Download Multidisciplinary management of potentially resectable liver

Multidisciplinary management of potentially resectable liver
metastases: the role of the radiologist.
Poster No.:
C-1011
Congress:
ECR 2015
Type:
Educational Exhibit
Authors:
M. D. Monedero, R. Pastor Juan, J. A. González Masiá, J. I. Miota
de LLama, E. Lozano Setién, E. Julia; Albacete/ES
Keywords:
Abdomen, Liver, CT, MR, Percutaneous, Diagnostic procedure,
Chemoembolisation, Ablation procedures, Neoplasia, Metastases,
Multidisciplinary cancer care
DOI:
10.1594/ecr2015/C-1011
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Page 1 of 34
Learning objectives
1. Describe the management of patients with resectable liver metastases in the context
of a multidisciplinary committee.
2. Show the role of the radiologist in the diagnosis, treatment and follow-up of these
patients.
3. Describe the diagnosis and treatment algorithm followed in our center.
4. Reflect our experience with these patients since the launch of the multidisciplinary
committee hepatobiliary pathology in our center.
Background
OVERVIEW
OF
OUR
HEPATOBILIOPANCREATIC
MULTIDISCIPLINARY COMMITTEE
PATHOLOGY
OPERATION OF OUR COMMITTEE
ROLE OF RADIOLOGISTS IN THE COMMITTEE
POTENTIALLY RESECTABLE LIVER METASTASES: AN INCREASING CLINIC
SITUATION
INDICATION OF SURGICAL RESECTION IN THE LIVER RECURRENCES
INDICATION OF SURGICAL RESECTION IN PATIENTS WITH EXTRAHEPATIC
DISEASE
DOWNSTAGING OR DOWNSIZING
THE ROLE OF RADIOLOGISTS IN THE MANAGEMENT OF POTENTIALLY
RESECTABLE LIVER METASTASES
Page 2 of 34
•
DIAGNOSIS
- ULTRASOUND
- ¿MDCT or MRI?
- USE OF GADOXETATE (Gd-EOB-DTPA, Primovist®)
- PET-CT
- INTRAOPERATIVE ULTRASOUND
•
TREATMENT
- PORTAL VEIN EMBOLIZATION (PVE)
- CT-GUIDED RADIOFREQUENCY
- INTRAOPERATIVE RADIOFREQUENCY
- INTRA-ARTERIAL CHEMOTHERAPY
OUR EXPERIENCE
.........................................................................................................
Page 3 of 34
Fig. 1: Hepatobiliary pathology multidisciplinary committee in our hospital.
References: RADIOLOGY, SESCAM, COMPLEJO HOSPITALARIO UNIVERSITARIO
ALBACETE - Albacete/ES
OVERVIEW
OF
OUR
HEPATOBILIOPANCREATIC
MULTIDISCIPLINARY COMMITTEE
PATHOLOGY
Clinical cases involving hepatobiliopancreatic (HBP) area represent a group of
heterogeneous disorders with potentially complicated management, requiring multiple
and different imaging techniques for diagnosis and treatment. Skilled and qualified
clinicians and surgeons, as well as radiologists, are necesary to take care of these
patients.
The HBP committee was created in the University Hospital of Albacete (CHUA) in 2009.
Different specialties are included as General Surgery Specialists (BPH Pathology Unit),
Radiology, Interventional Radiology, Gastroenterology, Oncology, Radiation Oncology
and Pathology. Eventually, other specialists attend to present related cases, mainly from
Internal Medicine.
Page 4 of 34
As a reference center in the spanish region of Castilla-La Mancha, not only patients from
Albacete are included, but patients of near provinces as Cuenca too.
The multidisciplinary management of these patients has made posible to establish new
protocols. Continuing education is stimulated with periodic monographic lectures. This
approach has allowed a saving and optimization of tests or procedures, avoiding to repeat
imaging procedures or perform inadequate techniques.
It has also allowed certain subspecialties within each Department, allowing improvement
and progress in the diagnosis and treatment of these patients. As an example, we can
cite the liver metastases surgical resection technique itself as well as intraoperative
ultrasound and radiofrequency performed by radiologists and surgeons.
Images for this section:
Page 5 of 34
Fig. 1: Hepatobiliary pathology multidisciplinary committee in our hospital.
