Met hepsarcoma pequim final

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

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

Resections of Colorectal Metastases
Well Established
Hepatic Metastases of Sarcomas
?
INTRODUCTION

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

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

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.
INTRODUCTION

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
Before Imatinib

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.

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%

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 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).

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).

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

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

Angiomyosarcoma Leiomyosarcoma

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.
sarcoma metastases

Results
• Patients
• Gender: 17 women (60.7%)
• 11 men (39.3%)
•
• Age: 30 - 72 y (median 55 y)
sarcoma metastases

Results
• Tumour 26 abdominal origin
• 8 Gastric;
• 7 Small Bowel;
• 6 Retroperitoneal;
• 2 Uterine;
• 1 IVC, Kidney, Colon, Breast and Deltoid.
sarcoma metastases

Results
• Histology:
• 16 (54.1%) - Leiomyosarcoma
• 8 (28.6%) - GIST
• 2 Endometrial Sarcomas
• 1 Fibrosarcoma
• 1 Angiosarcoma
sarcoma metastases

• Histology:
sarcoma metastases
Histology Median
Visceral 66.33
Non
Visceral
33.23
Overall 62.73
P= 0.208

Results
• Histology:
sarcoma metastases
P= 0.171
Histology Median
GIST -
Others
Sarcomas
37.97
Overall 62.73

Results
• Tumour Grade:
G3 - 11 (39.3%)
• G2 - 8 (28.6%)
• G1 - 2 (7.1%)
GX – 4 (14.3%)
• Metastases Size: 2 to 25 cm (median 6 cm)
• 20 cases Metachronic – Median 30 months (5 - 292)
• 8 Synchronic disease
sarcoma metastases

Results
• Tumour Grade:
sarcoma metastases
P= 0.529

Results
• Diagnostic
• CT 26 cases
• US 4 cases
• MRI 1 case
sarcoma metastases

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
sarcoma metastases

RADIOFREQUENCY
ABLATION

Results
• Radicality
– R0: 18 patients (64.3%)
– R1: 03 patients (10.7%)
– R2: 7 patients (25%)
sarcoma metastases

Results
• Radicality
sarcoma metastases
P= 0.876
Mean
R0 – 63 months
R1 + R2 – 34 months

Results
• Radicality
Without GIST
sarcoma metastases
P= 0.229
Mean
R0 – 63 months
R1 + R2 – 33 months

Results
• Surgery
• Average Surgical time 332 min (180-840)
3h to 14h
sarcoma metastases

Results
• Surgery
• Hospitalisation 10 days
• Morbidity 25% - 7 cases
• Post op mortality (30 days): 1 case (3.6%)
• Pneumonia and wound infection
sarcoma metastases

Results
• Disease free survival 11 months (5-37)
sarcoma metastases

Results
• Median Overall Survival 63 months (1 – 105)
sarcoma metastases
5y surv – 52.7%

Results
• Blood Transfusion x Survival
– No: 19 patients (68%) - SV 74 months
– Yes: 09 patients (32%) - SV 21 months
• Mean 1200 ml ( 600-1800 ml)
sarcoma metastases

sarcoma metastases
P= 0.001

Results
• Recurrence
- 76.5% R0 patients recurred (50% liver)
-7 patients 2nd resection
-4 patients 3rd resection
-2 patients 4th resection
sarcoma metastases

Results
• Repeat Resection
sarcoma metastases
P= 0.060Repeat
Resection
Median
Yes 66.33
No 33.23
Overall 62.73

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
sarcoma metastases

Results
• Neo or Adjuvant treatment X Survival (R0)
sarcoma metastases
P= 0.212 P= 0.668

Results
• OS Neo or Adjuvant treatment X Survival (All patients)
sarcoma metastases
P= 0.703

Results
• OS Neo or Adjuvant treatment X Survival (GIST)
sarcoma metastases
P= 0.051
Adv.
Treat.
Median
GIST -
Others
Sarcomas
33.23
Overall 62.73

GENERALIZED PROGRESSION
Metastas
is
SURGERY NOT
RECOMMENDED

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

Good news Sir, We achieve a complete resection !

Met hepsarcoma pequim final

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