Call Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore Escorts
Colorectal liver metastases (Dr Juan Carlos Meneu Diaz). Oncocir. Clinica Ruber
1. COLORECTAL LIVER METASTASES
Surgery, cryotherapy, radiofrequency and chemotherapy
An-update
Juan Carlos Meneu Diaz MD PhD
Chief of Section
Department of General, Digestive and Abdominal Organs Transplantation
University Hospital 12 de Octubre
Department of Surgery And Organ Transplantation
“Doce de Octubre” Hospital - Complutensis University
2. COLORECTAL LIVER METASTASES
Natural history of colorectal liver metastases
Cancer Research Compaign, 1999
• CRC: the second cause of
cancer death in Europe
• A 80% surgery (curative intent)
• Between 20%-50% will relapse
Local
Peritoneal
Distant
• 33% isolated liver deposits
3. COLORECTAL LIVER METASTASES
Natural history of colorectal liver metastases
Midgley R. Lancet 1999
• 80% of patients will die with liver
mets
• 20% first relapse: liver
• For advanced disease
Systemic chemotherapy
5-Fluorouracil (5-FU)
Merely palliative
12 months
4. COLORECTAL LIVER METASTASES
Natural history of colorectal liver metastases
Stangl R. Lancet 1994
No treatment of LM (median: 9 mos)
• Prospective study
• 1980-1990
• 484 untreated hepatic metastases
31% at 1 year
7.9% at 2 years
2.6% at 3 years
0.9% at 4 years
5. COLORECTAL LIVER METASTASES
Natural history of colorectal liver metastases
Cancer Research Compaign, 1999
• Untreated liver metastases:
Dismal outcome
• Lymphatic and blood borne spread
from liver metastases
Lung mets
Intrabdominal lymph nodes
6. COLORECTAL LIVER METASTASES
Natural history of colorectal liver metastases
Penna C. British Medical Bulletin 2002
Liver resection for LM
(median 36 mos)
Retrospective studies comparing
resection vs no treatment
• Wilson (1976): 28% 5y-survival
• Wanebo (1978): 25% 5y-survival
8. Penna C. British Medical Bulletin 2002
Selection of patients for resection
• Patient´s condition
• Extension of the disease
• Liver function
Goals of pre-op assessment
• Patient´s ability to tolerate surgery
• Non resectable extrahepatic disease?
• Anatomy of liver and metastases
COLORECTAL LIVER METASTASES
Assessment for liver resection
9. Penna C. British Medical Bulletin 2002
Patient´s condition
• Cardiocirculatory status (clamping
manouevres)
• Coagulation profile (hemorrhagic surg)
Liver function
• 75% of liver volume (6 segments)
• Caution with pre op chemotherapy
• Child-Pugh, ICG
• CT scan-residual liver volume (>0.5%)
COLORECTAL LIVER METASTASES
Assessment for liver resection
10. Penna C. British Medical Bulletin 2002
Extrahepatic disease assessment
• Primary tumor
Rectal examination
Colonoscopy
MRI
Endorectal US
• Other metastatic sites
Thorax Rx
Brain CT
Bone scintigraphy
COLORECTAL LIVER METASTASES
Assessment for liver resection
11. Penna C. British Medical Bulletin 2002
Hepatic involvement
• Preoperative
US
Spiral CT scan
MRI
• Intraoperative
Laparoscopy w/o lap-US
Intraoperative US (IOUS)
Radioguided surgery
COLORECTAL LIVER METASTASES
Assessment for liver resection
12. Spiral CT scan with portal phase
COLORECTAL LIVER METASTASES
Liver involvement and anatomy of Liver Metastases
13. IOUS mapping of the anatomical relations
COLORECTAL LIVER METASTASES
Anatomy of liver metastases
17. COLORECTAL LIVER METASTASES
Liver resection
Adam R. Arch Surg 2002
• The treatment of choice of LM
• Feasible in < 30% of the cases
• Goals of liver resection
Remove all deposits
Get clearance margins (> 1 cm)
Preserve healthy parenchyma
18. COLORECTAL LIVER METASTASES
Liver resection
Adam R. Arch Surg 2002
• Contraindications for resection:
Multifocal bilateral unresectable disease
Major vascular/biliary structures involvement
Inadequate liver reserve
Unresectable extrahepatic disease
19. COLORECTAL LIVER METASTASES
Liver resection
Fong Y. J Clin Oncol 1997
Pichlmayr R. World J Surg 1982.
Candidates for surgery
• No non-resectable extrahepatic disease
• Tumor free margins (all deposits)
• Avoid postoperative liver failure
20. COLORECTAL LIVER METASTASES
Liver resection
Fong Y. J Clin Oncol 1997
Pichlmayr R. World J Surg 1982.
