Journées de Chirurgie 2016 En pratique : Hépatectomie majeure ou "economique" quand les deux sont possibles?

1. Métastase colorectale unique ≤ 3 cm
Hépatectomie droite ou Résection limitée ?
Une étude LiverMetSurvey
Isamu HOSOKAWA, René ADAM

2. • Occasionally, right hepatectomy (RH), rather than
parenchymal-preserving hepatectomy (PH), has
performed for solitary small colorectal liver metastasis
(CLM) in the right liver.
• The relative oncological benefit of PH and RH for
solitary small CLM is unclear.
Introduction

3. 25,868 Pts , Dec. 2015

4. • Patients: LiverMetSurvey (2000-2015)
• Tumor number and size: Solitary, ≤ 30 mm in histology
• Tumor location: Right liver (Segment 5, 6, 7, 8)
• Surgical procedure:
 PH group: Partial hepatectomy, Segmentectomy, Bisegmentectomy,
Sectionectomy
 RH group: Right hepatectomy
• Primary end points: Major complications (Clavien-Dindo, grade III-
IV), 90-day mortality, recurrence-free survival (RFS), time to last
unresectable recurrence, overall survival (OS)
• Secondary end points: Liver recurrence, repeat hepatectomy
Patients and Methods

5. Study Population
Solitary, ≤ 30 mm tumor in histology
n=3890
PH group
n=1478 (86%)
RH group
n=242 (14%)
Segment 5, 6, 7, 8
n=2060 n=340patients excluded:
• Portal vein embolization: n=50
• R2 resection: n=76
• Concomitant extrahepatic disease:
n=214
LiverMetSurvey (2000-2015)
Total no. of liver resection for CLM
n=21072
Remaining study population
n=1720

6. Comparisons of Characteristics of Each Group
PH group
(n=1478)
RH group
(n=242) p
Variables No. % No. %
Patients
Age, years (mean ± SD) 64.1 ± 11.0 64.0 ± 10.0 0.96
Sex: Male 888 60 141 58 0.62
Primary tumor
Location: Rectum 498 34 84 35 0.77
T stage: 3/4 1193 88 176 87 0.65
N positive 846 62 126 61 0.76
CLM characteristics
Timing of diagnosis: Synchronous 721 49 121 50 0.78
Tumor size, mm (mean ± SD) 19.3 ± 7.6 20.4 ± 8.0 0.04
CEA level, ng/mL (mean ± SD) 65.7 ± 303.0 159.7 ± 1347.6 0.06
Initially unresectable 57 4 16 7 0.03
Periopearative management
Preoperative chemotherapy 455 32 84 36 0.23
Laparoscopic approach 140 10 5 2 <0.001
Postoperative chemotherapy 659 57 93 47 0.02

7. Comparisons of Surgical and Long-Term Outcomes
of Each Group
PH group
(n=1478)
RH group
(n=242) p
Variables No. % No. %
Surgical outcomes
Blood transfusion 97 8 40 18 <0.001
Hospital stay, days (mean ± SD) 10.5 ± 8.1 12.7 ± 12.5 <0.001
R0 resection 1238 94 215 95 0.64
Major complications 49 3 24 10 <0.001
90-day mortality 11 1 7 3 0.008
Long-term outcomes
Recurrence 529 36 84 35 0.77
Liver recurrence 294 20 54 22 0.39
Liver-only recurrence 172 12 35 14 0.20
Extrahepatic disease recurrence 357 24 49 20 0.19
Repeat hepatectomy 187 13 18 7 0.02

8. Comparisons of RFS and Time to Last Unresectable
Recurrence of Each Group
Time to last unresectable recurrenceRFS
PH group (n=1478)
RH group (n=242)
p=0.17p=0.54
62%
64%
52%
48%50%
51%
43%
41%
PH 1478 874 543 361 255 194 131
RH 242 144 98 65 53 34 21
PH 1478 967 662 472 328 245 162
RH 242 158 116 83 65 42 25

9. Comparison of OS of Each Group
OS
PH group (n=1478)
RH group (n=242)
p=0.29
75%
78%
63%
62%
PH 1478 1058 781 571 398 291 184
RH 242 178 135 101 80 54 34

10. Comparisons of Characteristics in Patients with
Liver-Only Recurrence of Each Group
PH group
(n=172)
RH group
(n=35) p
Variables No. % No. %
Patients
Age, years (mean ± SD) 63.7 ± 10.9 63.6 ± 10.5 0.99
Sex: Male 104 60 20 57 0.71
Primary tumor
Location: Rectum 61 35 14 42 0.55
T stage: 3/4 140 89 24 80 0.22
N positive 105 66 20 67 1.00
CLM characteristics
Timing of diagnosis: Synchronous 103 60 13 37 0.02
Tumor size, mm (mean ± SD) 17.7 ± 8.0 17.6 ± 7.5 0.97
CEA level, ng/mL (mean ± SD) 41.3 ± 127.4 58.0 ± 110.2 0.60
Initially unresectable 10 6 2 6 1.00
Periopearative management
Preoperative chemotherapy 58 34 11 33 1.00
Laparoscopic approach 13 8 0 0 0.13
Postoperative chemotherapy 68 48 16 53 0.69

