RESSECÇÃO DA METÁSTASE HEPÁTICA NO ADENOCARCINOMA COLORRETAL SUBMETIDOS A CIRURGIA COM INTENÇÃO CURATIVA- EXPERIÊNCIA DO INCA DIAS JA ; MONTEIRO M; ALBAGLI R; CASTRO LS; RYMER EM; MACHADO ALMC; BARETTA R; SANTOS ALS; GUIMARAES VG; BERG S; SANTOS CER CONCLUSIONS: The survival rate following HR of solitary colorectal liver metastasis exceeds 70% at 5 years. Radiofrequency ablation for solitary metastasis is associated with a markedly higher LR rate and shorter recurrence-free and overall survival rates compared with HR, even when small lesions (< or = 3 cm) are considered. Every method should be considered to achieve resection of solitary colorectal liver metastasis, including referral to a specialty center, extended hepatectomy, and chemotherapy. PMID: 16702517 [PubMed - indexed for MEDLINE] Solitary colorectal liver metastasis: resection determines outcome. Aloia TA, Vauthey JN, Loyer EM, Ribero D, Pawlik TM, Wei SH, Curley SA, Zorzi D, Abdalla EK. Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston 77230-1402, USA. [Treatment efficacy of surgical management for liver metastasis from colorectal cancer--a report of 198 cases] [Article in Chinese] Zhang ZG, Song C, Wang H. Department of Colorectal Oncology, Liaoning Provincial Cancer Hospital, Shengyang, Liaoning, 110042, P. R. China. doctorchina@hotmail CONCLUSIONS: Radical resection could improve survival of the patients with liver metastasis from colorectal cancer. Palliative resection has no advantage over adjuvant therapy. Adjuvant hepatic arterial infusion should be applied in the unresectable cases. 1: Chirurgia (Bucur). 2006 Jan-Feb;101(1):13-24. Links [Surgical treatment of liver metastases from colorectal cancer][Article in Romanian] Popescu I, Ionescu M, Alexandrescu S, Ciurea S, Hrehoret D, Sarbu-Boeti P, Boros M, Croitoru A, Anghel R. Centrul de Chirurgie Generala si Transplant Hepatic Institul Clinic Fundeni, Bucuresti. irinel.popescu@icfundeni.ro The morbidity, mortality and survival rates after simultaneous liver and colorectal resection are similar with those achieved by delayed resection. Postoperative outcome of patients with major hepatic resection is correlated with the surgical team experience. The long-term survival was increased using the new multimodal treatment schemes. Suppl Tumori. 2005 May-Jun;4(3):S15. Links [Multimodal approach to rectal carcinoma with hepatic metastasis][Article in Italian] Orsenigo E, Aldrighetti L, Pulitano C, Bissolotti G, Bisagni P, Staudacher C. Dipartimento Assistenziale di Scienze Chirurgiche, Universita Vita-Salute, Istituto Scientifico Universitario San Raffaele, Milano. BACKGROUND: The role of surgery in the treatment of rectal cancer has been demonstrated worldwide. Moreover, curative liver resection of colorectal liver metastases is the only treatment offering a chance of long-term survival. Unfortunately, the liver resection can be performed in only 10% of the patients. AIM: In order to extend the frontiers of surgical indications in the treatment of liver metastases from colorectal cancer, we describe, in the video, a multimodal approach to rectal cancer with liver metastasis in the right lobe. Patient and methods. A 51 years old woman was admitted to our Department for adenocarcinoma of the distal rectum and a resectable solitary synchronous liver metastasis located across the right and the middle hepatic vein. Unfortunately, the future remnant liver was too small, risking severe post-operative liver failure. For this reason, a portal vein embolization or occlusion has been proposed. First of all, the patient has been submitted to laparoscopic low anterior resection with simultaneous right portal vein ligature. Two months later, after a CT estimation of liver volume in vivo, she was submitted to right hepatectomy (open surgery). RESULTS: Both postoperative courses were uneventful. CONCLUSIONS: As a preparation for large hepatic resection for liver rectal metastasis the laparoscopic ligature of the right portal vein performed simultaneously to the laparoscopic low anterior resection is feasible and safe. PMID: 16437876 [PubMed - indexed for MEDLINE] ·        Df The morbidity rates and mortalities reported after repeat hepatectomy for metastatic colorectal cancer92–104 and hepatocellular carcinoma105–112 are comparable to those reported after initial hepatectomy. 92. Bismuth H, Adam R, Navarro F: Re-resection for colorectal liver metastasis. Surg Oncol Clin North Am 5:353, 1996 104. Kin T, Nakajima Y, Kanehiro H, et al: Repeat hepatectomy for recurrent colorectal metastases. World J Surg 22:1087, 1998 [PMID 9747172]   NCCN v 2-2006 Treatment of liver metastases by resection has been demonstrated to result in a 38% five-year survival Journal of the American College of Surgeons Volume 197, Issue 2 , August 2003, Pages 233-241 Simultaneous liver and colorectal resections are safe for synchronous colorectal liver metastasis*1 Presented at the American College of Surgeons 88th Annual Clinical Congress, San Francisco, CA, October 2002. Robert Martin MDa, Philip Paty MD, a, Yuman Fong MD, FACSa, Andrew Grace MDa, Alfred Cohen MD, FACSb, Ronald DeMatteo MD, FACSa, William Jarnagin MD, FACSa and Leslie Blumgart MD, FACSa a Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA (Martin, Paty, Fong, Grace, DeMatteo, Jarnagin, Blumgart) b Lucille Markey Cancer Center, University of Kentucky, Lexington, KY, USA (Cohen) Received 23 October 2002; accepted 26 November 2002. ; Available online 23 July 2003. Abstract Background The optimal surgical strategy for the treatment of synchronous resectable colorectal liver metastasis has not been defined. The aims of this study were to review our experience with synchronous colorectal metastasis and to define the safety of simultaneous versus staged resection of the colon and liver. Study design From September 1984 through November 2001, 240 patients were treated surgically for primary adenocarcinoma of the large bowel and synchronous hepatic metastasis. Clinicopathologic, operative, and perioperative data were reviewed to evaluate selection criteria, operative methods, and perioperative outcomes. Results One hundred thirty-four patients underwent simultaneous resection of a colorectal primary and hepatic metastasis in a single operation (Group I), and 106 patients underwent staged operations (Group II). Simultaneous resections tend to be performed for right colon primaries (p < 0.001), smaller (p < 0.01) and fewer (p < 0.001) liver metastases, and less extensive liver resection (p < 0.001). Complications were less common in the simultaneous resection group, with 65 patients (49%) sustaining 142 complications, compared with 71 patients (67%) sustaining 197 complications for both hospitalizations in the staged resection group (p < 0.003). Patients having simultaneous resection required fewer days in the hospital (median 10 days versus 18 days, P = 0.001). Perioperative mortality was similar (simultaneous, N = 3; staged, N = 3). Conclusions Simultaneous colon and liver resection is safe and efficient in the treatment of patients with colorectal cancer and synchronous liver metastasis. By avoiding a second laparotomy, the overall complication rate is reduced, with no change in operative mortality. Given its reduced morbidity, shorter treatment time, and similar cancer outcomes, simultaneous resection should be considered a safe option in patients with resectable synchronous colorectal metastasis.

