUR EXPERIENCE IN
LIVER METASTASES OF SARCOMA
Carlos Eduardo Rodrigues Santos, PhDRio de Janeiro - Brazil
Oncology Surgeon of the Brazilian National Cancer InstitutePresident of the Brazilian Chapter of the International Hepato Biliary Pancreatic Association (CB-IHPBA)
Compagnon Hepatobiliare
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HEPATIC METASTASES OF SARCOMA
INTRODUCTION
Sarcomas are mesodermic origin tumors, low frequency and several times arrived with advanced disease in our center.
NCI Brazil66587 last 10 y => near 1531 (2,29%) sarcomas
Hepatic Metastases = stage IV
Up to 60% Hepatic Metastases in Abdominal Sarcomas
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Resections of Colorectal Metastases
Well Established
Hepatic Metastases of Sarcomas
?
HEPATIC METASTASES OF SARCOMA
INTRODUCTION
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Hepatic resection for Noncolorectal Nonendocrine Liver Metastases. Analysis of 1452 patients and development of a
Prognostic Model.Adan R, Chiche L, Aloia T and others.
Ann Surg. 2006 Oct;244(4):524-35; French Group
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1452 patients 1983 – 200456% solitary - 71% unilateral - Med 5,05 cmGIST/Sarcoma (33/125 - 13,5%)Metachronous 76%83% R0, Mortality rate 2,3%Overall 5 and 10 years => 36% and 23%Recurrence free survival 11 months5y surv GIST 70% and Sarcoma 31%
Hepatic resection for Noncolorectal Nonendocrine Liver Metastases. Analysis of 1452 patients and development of a
Prognostic Model.Adan R, Chiche L, Aloia T and others.
Ann Surg. 2006 Oct;244(4):524-35; French Group
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Except for patients with gastrointestinal stromal tumors (GIST), systemic chemotherapy in patients with liver metastasis of soft-
tissue sarcoma (STS) is not effective.
We believe that all patients with resectable liver metastases should underwent surgical therapy.
HEPATIC METASTASES OF SARCOMA
INTRODUCTION
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Results of hepatic resection for sarcoma metastatic to liver.DeMatteo RP, Shah A, Fong Y, Jarnagin WR, Blumgart LH, Brennan MF.
Ann Surg. 2001 Oct;234(4):540-7; discussion 547-8. Memorial Sloan-Kettering Cancer Center
56 pac in 331 between 1982 – 200034 (61%) GIST or Leiomyossarcoma Gastrointestinal50% Major Hepatectomies ( > 3 Segments)Zero MortalitySurvival in 1, 3 and 5 y R0 = 88%, 50% and 30%5 y survival R1 and R2 = 4%Median surv 39 months GIST = Leiomyossarcoma
HEPATIC METASTASES OF SARCOMA
Before Imatinib
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Results of hepatic resection for sarcoma metastatic to liver.DeMatteo RP, Shah A, Fong Y, Jarnagin WR, Blumgart LH, Brennan MF.
Ann Surg. 2001 Oct;234(4):540-7; discussion 547-8. Memorial Sloan-Kettering Cancer Center
Multivariate Analysis => Metachronous > 2 years45 (80%) Metachronous disease > 2 years in 57%Recurrence 47 (84%) Med 16 months (liver)Highly selected
Conclusion:Hepatectomies must be performed when R0 is
possible and increase survival.
HEPATIC METASTASES OF SARCOMA
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Results of a single-center experience with resection and ablation for sarcoma metastatic to liver.
Pawlik TM, Vauthey JN, Abdala EK, Pollock RE, Ellis LM, Curley SA. Arch Surg. 2006 Jun;141(6):537-43. Huston Texas
1996 – 2005 66 patients, Median 3 lesions with 3,9 cm, bilobar36 GIST , 18 Leiomyosarcoma, 12 Others35 Resection, 13 Radiofrequency, 18 Both66,7% Recurrence, More Radiofrequency (p < 0,05)1, 3 and 5 years survival 91,2%, 65,4% and 27,1% (47,2 months)GIST with Imatinib Mesylate => Longest Survival p = 0,003 and
Disease free survival Complication Rate 15,2%, Mortality 4,5%
HEPATIC METASTASES OF SARCOMA
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Results of a single-center experience with resection and ablation for sarcoma metastatic to liver.
Pawlik TM, Vauthey JN, Abdala EK, Pollock RE, Ellis LM, Curley SA. Arch Surg. 2006 Jun;141(6):537-43. Huston Texas
Good Prognostic Factors
• Size < 3 cm• Surgery alone• Chemotherapy pre or post op• Imatinib in GIST
HEPATIC METASTASES OF SARCOMA
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Hepatic metastasectomy for soft-tissue sarcomas: is it justified?Rehders A, Peiper M, Stoecklein NH, Alexander A, Boelke E, Knoefel WT, Rogiers X.
World J Surg. 2009 Jan;33(1):111-7
• 27 hepatic resection patients; 1995 to 2008.• 59% Solitary metastasis, 22% had two metastases, and 18% had three
or more metastatic nodules. • Mortality 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).
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Hepatic Resection of Soft Tissue Sarcomas Silva R., Kesley R., Santos CER., Melo E., Dias J., Bravo GP.
Rev.Col. Bras. Cir. 2006; 33(6): 380-386.
