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Met hepsarcoma pequim final
1. www.CirurgiaOnline.com.br
Oncology Surgeon of the Brazilian National Cancer Institute
President of the Brazilian Chapter of the International Hepato Biliary Pancreatic Association (CB-IHPBA)
Compagnon Hepatobiliare
2. www.CirurgiaOnline.com.br
HEPATIC METASTASES OF SARCOMA
INTRODUCTION
Sarcomas are mesodermic origin tumors, low frequency
and several times arrived with advanced disease in our
center.
NCI Brazil
66587 last 10 y => near 1531 (2,29%) sarcomas
Hepatic Metastases = stage IV
Up to 60% Hepatic Metastases in Abdominal Sarcomas
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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 – 2004
56% solitary - 71% unilateral - Med 5,05 cm
GIST/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 months
5y 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
6. www.CirurgiaOnline.com.br
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 – 2000
34 (61%) GIST or Leiomyossarcoma Gastrointestinal
50% Major Hepatectomies ( > 3 Segments)
Zero Mortality
Survival 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 years
45 (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, bilobar
36 GIST , 18 Leiomyosarcoma, 12 Others
35 Resection, 13 Radiofrequency, 18 Both
66,7% 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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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
20. www.CirurgiaOnline.com.br
• 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
• 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
31. www.CirurgiaOnline.com.br
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
• 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
39. 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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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