Page 6 of 34
Findings and procedure details
OPERATION OF OUR COMMITTEE
The committee meets once a week. The referrals include new patients, recurrences
of pathologies, plan updates on diagnosis and/or treatment of patients already known
and relevant case results already presented previously. These cases are sent by
clinicians to the Secretary of General Surgery, centralizing information and sends the
other participants relevant information to be discussed at the next committee, so that
all participants know in advance and can review cases properly. After being presented
cases, the relevant decisions jointly agreed and binding are taken, sending the final
consensus all participants once the meeting ends.
ROLE OF RADIOLOGISTS IN THE COMMITTEE
Radiologists dedicated to the diagnosis prepare the patient images presented, discussed
them in cases of doubt or have special interest for patient management. They provide
also guidance on the most appropriate diagnostic algorithm for patients under study or
monitoring.
Interventional radiologists act as consultants in their area, assessing the indications of
the different procedures they are required.
POTENTIALLY RESECTABLE LIVER METASTASES: AN INCREASING CLINIC
SITUATION
In Spain, there are over 20.000 cases/year of colorectal cancer (CRC), finding liver
metastases (LM) along the disease in 50-70% of patients: 20-25% synchronous and
25-35% metachronous. 10-15% of these metastases are potentially resectable.
The concept of RESECTABLE metastases involves the ability to completely
remove the lesions with negative margins (R0), whatever their number, size and
location, leaving a liver sufficient to allow normal liver function remnant (Fig. 2 on
page 21) .
The following data reflect the survival of CRC with MH:
Page 7 of 34
•
•
•
Untreated: 6-16 months of median survival (5-year, zero)
With chemotherapy: 20% at 3 years
Surgical resection (R0) + chemotherapy: approximately 42-58% at 5 years
(varies depending on the series by the multitude of prognostic factors).
Thus, the treatment of choice of in CRCLM is complete surgical resection (Fig. 3
on page 22).
These close to 60% survival at 5 years in the last group results occurred due to several
factors:
•
•
•
•
advances in preoperative imaging techniques,
improvement in surgical and anesthetic techniques,
the introduction of new cytotoxic and biological agents for pre- and
postoperative chemotherapy and
proper selection of patients.
These changes have increased the number of patients for resection surgery CRCLM and
require a complex management of these patients.
Therefore, it is accepted that treatment of all patients with CRC and surgical indication
of CRCLM should be the responsibility of a multidisciplinary team including oncologists,
radiologists and liver surgeons to coordinate the most appropriate action in each case.
In our hospital, there are two multidisciplinary committees related to CRC.
One of them decide the treatment of all patients with CRC and our HBP committee
in consensus with the CRC team defines the treatment of patients with CRC and liver
metastases.
INDICATION OF SURGICAL RESECTION IN THE LIVER RECURRENCES
In patients treated surgically with curative intent recurrence of the disease recurrence is
present in about 60% of cases, of which 20% will be exclusively liver recurrence.
It has been shown that surgical mortality and morbidity are comparable to the first
resection and a median survival of 32 to 46 months is achieved.
Therefore, it seems reasonable to consider reoperation in patients with liver disease
recurrence if they fulfill the criteria followed in the indication of the first resection.
Page 8 of 34
INDICATION OF SURGICAL RESECTION IN PATIENTS WITH EXTRAHEPATIC
DISEASE
Traditionally, extrahepatic disease was almost universally regarded as a contraindication
to resection of the CRCLM.
However, it has been able to demonstrate a survival rate of 12-37% five years after
liver resection in selected patients with extrahepatic disease, regardless of their location
(lung, lymph nodes of the primary tumor, retroperitoneal or hepatic pedicle, peritoneal
carcinomatosis...).
The presence of peritoneal metastases is controversial. In some series the total number
of metastases is considered more important to be resected, rather than the location, also
including peritoneal.
Currently there is agreement that peritoneal metastases localized in small numbers, are
not an absolute contraindication to resection.
The metastatic lymph nodes in area 1 (hepatic hilum or retroduodenal) worsen the
prognosis but not absolutely contraindicate removal.
However, lymph node metastases in area 2 (around the hepatic artery or celiac
trunk) are associated with such a poor prognosis than they should be considered
a contraindication to resection.
Therefore, these patients should be carefully selected and resection should be
considered only after confirming stability of the disease or after a good response to
systemic chemotherapy. Moreover, obtaining a R0 resection of the intra- and extrahepatic
disease should be ensured.
