Luc-Antoine Veilhan

Long-term results of two-stage hepatectomy for irresectable colorectal cancer liver metastases.

Objective:To assess feasibility, risks, and long-term outcome of 2-stage hepatectomy as a means to improve resectability of colorectal liver metastases (CLM). Summary Background Data:Two-stage hepatectomy uses compensatory liver regeneration after a first noncurative hepatectomy to enable a second curative resection. Methods:Between October 1992 and January 2007, among 262 patients with initially irresectable CLM, 59 patients (23%) were planned for 2-stage hepatectomy. Patients were eligible when single resection could not achieve complete treatment, even in combination with chemotherapy, portal embolization, or radiofrequency, but tumors could be totally removed by 2 sequential resections. Feasibility and outcomes were prospectively evaluated. Results:Two-stage hepatectomy was feasible in 41 of 59 patients (69%). Eighteen patients failed to complete the second hepatectomy because of disease progression (n = 17) or bad performance status (n = 1). The 41 successfully treated patients had a mean number of 9.1 metastases (mean diameter, 48.5 mm at diagnosis). Chemotherapy was delivered before (95%), in between (78%), and after (78%) the 2 hepatectomies. Mean delay between the 2 liver resections was 4.2 months. Postoperative mortality was 0% and 7% (3/41) after the first and second hepatectomy, respectively. Morbidity rates were also higher after the second procedure (59% vs. 20%) (P < 0.001). Five-year survival was 31% on an intention to treat basis, and all but 2 patients who did not complete the 2-stage strategy died within 19 months. After a median follow-up of 24.4 months (range, 3.7–130.3), overall 3- and 5-year survivals for patients that completed both hepatectomies were 60% and 42%, respectively, after the first hepatectomy (median survival, 42 months from first hepatectomy and 57 months from metastases diagnosis). Disease-free survivals were 26% and 13% at 3 and 5 years, respectively. Conclusions:Two-stage hepatectomy provides a 5-year survival of 42% and a hope of long-term survival for selected patients with extensive bilobar CLM, irresectable by any other means.

Mehrzeitige Leberresektionen bei colorectalen Lebermetastasen Das Paul Brousse-Konzept

Abstract. Hepatic resection is currently the only form of treatment that offers a chance of long-term survival, with rates ranging from 25 % to 39 %. However, a curative operation can be performed in only 10 % of patients with colorectal metastases to the liver. Our policy is to increase the number of patients that can benefit from liver resection. Liver metastases can be considered as irresectable mainly in three different situations (sometimes associated): (I) large and/or poorly located tumors; (II) bilateral tumors in both liver lobes; (III) tumors technically resectable, but not operable because the liver remnant is too small, which is associated with a prohibitive risk of postoperative severe liver failure. The aim of this paper is to report the strategies we use in our center to achieve curative resection in these three schematic situations despite initial contraindications.Zusammenfassung. Die Leberresektion ist häufig die einzige Behandlungsform, die eine Chance zu langfristigem Überleben bietet, mit Raten von 25–39 %. Aber nur bei 10 % der Patienten mit colorectalen Metastasen in der Leber kann eine kurative Operation durchgeführt werden. Wir sind grundsätzlich darum bemüht, die Zahl der Patienten, die von einer Leberresektion profitieren können, zu erhöhen. Lebermetastasen sind hauptsächlich in drei Erkrankungssituationen (die manchmal in Kombination auftreten) als irresektabel anzusehen: 1) große und/oder schlecht lokalisierte Tumoren, 2) bilaterale Tumoren in beiden Leberlappen, 3) technisch resektable, aber wegen zu kleiner verbleibender Leber mit dem (zu großen) Risiko eines schweren postoperativen Leberversagens inoperable Tumoren. Der folgende Beitrag soll die Strategie unseres Zentrums erläutern, mit der angestrebt wird, in den genannten Situationen trotz initialer Kontraindikation kurative Resektionen durchzuführen.

Long-Term Results of Transplantation for Hepatocellular Carcinoma With or Without Cirrhosis: 15 Years’-Experience at Paul Brousse Hospital

Hepatocellular carcinoma (HCC) still remains a controversial indication for liver transplantation (LT). An evaluation of long-term results is mandatory to define the patients who are likely to benefit from cadaveric or living-related LT. During 15 years’ experience, 220 LTs were performed consecutively at a single institution for HCC in patients with or without underlying cirrhosis (195 and 25 cases, respectively). The patients were younger and the proportion of females was higher in the noncirrhotic group (P < 0.001). Perioperative mortality (≤2 months) was 4% in cirrhotic and 0% in non cirrhotic patients. In spite of a higher incidence of recurrence related to more extensive tumors in HCC without cirrhosis (54% vs. 20%, P < 0.001), survival after transplantation was similar: 60% and 48% at 5 and 10 years, respectively, for patients without cirrhosis, and 73% and 39%, respectively, for patients with underlying cirrhosis (P not significant). While the combination of size and number of tumors was highly predictive of recurrence and survival in the cirrhotic group, this was not the case for non-cirrhotic patients. However, portal invasion was poorly associated with survival in both groups. HCC with and without underlying cirrhosis represents two separate entities with different patterns of evolution. The criteria of selection for transplantation should follow different policies in these two groups of patients.

P. 227 Résultats à long terme des hépatectomies en 2 temps pour métastases de cancer colorectal

Objectif L’objectif de cette etude a ete de determiner la faisabilite, les risques et le benefice a long terme de l’hepatectomie en 2 temps comme strategie programmee, destinee a augmenter la resecabilite des metastases hepatiques de cancer colorectal (MHCCR). Patients et Methodes De 1992 a 2007, a partir d’une cohorte de 262 patients ayant des MHCCR initialement non resecables, 59 patients (23 %) ont ete programmes pour une hepatectomie en 2 temps. Les patients etaient eligibles quand l’exerese complete des metastases ne pouvait etre faite par une seule resection, meme combinee a une embolisation portale ou a une radiofrequence. Resultats L’hepatectomie en 2 temps s’est revelee faisable chez 41 des 59 patients (69 %). Dix-huit patients n’ont pu avoir la seconde hepatectomie (progression tumorale (N = 17) ou alteration de l’etat general (N = 1)). Les 41 patients traites completement avaient un nombre moyen de 9,1 metastases et un diametre maximal moyen de 48,5 mm. Une chimiotherapie a ete administree avant (95 %), entre (78 %), ou apres (78 %) les deux hepatectomies. Le delai moyen entre les 2 resections etait de 4,2 mois avec 78 % des patients traites en premier par une hepatectomie partielle gauche couplee a une embolisation portale droite et dans 20 % des cas, une exerese synchrone de la tumeur primitive. La mortalite post-operatoire a ete de 0 % et 7 % apres la premiere et la seconde hepatectomie. Le taux de complications etait plus eleve (59 % vs 20 % respectivement, P Conclusion L’hepatectomie en 2 temps permet une survie a 5 ans de 42 % chez des patients selectionnes ayant des MHCCR bilobaires, non resecables par d’autres moyens et autrement promis a un tres mauvais pronostic.