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

http://www.compagnons-hb.com/


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


Resections of Colorectal Metastases

Well Established

Hepatic Metastases of Sarcomas

?


INTRODUCTION


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


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


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.


INTRODUCTION


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


Before Imatinib


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.



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%



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 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).


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).


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


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

http://www2.inca.gov.br/wps/wcm/connect/inca/portal/home/

http://www.ncbi.nlm.nih.gov/pubmed?term=Groeschl%20RT%5BAuthor%5D&cauthor=true&cauthor_uid=22425166


Angiomyosarcoma Leiomyosarcoma


• 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.




• Results

• Patients• Gender: 17 women (60.7%) • 11 men (39.3%) •

• Age: 30 - 72 y (median 55 y)




• Results

• Tumour 26 abdominal origin• 8 Gastric;• 7 Small Bowel;• 6 Retroperitoneal;• 2 Uterine;• 1 IVC, Kidney, Colon, Breast and Deltoid.




• Results

• Histology:• 16 (54.1%) - Leiomyosarcoma• 8 (28.6%) - GIST• 2 Endometrial Sarcomas• 1 Fibrosarcoma• 1 Angiosarcoma




• Histology:



Histology Median

Visceral 66.33

Non Visceral

33.23

Overall 62.73

P= 0.208


• Results• Histology:



P= 0.171Histology Median

GIST -

Others Sarcomas

37.97

Overall 62.73


• 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




• Results• Tumour Grade:



P= 0.529


• Results

• Diagnostic• CT 26 cases• US 4 cases• MRI 1 case




• 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




RADIOFREQUENCY ABLATION


• Results

• Radicality– R0: 18 patients (64.3%)– R1: 03 patients (10.7%)– R2: 7 patients (25%)




• Results• Radicality



P= 0.876

MeanR0 – 63 monthsR1 + R2 – 34 months


• Results• Radicality

– Without GIST



P= 0.229MeanR0 – 63 monthsR1 + R2 – 33 months


• Results• Surgery

• Average Surgical time 332 min (180-840)– 3h to 14h




• Results• Surgery

• Hospitalisation 10 days• Morbidity 25% - 7 cases• Post op mortality (30 days): 1 case (3.6%)

• Pneumonia and wound infection




• Results• Disease free survival 11 months (5-37)




• Results• Median Overall Survival 63 months (1 – 105)



5y surv – 52.7%


• 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)






P= 0.001


Results

• Recurrence

- 76.5% R0 patients recurred (50% liver)- 7 patients 2nd resection- 4 patients 3rd resection- 2 patients 4th resection




Results• Repeat Resection



P= 0.060Repeat Resection

Median

Yes 66.33

No 33.23

Overall 62.73


• 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




Results

• Neo or Adjuvant treatment X Survival (R0)



P= 0.212 P= 0.668


Results• OS Neo or Adjuvant treatment X Survival (All patients)



P= 0.703


Results• OS Neo or Adjuvant treatment X Survival (GIST)



P= 0.051

Adv. Treat.

Median

GIST -

Others Sarcomas

33.23

Overall 62.73


GENERALIZED PROGRESSION

Metastasis

SURGERY NOT RECOMMENDED


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



Good news Sir, We achieve a complete resection !


非常感謝THANK YOU !

[email protected]

Met hepsarcoma pequim final

Health & Medicine

hepatic resection patients

sarcoma metastatic

resection andablation

sarcomashepatic metastases

median survival

years survival

others35 resection

repeated resection