• INCA 1992 - 2002 – 11 cases• 5 gastrointestinal tract, 4 retroperitoneum, 1 uterus and 1 deltoid muscle. • 10 leiomyosarcomas and 1 dermatofibrosarcoma. • 6 G2 and 5 G3 tumors. • 5 segmentectomies, 4 lobectomies and 2 major hepatic resections.• 2 extra-hepatic associated resections. • 7 R0• OS complete resection with a 49-month survival for R0 resections compared to
a 15-month with residual disease (p<0.05). • G2 a 49-month survival compared to a 15-month with G3 tumors (p<0.0447).
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Hepatic Resection of Liver Metastases of Soft Tissue Sarcoma
Silva R., Kesley R., Santos CER., Melo E., Dias J., Bravo GP. Rev.Col. Bras. Cir. 2006; 33(6): 380-386.
Conclusion
Liver resections for hepatic metastasis of soft tissue
sarcomas can improve overall survival particularly for patients with complete resection (R0) and for low
grade tumors.
Lead us to increased indication and pursuit of radicality
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Authors: Santos CER, Rosa BR, Meton F, Monteiro M Brazilian National Cancer Institute
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
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Angiomyosarcoma Leiomyosarcoma
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• Material and Methods
• Retrospective study based on a prospective data base of 28 patients with hepatic metastases of sarcoma, ressected at Brazilian National Cancer Institute - INCA-Rio de Janeiro, between 1996-2011.
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
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• Results
• Patients• Gender: 17 women (60.7%) • 11 men (39.3%) •
• Age: 30 - 72 y (median 55 y)
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
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• Results
• Tumour 26 abdominal origin• 8 Gastric;• 7 Small Bowel;• 6 Retroperitoneal;• 2 Uterine;• 1 IVC, Kidney, Colon, Breast and Deltoid.
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
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• Results
• Histology:• 16 (54.1%) - Leiomyosarcoma• 8 (28.6%) - GIST• 2 Endometrial Sarcomas• 1 Fibrosarcoma• 1 Angiosarcoma
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
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• Histology:
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
Histology Median
Visceral 66.33
Non Visceral
33.23
Overall 62.73
P= 0.208
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• Results• Histology:
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
P= 0.171Histology Median
GIST -
Others Sarcomas
37.97
Overall 62.73
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• Results
• Tumour Grade: » G3 - 11 (39.3%)
• G2 - 8 (28.6%) • G1 - 2 (7.1%)
GX – 4 (14.3%)
• Metastases Size: 2 to 25 cm (median 6 cm)• 20 cases Metachronic – Median 30 months (5 - 292)• 8 Synchronic disease
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
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• Results• Tumour Grade:
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
P= 0.529
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• Results
• Diagnostic• CT 26 cases• US 4 cases• MRI 1 case
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
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• Results• Surgery• - Types of resection:
• 15 Major Hepatectomies (2 1992-2002)• 13 Segmentectomies (1, 2 or 3 seg)
• - Synchronic resection 5 cases (62.5%)• - Synchronic resection of extra hepatic
disease in 13 cases (46.5%) (2 1992-2002)
• MORE AGRESSIVE APROACH
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
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RADIOFREQUENCY ABLATION
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• Results
• Radicality– R0: 18 patients (64.3%)– R1: 03 patients (10.7%)– R2: 7 patients (25%)
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
www.CirurgiaOnline.com.br
• Results• Radicality
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
P= 0.876
MeanR0 – 63 monthsR1 + R2 – 34 months
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• Results• Radicality
– Without GIST
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
P= 0.229MeanR0 – 63 monthsR1 + R2 – 33 months
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• Results• Surgery
• Average Surgical time 332 min (180-840)– 3h to 14h
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
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• Results• Surgery
• Hospitalisation 10 days• Morbidity 25% - 7 cases• Post op mortality (30 days): 1 case (3.6%)
• Pneumonia and wound infection
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
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• Results• Disease free survival 11 months (5-37)
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
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• Results• Median Overall Survival 63 months (1 – 105)
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
5y surv – 52.7%
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• Results
• Blood Transfusion x Survival– No: 19 patients (68%) - SV 74 months– Yes: 09 patients (32%) - SV 21 months
• Mean 1200 ml ( 600-1800 ml)
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
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Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
P= 0.001
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Results
• Recurrence
- 76.5% R0 patients recurred (50% liver)- 7 patients 2nd resection- 4 patients 3rd resection- 2 patients 4th resection
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
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Results• Repeat Resection
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
P= 0.060Repeat Resection
Median
Yes 66.33
No 33.23
Overall 62.73
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• Results• Treatment
• Neoadjuvant Radiotherapy 1 case• Neoadjuvant Chemo 5 cases • Adjuvant Radiotherapy 1 case• Adjuvant Chemo 15 cases• Adjuvant Radio + Chemo 3 cases
• No Other treatment 8 cases
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
www.CirurgiaOnline.com.br
Results
• Neo or Adjuvant treatment X Survival (R0)
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
P= 0.212 P= 0.668
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Results• OS Neo or Adjuvant treatment X Survival (All patients)
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
P= 0.703
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Results• OS Neo or Adjuvant treatment X Survival (GIST)
Analysis of the hepatectomies for sarcoma metastases
15 years experience of NCI Brazil 1996-2011
P= 0.051
Adv. Treat.
Median
GIST -
Others Sarcomas
33.23
Overall 62.73
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GENERALIZED PROGRESSION
Metastasis
SURGERY NOT RECOMMENDED
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Conclusion
Although only 8 patients are alive at the moment ( 6 GIST) and 2 are disease free
Imatinib - 2003
The Complete Resection and Repeat Resection should improve survival and
is recommended.
Blood Transfusion should be Avoided
HEPATIC METASTASES OF SARCOMA
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Good news Sir, We achieve a complete resection !