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WORLD Journal of SURGERY @ 1995 by the Société Internationale de Chirurgie
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XEIDOUPTIKHI AM
Hepatic Resection for Noncolorectal Nonneuroendocrine Metastases
Seymour I. Schwartz, M.D.
Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, New York 14642, U.S.A.
Abstract. The experience with hepatic resection for metastatic lesions, exclusive of colorectal and neuroendocrine tumors, is anecdotal. The reduction in operative mortality leads to a reconsideration of the subject. A review of the literature suggests a selective approach. There is little improvement to be anticipated for resection of metastases from tumors of the esophagus, stomach, small intestine, or pancreas. Resection of metastases from primary renal cell carcinoma, Wilms’ tumor, and adrenocortical carcinoma is indicated. There is little to recommend resection of metastases from gynecologic or breast primary carcinomas. Resection as palliation is to be considered for all lesions, particularly bulky metastases from ocular melanomas.
Hepatic resection for metastatic tumors has gained acceptance as potentially curative treatment for primary tumors originating in the colon or rectum. Significant long-term palliation can be achieved by debulking hepatic resections for metastatic neuroen- docrine malignancies. The reduction in operative mortality asso- ciated with major hepatic resection to less than 5% in most series has led to more liberal application of the procedure. The appli- cability of hepatic resection for metastases from other gastroin- testinal primaries and from a broad spectrum of malignancies originating outside the gastrointestinal system has not been defined. A review of the literature, augmented by communication with the authors and personal anecdotal experiences, is presented to aid in assessment.
Gastrointestinal Tumors
Many reports have included a variety of gastrointestinal meta- static tumors exclusive of colorectal and neuroendocrine lesions; they include 28 adenocarcinomas of the stomach [1-4; D.M. Nagorney and G.V. Raikar, personal communication]. In 11 patients from one series there was no indication whether the hepatic resection was performed for a metastasis or for contigu- ous involvement [2]. Among all reported patients there was only one long-term survival (56 months without recurrence) [4] in the remaining group. Bengmark et al. [5] and Jaffe et al. [6] reported that the median survival of patients undergoing gastric surgery or exploratory celiotomy in whom liver metastases were noted was 2 to 3 months.
In the cumulative literature four patients with hepatic metas- tases from esophageal lesions [2, 4; Nagorney and Raikar, per- sonal communication] and 14 patients with metastases from
pancreatic or periampullary malignancies [1-3; Nagorney and Raikar, personal communication] underwent hepatic resection. The only long-term survivor cannot be included in this paper because the primary lesion was a malignant insulinoma.
Renal Tumors
Wilms’ tumor and renal cell carcinoma metastatic to the liver have been resected with relative frequency and are associated with a more favorable prognosis than are the other lesions under con- sideration. Twenty patients in whom hepatic resection was per- formed for Wilms’ tumor have been reported [1, 2, 7-9; Nagorney and Raikar, personal communication]. Of the 16 patients in whom survival could be assessed, 7 were alive 5 years after hepatic resection and had no evidence of disease [1, 2, 9]. Each had received adjuvant chemotherapy, radiation therapy, or both.
Thirteen patients in whom hepatic resection was performed for metastatic renal carcinoma have been reported [1-4, 7, 8, 10]. Four survived more than 5 years without recurrence [1, 2, 4, 10]. Long-term survival subsequent to hepatic resection for this met- astatic lesion must be considered in light of the unusual biologic behavior of some of these lesions. One patient underwent left lateral segmentectomy for metastatic hypernephroma 5 years after the nephrectomy. She was alive 5 years after hepatic resection without evidence of recurrence. In another patient, a metastatic renal cell carcinoma was detected in the liver 19 years after nephrectomy. She died of the disease 2 years later, 21 years after the nephrectomy [10].
Adrenal Tumors
Hepatic metastases from eight adrenocortical carcinomas [8, 11; Nagorney and Raikar, personal communication], one neuroblas- toma [8], and one aldosteronoma [2] have been reported. Two long-term survivals of 131 and 132 months in the carcinoma group were reported by associates in 1983 [10].
Gynecologic Tumors
A variety of gynecologic tumors that metastasized to the liver have undergone hepatic resection. There is one long-term survivor
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among the 10 reported cases with ovarian carcinoma [1, 4, 8, 12; Nagorney and Raikar, personal communication].
A left lateral lobectomy performed for metastatic choriocarci- noma [7] was followed by early recurrence [11]. Hepatic metas- tases from primary carcinoma of the cervix or endometrium were resected on eight occasions [1, 7, 8, 12]. The only long-term survivor had primary endometrial carcinoma. She had a right lobectomy followed by local recurrence and the development of an enterocutaneous fistula, which was resected. She lived for an additional 12 years; and when she died there was no evidence of recurrent disease [R.S. Jones, personal communication]. Five patients with metastatic leiomyosarcoma of the uterus and one with vaginal carcinoma underwent hepatic resection; there were no long-term survivors [Nagorney and Raikar, personal commu- nication].
