Two-stage hepatectomy for 'unresectable' liver mets

ORLANDO­-“Unresectable” colorectal cancer liver metastases may actually be resectable with a two-stage hepatectomy approach, Rene Adam, MD, PhD, of the Hospital Paul Brousse, Villejuif, France, said at the 2008 Gastrointestinal Cancers Symposium (abstract 283). In a two-stage strategy, compensatory liver regeneration after a first noncurative hepatectomy may enable a second curative resection. When feasible, this approach renders a 5-year survival benefit of nearly 40%, he said.

Dr. Adam reported his single-center experience with two-stage hepatectomy from 1992 to 2006 for liver metastases initially considered unresectable. Of 262 patients who were initially unresectable, 51 (20%) were deemed eligible for a two-stage procedure-6% of the entire metastatic population (817 patients). Of the 51 eligibles, 35 (69%) underwent both operations

In 74% of patients, the major resection was performed during the second operation. Portal vein embolization was performed alongside the first resection in 77%. Local treatment was also delivered to 14% of patients during the second hepatectomy. All but one patient (97%) received preoperative chemotherapy, while 77% continued chemotherapy between the two procedures and 74% also received postoperative chemotherapy.

At a median follow-up of 26 months, overall 3-year and 5-year survival rates were 57% and 39%, respectively, from the time of the first hepatectomy, in patients who underwent both resections. “But for the 16 patients who were unable to undergo the two-stage procedure, none were alive past 1.5 years,” Dr. Adam added.

Recurrences after the second hepatectomy were observed in 19 patients (54%), which included intra-and extrahepatic metastases in 31%, hepatic metastases only in 14%, and extrahepatic metastases only in 9%.

One-third of these recurrences were treated with a repeat hepatectomy. Extrahepatic resection was performed in 21% and both operations in 16% of patients. Altogether, in the 35 patients, 81 hepatectomies were performed along with 34 adjunctive procedures (portal vein embolization and local ablation) and 15 extrahepatic resections, for a mean number of procedures of 3.7 per patient.

Factors determined to be prognostic for poor overall survival after an effective two-stage procedure were presence of six or more metastases, concomitant extrahepatic disease, and no chemotherapy after the second hepatectomy.

Dr. Adam recommends the following treatment algorithm for the colon cancer patient with unresectable liver metastases:

• Multiple unilobar lesions with remnant liver < 30%: portal embolization.
• Multiple bilobar lesions with ≤ 3 nodules ≤ 30 mm: hepatectomy plus radiofrequency ablation or cryotherapy.
• Multiple bilobar lesions with > 3 nodules > 30 mm: two-stage hepatectomy.