Candidates for liver
transplantation
• Has been
abandoned
2y survival:
14%
5y survival:
0%
FIG. 1
End-to-end technique (group I)
Coronary artery
(Re)
Common hepatic
artery (Re)
Celiac axis (Do)
Splenic artery
(Do)
Coronary artery
(Do)
Gastroduodenal
artery (Do)
Proper hepatic
artery (Do)
Splenic artery
(Re)
24. COLORECTAL LIVER METASTASES
Results of liver resection for colorectal metastases
100 Patients (1999-2001)
39%
61% MALE
FEMALE
Mean age: 56,5 ± 12,8
Moreno E at al. Cir Esp 2002
25. COLORECTAL LIVER METASTASES
Results of liver resection for colorectal metastases
Moreno E at al. Cir Esp 2002
40% 60%
SYNCHRONIC METECHRONIC
Mean interval for metachronic
6 ± 2,7 months
26. COLORECTAL LIVER METASTASES
Results of liver resection for colorectal metastases
Moreno E at al. Cir Esp 2002
3 4 %
6 6 %
UNILOBAR
BILOBAR
70%30%
27. COLORECTAL LIVER METASTASES
Results of liver resection for colorectal metastases
Moreno E at al. Cir Esp 2002
30
41,25
7,5
2,5
15
3,75
% 30 41,25 7,5 2,5 15 3,75
Rectum Sigmoid
Left
colon
Transve
rse
Right
colon
Multifo
cal
29. • Operative mortality
• Inhospital mortality
• Complications
• Liver failure
• Reoperations
• Mean PRC transfusion
• No transfusionç
• Median stay
0%
3%
11%
7%
0%
702 ml (1200 SD)
65%
10.5 days
COLORECTAL LIVER METASTASES
Results of liver resection for colorectal metastases
Moreno E at al. Cir Esp 2002
30. COLORECTAL LIVER METASTASES
Results of liver resection for colorectal metastases
Moreno E at al. Cir Esp 2002
Survival Function
superv tras metastasectomía(meses)
100806040200
PorcentajePacientes
1,0
,9
,8
,7
,6
,5
,4
,3
,2
,1
,0
Survival Function
Censored
5ys 47%
3ys 70%
Mean survival
61 months (95%IC: 50-73
31. COLORECTAL LIVER METASTASES
Results of liver resection for colorectal metastases
Moreno E at al. Cir Esp 2002
superv tras reresección(meses)
100806040200
Porcentajepacientes 1,0
,9
,8
,7
,6
,5
,4
,3
,2
,1
,0
Survival Function
Censored
Mean survival after repeated
resection
50 months (95%IC: 30-70)
5ys 37%
3ys 47%
32. Midgley R. Lancet 1999
• Liver resection is safe and effective
• Distant metastases does not
preclude curative treatment
• Liver resection can ensure
Long term survival
Cure
• A minority will benefit from resection
COLORECTAL LIVER METASTASES
Liver resection
33. COLORECTAL LIVER METASTASES
How to increase resectability?
Adam R. Annals of Surgery 2002
Preoperative chemotherapy (Two-stage hepatectomy)
34. COLORECTAL LIVER METASTASES
How to increase resectability?
Adam R. Annals of Surgery 2002
Acchieved in 16% of previously considered
unresectable
Similar 3 and 5 years survival rate to initially resectable
tumors (81% and 67% vs 88% and 61%)
36. COLORECTAL LIVER METASTASES
How to increase resectability?
Azoulay D. Ann Surg 2000
Resection feasible in 60% of the cases
Comparable survival rate at 1 and 3 years
38. Midgley R. Lancet 1999
Criotherapy
• Low temperature (-196ºC)
• Cyclic aplication
• Liquid nitrogen/argon
• Effects:
Cellular dehydration
Protein denaturalization
Microcirculatory failure
COLORECTAL LIVER METASTASES
How to treat unresectable tumors?
39. Midgley R. Lancet 1999
Radiofrequency
• High temperature (> 50ºC)
• 460-500kHz
• Effects:
Cellular dehydration
Protein denaturalization
Coagulation necrosis
COLORECTAL LIVER METASTASES
How to treat unresectable tumors?
44. • Complete surgical resection
Low mortality(<2%)
Long term survival (>40% at 5 years)
• However: feasible in 20% of the cases
• Best candidates
No extrahepatic disease
More than 2 years of interval
CEA levels < 5 ng/ml
COLORECTAL LIVER METASTASES
Summary and conclusions
46. IX WOR LD CONGR E SS
OF T HE IS DE
Madrid, 2004
May 27th-29th
Preparation s tatus for the Meeting
E. Moreno-Gonzalez
Professor and Chairman
Department of Surgery And Organ
Transplantation
“Doce de Octubre” Hospital - Complutensis
University
Department of Surgery And Organ
Transplantation
“Doce de Octubre” Hospital - Complutensis
University
THANK YOU FOR YOUR ATTENTION