Breast Tumors
The literature review revealed that hepatic resection was per- formed for metastatic carcinoma of the breast in 22 patients [1, 3, 4, 12, 13; Nagorney and Raikar, personal communication]. There were two 5-year survivals [13; Nagorney and Raikar, personal communication]. L.H. Blumgart indicated that he performed hepatic resection for breast carcinoma in five patients [personal communication]. Recurrence occurred within 6 months, 2.5 years, and 5.0 years; the remaining two patients were operated on too recently to assess. One metastasis from a primary hemangiosar- coma of the breast was removed, but the status of the patient was not reported [8].
Melanoma
In one review [1], 1 of 11 patients who underwent hepatic resection for metastatic cutaneous melanoma lived 5 years but subsequently died of recurrence. Eight additional cases appear in
the literature with one long-term survival [8, 12, 13; Nagorney and Raikar, personal communication]. My experience includes two interesting patients with metachronous metastases from ocular melanoma. In one patient the hepatic lesion became apparent 26 years after enucleation of the eye for the primary lesion, and in the second patient a hepatic metastasis was noted 17 years after enucleation. Both patients underwent trisegmentectomy to relieve the tumor that was causing early satiety; the lesions weighed 3 and 4 pounds, respectively. One of the two patients died 3 years later of diffuse metastases; the other patient had a thyroidectomy for metastatic melanoma 3 years after the hepatic resection and 2 years later had a large metastasis removed from the soft tissue around the hip. She lived 6 years after the hepatic resection (Figs. 1, 2).
Sarcomas
Although the numbers are small, the sarcoma most commonly resected as a hepatic metastasis is the leiomyosarcoma originating in the stomach. It is difficult to determine if the hepatic lesion was truly a metastasis or a direct extension of the gastric tumor. In the largest series [1] the origin of the tumor in the nine patients in whom hepatic resection was performed for metastatic leiomyo- sarcoma was not defined. One of 11 patients survived 5 years but subsequently died of recurrence [J.H. Foster, personal communi- cation]. In another series [2] the one patient who underwent left hepatic lobectomy survived 12 years; but whether this hepatic
lesion was a direct extension or a metastasis is not stated. One additional leiomyosarcoma had a gastric primary lesion, but survival was not stated [8]. In two patients the primary leiomyo- sarcoma was in the duodenum [3; L.H. Blumgart, personal communication]. Blumgart’s patient survived 5 years without recurrence. There was one survival among the six patients at the Mayo Clinic who had hepatic resection for metastases secondary to small intestinal leiomyosarcomas [Nagorney and Raikar, per- sonal communication]. One patient, in whom the primary lesion was located in the abdominal wall, died of recurrence 46 months after hepatic resection [B. Langer, personal communication].
Reports have included resection of hepatic metastases from one spindle cell sarcoma of the small intestine [8], one rhabdomyo- sarcoma [2], one reticulum cell sarcoma of the stomach [3], and three sarcomatous lesions [1] not more precisely defined. No long-term survivors were recorded.
Miscellaneous Tumors
Hepatic resection for metastatic lesions originating in the lung in five patients has been reported [1, 4; Nagorney and Raikar, personal communication]. In two instances [8, 11] the primary lesion was in the thyroid. There are no long-term survivors in these two groups of patients. In the Foster and Lundy report [1] three cases are included where the primary was unknown; in the Mayo experience [Nagorney and Raikar, personal communica- tion] six patients were in this category, one of whom was a 5-year survivor. I have performed a left hepatic lobectomy on a 62-year- old woman for what was interpreted as metastatic, well differen- tiated papillary adenocarcinoma, probably originating in the ovary. That patient remains alive without evidence of recurrence for 10 years. One patient with metastatic embryonal cell carci- noma and one with metastatic VIPoma were alive and free of disease 11 months and 27 months, respectively, after hepatic resection [12].
Discussion
Nagorney and Raikar, in an unpublished review of hepatic resection for noncolorectal, nonneuroendocrine metastases (study 1-4938, Mayo Clinic), evaluated the results for 63 patients. The median survival to death from any cause was 2.2 years. The 6 month, 1 year, 2 year, and 3 year survivals were 86%, 75%, 52%, and 30%, respectively. One patient was alive 10 years after resection. There was one operative death and a 14% incidence of significant morbidity.
It is apparent from all reviews that the prognosis for these patients is distinctly poorer than it is for patients having hepatic resection for colorectal metastases [14]. The improvement in operative mortality consequent to hepatic resection-to the cur- rent rate of 2% to 3% in most centers with experience in hepatic surgery-could lead to more liberal attitudes toward operation for noncolorectal and nonneuroendocrine metastases. Applying the parlance of the medical and radiation oncologists, a 100% complete response is immediately achieved, and the patient is provided with hope.
