Management of Metastatic tumors in liver.pptx

A rapid review of metastatic tumors in liver

1. Metastatic tumors in liver Nabin Paudyal

2. Introduction MC tumors of liver are metastatic tumors in liver Usually GIT tumors mostly metastasize through the portal venous route MC cancer metastasizing to liver is the CRC Other tumors metastasizing to liver include Upper GIT GUT Neuroendocrine Breast Eye Skin Soft tissue Gynecological malignancies

3. Large majority of metastatic liver tumors that present with concomitant extrahepatic disease will have unresectable liver disease and are not curable with resection, limiting the role of surgeon to highly select cases requiring operation. Metastatic adenocarcinoma to the liver of unknown primary is often a primary IHC. Metastatic colorectal cancer isolated in the liver can be resected with the potential for long-term survival and cure. Advances in systemic and regional chemotherapy have also broadened the number of patients eligible for surgical therapy and improved long term survival Selection of patients is the most important aspect of surgical therapy for metastatic disease in the liver. A realistic expectation and honest patient opinion is important.

4. COLORECTAL METASTASIS IN LIVER Up to 60% of CRC patients develop metastasis during the course of their illness. Among a large group of patients who develop metastasis, only few patients develop CRC 2 types of growth seen Synchronous  at the time of diagnosis of primary disease [ Synchronous is defined as the detection (by imaging) of suspicious liver metastases within 90 days before or after the date of histologic diagnosis of the primary colon or rectal cancer. ] Metachronous  at > 1 year after the diagnosis of primary disease Synchronous liver metastasis portend to a worse prognosis that metachronous disease . Only 5-10% OF PATIENTS ARE CANDIDATES FOR POTENTIALLY CURATIVE LESION.

5. Presentation of patients Symptoms of advanced malignancy Pain Ascites Jaundice Weight loss Palpable mass Patients who are carefully observed with serial P/E, cross-sectional imaging studies, LFTs and determination of CEA levels are those found to have resectable metachronous disease at the time of diagnosis of primary CRC pre-operatively or during laparotomy

6. A RISING CEA LEVEL ON SERIAL EXAMINATION AND NEW SOLID MASS ON IMAGING STUDIES ARE DIAGNOSTIC OF METASTATIC DISEASE . LFT  Rising GGT, ALP and LDH CT/ MRI  Portal venous phase. WORKUP Colonoscopy (if > 1 year since primary CRC)  to rule out recurrence/ metachronous tumor CT abdomen/pelvis Chest CT

7. Management approach Surgical approach No trial for chemotherapy vs surgery Long term survival is extremely rare without treatment and is closely related to the extent of disease Combination chemotherapy is now done along with surgery→ 5-FU+ Irinotecan OR Oxaliplatin combined with antiangiogenic antibody→ Bevacizumab (anti-VEGF) or Cetuximab (anti-epidermal growth factor) [ @ FI- BO-CO] 50% of patients undergoing a liver resection for metastatic colorectal cancer will survive for 3 years and 20% will survive for 10 years. There is also significant morbidity rates of 30% to 50%. Complications Bleeding, bile leak, abscess and other generalized CVS complications .

8. Prognostic factors The only contraindication for surgery NOW is inability to resect all disease.

9. Hepatectomy for four or more metastasis is associated with approximate 5-year survival of 33%. Attempt at least 1 cm wide margin when possible. Attempt extrahepatic metastasis resection along with liver metastasis in following conditions Limited lung metastasis Locoregional recurrence Portal lymph node Although long term survival after liver resection for CRC mets is common, approx. overall 75% patients have recurrence in liver itself again After second liver resection, 5-survival falls to 30-40%

10. Adjuvant therapy Adjuvant hepatic intra-arterial therapy has shown some benefit. Adjuvant chemotherapy is independently a/w with OS and PFS. EORTC 40983 trial

11. Hepatic arterial infusion Fluorodeoxyuridine infusion

12. Role of neoadjuvant chemotherapy on going trial phase III

13. What if the tumor is unresectable? Pre-operative systemic and HAI chemotherapy  may convert some patients into resection candidates. Use of strategies like Parenchyma-preserving segmental resections, two-staged operations, thermal ablation ( Cryo , RFA, MW ablation) Combination techniques Multiple bi-lobar tumors can be extirpated by combination of resection and ablation with preservation of hepatic parenchyma.