Staged Hepatectomy for Colorectal Metastases to Liver

1. Staged Hepatectomy for Colorectal Metastases to Liver Dr. Steven, Kong Ling TING Caritas Medical Centre Joint Hospital Surgical Grand Round26 April 2014

2. Introduction • Surgical resection is considered as a curative therapy for colorectal liver metastases (CLM) • 5-year overall survival rate - 58% • Patient with unresectable colorectal liver metastases, and no other organs involved • Chemotherapy? • Use of preoperative portal vein embolization and ablative therapies? • Two stage hepatectomy (TSH)

3. Introduction • Selection of patients for resection of CLM: expert consensus statement. In Ann Surg Oncol 2006 • To preserve: 1. two contiguous liver segments 2. adequate vascular supply and biliary drainage 3. adequate functional liver volume (FLV) >20% • Unresectable disease – bilobar CLM, with inability to achieve margin negative (R0) resection of all tumors, while preserving the above three criteria

4. Case Discussion 1 2 4 3

5. Case Discussion 1 2 3 4

6. Review of Current Evidence • Past 5-year studies in PubMed and MEDLINE • Two stage hepatectomy with curative intention • Initially unresectable disease • Survival outcomes reported • Overlapping patient pool series • <10 patient number • 9 Observational studies

7. Review of Current Evidence 1. Bilobar multiple liver metastases 2. Response to chemotherapy 3. Adequate remnant liver volume (>25 / 30%) 4. Other conditions concerning surgical strategy, for example: left hemi-liver clear of metastases during 1st stage (Tsim et al.)

8. Review of Current Evidence

9. Review of Current Evidence

10. Case Discussion

11. Review of Current Evidence * R0 resection cases included only, DF = disease free

12. Review of Current Evidence • Adjuvant modalities • Portal vein embolization • Intra-operative ligation of portal vein • ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) • Ablation (RFA) – preferably <1cm tumors away from major vessels

13. Review of Current Evidence • Interval chemotherapy • Mentha et al. – histologic evidence supporting interval chemotherapy • Liver steatosis, steatohepatitis, sinusoidal liver injury, blue liver syndrome • Role of intra arterial chemotherapy (HAI)

14. Review of Current Evidence • Factors affect the survival outcome • Response to preoperative chemotherapy • FLR volume • Completion of both stages of hepatectomy • Presence of extra-hepatic metastases • ? Tumor number and size • ? Resection margin

15. Case Discussion 1 2 4 3

16. Case Discussion 1 2 4 3

17. Conclusion • Two stage hepatectomy in selected patients with initially unresectable CLM is associated with acceptable operative mortality and survival outcomes • Consensus on patient selection, combined adjuvant modalities, interval chemotherapy • Data inhomogeneity: synchronous versus metachronous disease, use of biological agents, presence of extra-hepatic disease

18. Dr. Francis Mok Dr. Chang SJ

19. Reference • Rees M, Tekkis PP, Welsh FKS, et al. Evaluation of long term survival after hepatic resection for metastatic colorectal cancer: a multifactorial model of 929 patients. Ann Surg 2008 247:125-135 • Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 2009 62:1-34 • Tanaka K, Shimada H, Ueda M et al. Perioperative complications after hepatectomy with or without intra-arterial chemotherapy for bilobar colorectal cancer liver metastases. Surgery 2006 139:599-607 • Kuniya Tanaka, Takafumi Kumamoto, Kazunori Nojiri, et al. Timing of two stage liver resection during chemotherapy for otherwise unresectable colorectal metastases. World J Surg 2012 36:1832-1841 • Mohammad H. Jamal, Mazen Hassanin, et al. Staged hepatectomy for bilobar colorectal hepatic metastases. HPB 2012 14:782-789 • Tsai S, Marques HP, et al. Two stage stretegy for patients with extensive bilateral colorectal liver metastases. HPB 2010 12:262-269 • Bowers KA, O’Reilly D, Bond Smith GE, et al. Feasibility study of two stage hepatectomy for bilobar liver metastases. Am J Surg 2011 203:691-697 • Brouquet A, Abdalla EK, Kopetz S, et al. High survival rate after two stage resection of advanced colorectal liver metastases: response based selection and complete resection define outcome. J Clin Oncol 2011 29:1083-1090 • Muratore A, Zimmitti G, Ribero D, et al. Chemotherapy between the first and second stages of a two stage hepatectomy for colorectal liver metastases: should we routinely recommend it? Ann surg Oncol 2011 19:1310-1315 • Turrini O, Ewald J, et al. Two stage hepatectomy: who will not jump over the second hurdle? Eur J Surg Oncol 2012 38:266-273 • Tsim N, Healey AJ, Frampton AE, et al. Two stage resection for bilobar colorectal liver metastases: R0 resection is the key. Ann Surg Oncol 2011 18:1939-1946 • Narita M, Jaeck D, et al. Two stage hepatectomy for multiple bilobar colorectal liver metastases. Br J Surg 2011 98:1463-1475 • Adam R, Wicherts DA, de Haas RJ, et al. Patients with initially unresectable colorectal liver metastases: is there a possibility of cure? J Clin Oncol 2009 27:1829-1835 • Mentha G, Terraz S, Morel P, et al. Danerous halo after neoadjuvant chemotherapy and two step hepatectomy for colorectal liver metastases. Br J Surg 2009 96:95-103 • Adam R, Pascal G, Castaing D, et al. Tumor progression while on chemotherapy: a contraindication to liver resection for multiple colorectal metastases? Ann Surg 2004 240:1052-1061 • Wicherts DA, Miller R, de Hass RJ et al. Long term results of two stage hepatectomy for irresectable colorectal cancer liver metastases. Ann Surg 2008 248:994-1005 • Hemming AW, Reed AI, et al. Preoperative portal vein embolization for extended hepatectomy Ann Surg 2003 237:686-693 • Picture sources: www.Intechopen.com, www.hopkinsmedicine.org