The published data suggest a selective approach. Although it is reasonable to resect a portion of the liver that is involved with direct extension from a gastrointestinal carcinoma, there is a low yield for resection of true metastases. Resection of hepatic
metastases from renal lesions, either Wilms’ tumor or adenocar- cinoma, should be performed with the same criteria used for colorectal metastases because equivalent results are to be antici- pated. It might also be appropriate to consider resection of metastases from adrenocortical carcinoma. There is little to recommend resection of metastases from gynecologic or breast primaries because long-term survivors have been only anecdotally reported. Long-term survival subsequent to resection of meta- static sarcomas is also rare. The reduced mortality associated with hepatic resection does liberalize the indications for palliation, essentially debulking to remove a symptomatic mass and to treat early satiety. This approach is particularly appropriate for metas- tases from an ocular melanoma.
Résumé
L’expérience acquise en matière de résection hépatique pour des lésions métastatiques en dehors des métastases d’origine colorec- tale ou endocrine, est tout à fait anecdotique. En raison de la réduction de la mortalité après chirurgie hépatique, cette situa- tion mérite réflexion. Une revue de la littérature suggère une approche élective. On peut n’espérer que peu d’amélioration après la résection de métastases provenant des tumeurs de l’oesophage, de l’estomac, de l’intestin grêle, du pancréas, des cancers gynécologiques ou du sein. La résection de métastases provenant de cancers rénaux, des tumeurs de Wilms et des cancers de la corticosurrénale est, par contre, indiquée. La résection palliative est également à recommander surtout en cas de métastases volumineuses provenant des mélanomes oculaires.
Resumen
La experiencia con la resección hepática para lesiones metastási- cas, excluyendo los tumores colo-rectales y neuroendocrinos, es de tipo anecdótico. La reducción en la mortalidad operatoria lleva a la reconsideración del tema. Una revisión de la literatura pertinente sugiere un enfoque selectivo. Se puede anticipar que hay escaso progreso en lo referente a tumores del esófago, estómago, intestino delgado o páncreas. La resección de metás- tasis de carcinoma de células renales, tumor de Wilms y carci- noma adrenocortical está indicada. Hay poco que recomendar en cuanto a la resección de metástasis de carcinomas ginecológicos o mamarios. La resección como forma de paliación debe ser considerada en todo tipo de lesiones, particularmente metástasis voluminosas de melanomas oculares.
References
1. Foster, J.H., Lundy, J .: Pathology of liver metastasis. Curr. Probl. Surg. 18:157, 1981
2. Morrow, C.E., Grage, T.B., Sutherland, D.E., et al .: Hepatic resection for secondary neoplasms. Surgery 92:610, 1983
3. Thompson, H.H., Tompkins, R.K., Longmire, W.P .: Major hepatic resection: a 25 year experience. Ann. Surg. 197:375, 1983
4. Tomas-de la Vega, J.E., Donahue, E.J., Doolas, A., et al .: A ten year experience with hepatic resection. Surg. Gynecol. Obstet. 159:223, 1984
5. Bengmark, S., Hafstrom, L., Jeppsson, B., et al .: Metastatic disease in the liver from colorectal cancer: an appraisal of liver surgery. World J. Surg. 6:61, 1982
6. Jaffe, B.M., Donegan, W.L., Watson, F., et al .: Factors influencing
Schwartz: Hepatic Resection for Metastases
survival in patients with untreated hepatic metastases. Surg. Gynecol. Obstet. 127:1, 1968
7. Kortz, W.J., Meyers, W.C., Hanks, J.B., et al .: Hepatic resection for metastatic cancer. Ann. Surg. 199:182, 1984
8. Iwatsuki, S., Shaw, B.W., Starzl, T.E .: Experience with 150 liver resections. Ann. Surg. 197:247, 1983
9. Sesto, M.E., Vogt, D.P., Hermann, R.E .: Hepatic resection in 128 patients: a 24-year experience. Surgery 102:846, 1987
10. Straus, F.H., Scanlon, E.F .: Five-year survival after hepatic lobectomy for metastatic hypernephroma. Arch. Surg. 72:328, 1956
11. Cobourn, C.S., Makowka, L.M., Langer, B.L., et al .: Examination of
patient selection and outcome for hepatic resection for metastatic disease. Surg. Gynecol. Obstet. 165:239, 1987
12. Wolf, R.F., Goodnight, J.E., Krag, D.E., et al .: Results of resection and proposed guidelines for patient selection in instances of noncolo- rectal hepatic metastases. Surg. Gynecol. Obstet. 173:454, 1991
13. Stehlin, J.S., DeIpolyi, P.D., Greeff, P.J., et al .: Treatment of cancer of the liver: twenty years’ experience with infusion and resection in 414 patients. Ann. Surg. 208:23, 1988
14. Hughes, K.S., Simon, R., Songhorabodi, S., et al .: Resection of the liver for colorectal carcinoma metastases: a multi-institutional study of patterns of recurrence. Surgery 100:278, 1986