Metastatic Tumors Flashcards
The most common malignant tumors of the liver
are metastatic lesions
Metastatic adenocarcinoma to the liver of unknown primary ? you should think of what?
- often a primary IHC,
> > and this diagnosis must always be kept in mind
Colorectal Metastases
Up to 60% Develop it through their life
synchronously vs metachronously
synchronously»_space;
at the time of diagnosis of primary disease
metachronously»_space;
arbitrarily defined as >1 year after the diagnosis of primary disease
Literature suggests that synchronous liver metastases portend to a worse prognosis than metachronous disease
poor prognostic sign
- pain
- ascites
- jaundice
- weight loss
- palpable mass
What should you look for when observing Patient with Colon Cancer ?
- rising CEA level on serial examinations
- new solid mass on imaging studies are diagnostic of metastatic disease.
What most commonly in labs can be elevated also ?
ALP
GGT
lactate dehydrogenase.
what type of imaging requested ?
- high-quality CT or MRI
- thin-cut (5 mm)
- high-resolution, dynamic, contrast-enhanced helical scanning techniques.
- Timing with IV administration of a contrast agent should correspond to the portal venous phase to maximize hepatic parenchymal enhancement, which improves the disparity between parenchyma and tumor.
Workup for colorectal liver metastases
- Colonoscopy > if it has been longer than 1 year since the last examination
- CT abdominal and pelvic
- CT Chest
Do you need PET/CT ??
- use of PET/CT did not result in significant changes in surgical management, and there was no difference in resectability or long-term outcomes between the two groups.
- This trial provides definitive evidence that routine use of PET does not significantly affect outcomes among patients with potentially resectable colorectal cancer liver metastasis
What Chemotherapy regiment to consider for Advanced Disease ?
- 5-FU with irinotecan or oxaliplatin combined
with targeted antiangiogenic antibodies such as bevacizumab (antivascular endothelial growth factor antibody)
or cetuximab (antiepidermal growth factor antibody)
Survival for Colorectal Liver Mets after Surgery ?
50 % survive 3 Yrs
20 % Survive 5 Yrs
what is the Problem with pre-op Chemo ?
- associated with hepatic toxicity
(steatohepatitis and sinusoidal obstructive syndrome)
and higher rates of postoperative liver failure.
What are the poor prognostic factors?
poor prognostic factors include :
- extrahepatic metastases
- involved lymph nodes with the primary colorectal tumor
- synchronous presentation (or shorter disease-free interval)
- larger number of tumors
- bilobar involvement
- CEA level elevation more than 200 ng/mL
- size of largest hepatic tumor more than 5 cm
- involved histologic margins
five preoperative factors as the most influential on outcome:
1- size larger than 5 cm
2- disease-free interval less than 1 year
3- more than one tumor
4- lymph node–positive primary
5- CEA level higher than 200 ng/mL.
Contraindication for Hepatectomy
- the inability to resect all disease.
what margin you aim for ? and locations for best outcomes ?
- Wide margins more than 1 cm are appropriate
- Sites associated with the best outcomes:
limited lung metastases
locoregional recurrences of the primary tumor
portal lymph nodes
Recurrence rate after Tx ?
- Overall, approximately 75% of patients have recurrence
- in high-risk situations (e.g., four or more tumors, extrahepatic disease), recurrence rates approach 100%
how do you approach recurrence ?
- 50% of recurrences are isolated to the liver
- ∼5% of all patients undergoing liver resection are candidates for a second liver resection.
- second liver resection with complete removal of all disease can expect further 5-year survival rates of 30% to 40%.
- Limited and isolated lung recurrences can also be resected with the potential for further long-term survival
Adjuvant Therapy role ?
Adjuvant chemotherapy was independently associated with both progression-free survival and overall survival in multivariable analysis
In summary for The role of Colorectal Liver Mets ?
- level 1 clinical evidence that adjuvant systemic chemotherapy, when combined with liver resection, modestly improves progression-free survival in patients with colorectal liver metastases.
- At this time, the general consensus is that patients with liver metastases benefit from 6 months of perioperative adjuvant therapy.
Neoadjuvant chemotherapy role ?
Neoadjuvant chemotherapy for resectable metastases is also a common strategy to treat occult systemic disease and can be helpful in selecting the small group of patients (<10%) who progress while receiving chemotherapy and have a poor outcome after hepatectomy.
Rationale of Using HAI ?
The rationale for adjuvant hepatic artery chemotherapy is based on the fact that liver metastases derive most of their blood supply from the hepatic artery.
Regional infusion of chemotherapeutic agents such as fluorodeoxyuridine has hepatic extraction rates of 90%, providing high local concentrations with minimal systemic toxicity
HAI therapy with fluorodeoxyuridine to be more effective than hepatectomy alone, with significantly improved disease-free survival
Unresectable liver-only metastatic disease
preoperative systemic and HAI chemotherapy has been shown to convert some patients to resection candidates.
Strategies to extend the limits of liver resection
- parenchyma-preserving segmental resections
- two-stage operations
- thermal ablative techniques, such as cryoablation or RFA
- microwave ablation is being studied as a treatment for these patients,
Recurrence rate increase with what ?
- recurrence rates increase with the size of the tumor and when ablation is performed for the tumor close to the vessels.
- microwave ablation either alone or in combination with liver resection can provide good long-term results.
- multiple bilobar tumors can be extirpated by a combination of resection and ablation with preservation of sufficient hepatic parenchyma.
Neuroendocrine Metastases to live
gastrinomas
glucagonomas
somatostatinomas
nonfunctional neuroendocrine tumors.
Insulinomas and carcinoid tumors metastasize to the liver less commonly.
Tx options ?
- Long-acting somatostatin analogues
» alleviating hormonal symptoms
» cytostatic role as well - Hepatic arterial embolization or thermo ablative
» cytoreducing tumor loads
» alleviating symptoms of hormonal excess. - Liver Resection
» enucleation and wedge resection are reasonable options.
Noncolorectal, Nonneuroendocrine Metastases
Patients with liver-only metastatic disease should be treated with systemic chemotherapy before being considered for liver resection
Which Liver Mets has the best Prognosis from all the others in this category ?
- long-term survival after resection of isolated liver metastases from upper gastrointestinal tumor, in general, these patients have a dismal prognosis and liver resection is not recommended.
- In most series, liver resection for genitourinary tumors has the best prognosis, and in well-selected patients, liver resection should be considered.