Ressecção de Metástase Hepática de origem colorretal 50 % dos pacientes com câncer colorretal irão desenvolver metástases hepáticas em algum período de sua doença Surgical strategies for colorectal liver metastases Surgical Oncology - Vol 13, I 2-3 , Aug-Nov 2004, Pag 125-136 Lesão sincrônica ( 15 a 20%) x lesão metacrônica ( 25 a 50%) Após ressecção: Sobrevida média de 30 a 40 meses Sobrevida em 5 anos: 38 % ( NCCN ) São elegíveis apenas 20 a 25 % dos pacientes Colorectal cancer remains the second commonest cause of death from cancer in Western society. Nearly half of all patients will develop liver metastases and many will die with disease confined to the liver. The accepted modern definitions of resectability now mean that over twenty per cent of patients are now resectable (with operative mortality of >2%) with curative intent, and nearly one third will be alive, disease free, five years later. The use of additional techniques such as radiofrequency ablation may bring many more patients the possibility of long term survival. The introduction of new chemotherapy regimens, including those based on oxaliplatin may convert one third of non-resectable patients to resectability with curative intent. Therefore, in 2004 nearly one third of patients with disease confined to the liver can now look forward to possibly curative liver surgery. Synchronous versus metachronous disease Metachronous, as opposed to synchronous, detection of colorectal metastases following diagnosis of the primary tumour usually carries a slightly more favourable prognosis; consistent with the likelihood that disease was less advanced when the initial diagnosis was made [20], [23] and [39]. Importantly however, a multicentre retrospective study of over 1800 patients found no significant difference in the proportion of short and long-term survivors after surgery between patients whose metastases were detected synchronously or metachronously [40]. Several other studies have shown that when analysed by multivariate analysis, the prognosis after resection is not dependent on the time of detection of metastatic disease [14], [18], [25] and [41]. In interpreting data concerning the benefits of resection of metachronous versus synchronous metastases, consideration should be given to progress in methods of earlier detection.

Ressecção de Metástase Hepática de origem colorretal “A ressecção hepática é o tratamento de escolha para metástases hepáticas ressecáveis de origem colorretal” NCCN, v 2-2006 “ A ressecção hepática e colorretal simultânea é segura para metástases colorretais sincrônicas “ Journal of the American College of Surgeons volume 197, Issue 2 , August 2003, Pages 233-241

Incisão

Lesões

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Secção do Parênquima

Aspecto Final

UIO

Ressecção de Metástase Hepática de origem colorretal Objetivo Avaliar os resultados de sobrevida da ressecção da metástase hepática para adenocarcinoma colorretal submetidos a cirurgia curativa

Ressecção de Metástase Hepática de origem colorretal Pacientes e Métodos 67 pacientes Submetidos a cirurgia hepática curativa Decorrentes de adenocarcinoma olorretal Abril 1996 a dezembro 2005

Ressecção de Metástase Hepática de origem colorretal

Ressecção de Metástase Hepática de origem colorretal

Ressecção de Metástase Hepática de origem colorretal Mediana de idade: 56 anos Mediana dos níveis de CEA: 9,3 ng/dl

Ressecção de Metástase Hepática de origem colorretal n=67 Houve discordância entre USG e TC em 14 (18%) dos casos Maior acurácia da tomografia em 10 (13 %) p=0,04

Ressecção de Metástase Hepática de origem colorretal Invasão vascular 25% casos ( 17) Trombo mural 14% casos ( 10)

Ressecção de Metástase Hepática de origem colorretal

Ressecção de Metástase Hepática de origem colorretal Cirurgia concomitante

Ressecção de Metástase Hepática de origem colorretal Sobrevida em 5 anos Sobrevida estimada 39% Tumores metacrônicos 59% Tumores sincrônicos 32% P=0,06

Ressecção de Metástase Hepática de origem colorretal Conclusão A ressecção curativa da metástase hepática no tumor colorretal propicia chance de cura, principalmente em tumores metacrônicos