2. Metastatic Liver Disease Indications and Limitations N.J.Lygidakis MD FACS, FRCST (Hon) “ HENRY DYNANT” Hospital Dept. of Surgical Oncology

8. Metastatic Liver Disease Indications and Limitations Surgery combined with neo and adjuvant regional chemo–immuno therapy From Nov. 1991 to May 200 2 , all patients with liver metastases of colorectal origin (n=61) were considered for adjuvant locoregional immuno-chemotherapy following liver resection

9. Surgery combined with neo and adjuvant regional chemo–immuno therapy Procedure No. of Pts n=60 right hemihepatectomy 26 extended right trisegmentectomy 12 left hemihepatectomy 14 segmentectomy 8

10. Surgery combined with neo and adjuvant regional chemo–immuno therapy … survival time: 79 months … survival free of hepatic progression: 75 months … survival of disease free – progression : 45.5 months Median….

11. Surgery combined with neo and adjuvant regional chemo–immuno therapy Cumulative proportion surviving 73 5 year 78 4 year 80 3 year 92 2 year 95 1 year

12. Surgery combined with neo and adjuvant regional chemo–immuno therapy Cumulative proportion surviving free of hepatic progression 82 5 year 85 4 year 86 3 year 95 2 year 97 1 year

13. Surgery combined with neo and adjuvant regional chemo–immuno therapy Cumulative proportion surviving of disease free progression 58 5 year 59 4 year 62 3 year 69 2 year 84 1 year

14. Liver metastasis from a colon primary …a right hepatectomy was done

15. … an extended right hepatectomy was done

16. Liver metastasis from a rectal primary …a right hepatectomy was done

17. Liver metastasis from a rectal primary …a right hepatectomy was done

18. Surgery combined with ablation therapy and Neo and adjuvant locoregional chemo-immunotherapy From Nov. 1991 to May 200 2 , sixty one patients (n=61) with liver metastases of colorectal origin were considered for Surgery combined with neo and adjuvant chemo–immuno therapy and ablation therapy

19. Surgery combined with ablation therapy and Neo and adjuvant locoregional chemo-immunotherapy Procedure No. of Pts n=61 right hepatectomy Plus ablation 27 left hepatectomy Plus ablation 13 Segmentectomy Plus ablation 21

20. … survival time: 26 months Median…. Surgery combined with ablation therapy and Neo and adjuvant locoregional chemo-immunotherapy

21. Surgery combined with ablation therapy and Neo and adjuvant locoregional chemo-immunotherapy 0 5 year 18 4 year 50 3 year 70 2 year 87 1 year

22. Surgery combined with ablation therapy and Neo and adjuvant locoregional chemo-immunotherapy

23. Metastatic liver disease from colon cancer Patient underwent Right hepatectomy catheter to the hepatic artery and Microwave coagulation of a solitary lesion in the left liver lobe

24. Metastatic liver disease from colon cancer Patient underwent Right hepatectomy catheter to the hepatic artery and Microwave coagulation of a solitary lesion in the lesion of segment IV

25. Metastatic liver disease from colon cancer Patient underwent Liver segmentectomy and Microwave coagulation of a solitary lesion in the left lobe

26. Two stage surgery Metastatic Liver Disease Indications and Limitations From November 1991 to May 2002 , 62 patients with metastatic liver disease of colorectal origin underwent main portal branch transection combined with liver resection and neo- and adjuvant transarterial immuno-chemotherapy.

27. Clinicopathological characteristics Age Median 62 Range 25-80 Sex Male 30 Female 32 Karnofski score Median 90 Range 70-100 Liver involvement Median 45% Rage 30-70 No of liver metastases 3 10 4-6 30 >6 22 Type of disease Synchronous 15 metachronous 47 Prior treatment None 18 Adjuvant chemotherapy 22 Chemotherapy for metastases 22

29. Main Portal branch ligation

30. Locoregional chemo-immunotherapy catheter insertion in the gastroduodenal artery

31. Two stage surgery Chemotherapy 1 st Day Oxaliplatin 150 mg per m 2 of bs 2nd Day Mitomycin 20 mg per m 2 of bs 5 FU 750 mg per m 2 of bs Leucovorin 200 mg per m 2 of bs Irinotecan 2 mg per m 2 of bs 3rd, 4th, 5th day 5-FU 750 mg per m 2 of bs Leucovorin 200 mg per m 2 of bs Irinotecan 2 mg per m 2 of bs Immunotherapy The next day and for (10) consecutive days 1ml of Proleukin

32. Two stage surgery LFT’s at admission LFT’s 40 days following main portal branch transection Albumin 30 g/l 45g/l Alkaline Phosphatase 450 iu/l 270 iu/l SGOT 68 iu/l 35 iu/l SGPT 62 iu/l 32 iu/l Bilirubin 2.8 mg/100ml 1.5 mg/100ml γ -GT 220 iu/l 95 iu/l INR 2 1.2

33. Phase II surgery - Liver resection Two stage surgery Procedure No. of Patients right hemihepatectomy 28 extended right trisegmentectomy 12 left hemihepatectomy 14 segmentectomy 8

34. Phase II surgery - Liver resection Video

35. … survival time: 66 months … survival free of hepatic progression: 43 months … survival of disease free – progression : 19 months Median…. Two stage surgery Metastatic Liver Disease Indications and Limitations

39. Lipiodol-Urografin emulsion, selectively retained in the tumor bearing area. Left liver lobe hypertrophy. Hepatectomy was possible one month later

40. Two months later after tumor reduction the patient underwent right hepatectomy CT scan after right hepatectomy

41. Patient with right liver metastasis underwent two-stage liver surgery

42. Patient with right liver metastasis underwent two-stage liver surgery

43. Patient with large right liver HCC underwent two-stage liver surgery

44. Patient with left liver metastasis underwent two-stage liver surgery

45. Patient with right liver metastases underwent two-stage liver surgery