11. Comparisons of Surgical and Long-Term Outcomes
in Patients with Liver-Only Recurrence of Each Group
PH group
(n=172)
RH group
(n=35) p
Variables No. % No. %
Surgical outcomes
Blood transfusion 12 8 10 33 0.001
Hospital stay, days (mean ± SD) 10.3 ± 6.1 15.6 ± 21.7 0.008
R0 resection 133 90 29 97 0.32
Major complications 6 3 2 6 0.63
Recurrence characteristics
Time to recurrence: <12 months 88 51 13 65 0.34
Tumor number (mean ± SD) 2.4 ± 2.9 1.4 ± 0.8 0.15
Maximum tumor size, mm (mean ± SD) 27.7 ± 23.2 26.0 ± 14.2 0.78
Tumor distribution: Bilober 53 32 0 0
CEA level, ng/mL (mean ± SD) 175.0 ± 621.9 96.4 ± 126.7 0.72
Repeat hepatectomy 115 67 11 31 <0.001

12. Distribution and Side of Liver Recurrence in Patients with
Liver-Only Recurrence after PH
Liver-only recurrence after PH
(n=172)
n %
Bilobar 53 32
Unilobar 119 68
Right (ipsilateral) liver 32 27
Left (contra-lateral) liver 87 41

13. Liver Recurrence and Repeat hepatectomy According to the Initial
Hepatectomy Procedure in Patients with Liver-Only Recurrence after PH
Liver recurrence
(n=172)
Repeat hepatectomy
(n=115)
%
Non-anatomical partial
resection
110 80 72
Anatomical resection 62 35 56
Segmentectomy 41 22 54
Bisegmentectomy 12 7 58
Sectionectomy 9 6 67
*
* p=0.04

14. Comparisons of RFS and Time to Last Unresectable Recurrence
in Patients with Liver-Only Recurrence of Each Group
p=0.005
p=0.72
25%
51%
35%
9%
PH 172 85 31 12 8 5 3
RH 35 21 9 3 0 0 0
PH 172 134 86 67 44 33 21
RH 35 27 15 8 4 2 1
PH group (n=172)
RH group (n=35)
Time to last unresectable recurrenceRFS

15. Univariate and Multivariate Analysis of Survival
in Patients with Liver-Only Recurrence
Variables n 5-yr OS (%) Univariate p Multivariate p RR 95% CI
Patients
Age, years
≤65 115 49 0.69
>65 92 51
Sex
Male 124 59 0.02 0.07 1.77 0.96-3.27
Female 83 37
Primary tumor
Location
Rectum 75 51 0.88
Colon 130 49
T stage
3/4 164 50 0.91
1/2 23 47
N stage
1/2 125 42 0.02 0.04 0.47 0.23-0.95
0 65 64
CLM characteristics
Timing of diagnosis
Synchronous 116 49 0.71
Metachronous 90 52
Tumor size, mm
≤20 136 54 0.11
>20 71 42
CEA levels, ng/mL
≤15 76 57 0.01 0.05 1.85 1.01-3.37
>15 51 36
Initial resectability
Resectable 185 51 0.92
Unresectable 12 39

16. Univariate and Multivariate Analysis of Survival
in Patients with Liver-Only Recurrence (Continue)
Variables n 5-yr OS (%) Univariate p Multivariate p RR 95% CI
Hepatectomy characteristics
Preoperative chemotherapy
+ 69 45 0.96
- 133 54
Type of approach
Laparoscopic 13 0 0.12
Open 192 49
Type of procedure
PH 172 55 <0.001 0.001 3.70 1.77-7.72
RH 35 23
Blood transfusion
+ 22 44 0.24
- 155 54
Hospital stay, days
≤14 163 53 0.004 0.10 1.82 0.89-3.72
>14 33 37
Margin status
R0 162 53 0.99
R1 16 43
Major complications
+ 8 56 0.14
- 199 50
Postoperative chemotherapy
+ 84 49 0.79
- 89 57

17. En analyse multivariée :
• Ganglions métastatiques de la T primitive,
• ACE pré-op ≤ 15 ng/mL,
• Hépatectomie limitée
indépendamment associés à un meilleur
pronostic chez les patients ayant une
récidive purement hépatique…

18. • Hépatectomie droite plutot qu’ Hep. limitée: 14% des cas
• Moins souvent par voie laparoscopique (2% vs 15% …)
• Risque augmenté de complications post-op majeures et de
mortalité à 3 mois vs hépatectomies limitées.
• La fréquence des récidives n’en est pas diminuée...
• En revanche, en cas de récidive purement hépatique, la
rehépatectomie est moins souvent réalisée et la survie sans
récidive en est très nettement diminuée (9% vs 35% à 5 ans)
Conclusions

19. Conclusions
Une hépatectomie limitée en cas de métastase unique
du foie droit doit etre considérée comme la procédure
standard lorsqu’elle est techniquement réalisable.