DOWNSTAGING OR DOWNSIZING
Page 9 of 34
Fig. 4
References: RADIOLOGY, SESCAM, COMPLEJO HOSPITALARIO UNIVERSITARIO
ALBACETE - Albacete/ES
This concept refers to the process of converting liver metastases that were initially
unresectable into resectable with neoadjuvant chemotherapy.
New chemotherapy regimens combining 5-fluorouracil, folinic acid and oxaliplatin or
irinotecan have succeeded to allow surgery 10 to 30% of patients, and higher numbers
are anticipated with the new monoclonal antibodies (cetuximab and bevacizumab).
The long-term survival achieved in these patients are almost superimposable to those of
patients resected by first intention.
Liver surgery should be performed as soon as the disease becomes resectable,
without prolonging chemotherapy.
Tumor progression during the administration of neoadjuvant chemotherapy should be
considered a relative contraindication to resection.
Page 10 of 34
Other ways to increase the resection of CRCLM are scheduled two-stage procedures,
resection combined with radiofrequency, intraarterial radiotherapy with Yttrium spheres
and portal embolization.
THE ROLE OF RADIOLOGISTS IN THE MANAGEMENT OF POTENTIALLY
RESECTABLE LIVER METASTASES
•
DIAGNOSIS
Early detection and appropriate characterization of the CRCLM are critical to addressing
the patient's treatment in order to increase their chances of survival.
What the radiologist should contribute to liver surgeon is:
•
•
•
•
Determine number, size, location and resectability of liver metastases.
Possible existence of metastatic lymph nodes.
Assess possible extrahepatic disease (abdominal, pelvic, lung).
Primary tumor staging in case of synchronous metastases.
ULTRASOUND (US)
US is performed in selected cases to complement the characterization of liver lesions,
making differential diagnosis of cystic and solid, especially in small lesions.
Sometimes, it is useful preoperatively to confirm the location before the intraoperative
ultrasound.
MDCT or MRI
In our hospital, the routine imaging technique to evaluate and follow patients with CRC is
MDCT. For this reason, it generally consists of a single liver acquisition. If it is previously
known the existence or suspect of LM, a triphasic acquisition is planned.
If the MDCT study can not confirm the diagnosis of LM and the suspicion persists, liver
MRI is performed with nonspecific extracellular gadolinium distribution (dynamic study).
In our case we use gadobutrol (Gadovist®). We don't perform always a liver MRI as a
first-line imaging study in patients with CRC due to high number of staging and follow-up
studies and limited access to MRI (we have only one 1.5T MR scanner in our institution).
The realization of a liver volumetry (Fig. 5 on page 23) is reserved for selected
patients. It is made from MDCT or MRI with gadobutrol in cases where there is doubt
Page 11 of 34
about the postoperative remnant liver and always if # 4 segments resection is required.
Insufficient remnant liver volume is considered if it is <25% in healthy livers and <35% in
pathological liver (steatosis by diabetics or prior chemotherapy).
USE OF MRI USING GADOXETATE (Gd-EOB-DTPA, Primovist®) WITH BOTH
DINAMYC AND HEPATOCITE PHASE IMAGES
If the diagnosis of CRCLM is confirmed, the patient is presented to the committee. If
surgical resection is decided, an MRI with Primovist® (Fig. 6 on page 24) is planned
(preferably the same week of the surgical procedure).
Page 12 of 34
Fig. 6: Only one CRCLM was found in this patient: a) MDCT after iv contrast; b) MR,
STIR transversal image; c) MR, T1-weighted image and d) MR, Fat supression T1weighted image after 30 minutes of iv Primovist® injection.
References: RADIOLOGY, SESCAM, COMPLEJO HOSPITALARIO UNIVERSITARIO
ALBACETE - Albacete/ES
MRI performed with Primovist® is used to confirm with the highest sensitivity the number,
size and location of liver metastases in order to avoid unexpected findings during surgery.
In the first patients evaluated in our committee before the current protocols established,
it was not routinely performed, often due to lack of coordination between the Department
of Surgery and Radiology. Thus, we found several discrepancies between the findings
of MDCT and MRI with gadolinium compared with findings in surgery, especially in small
lesions. These discrepancies have decreased dramatically since we program the MRI
with Primovist® in coordination with the surgeons before each surgical resection.
MRI with Primovist® acquiring a late hepatobiliary phase increases the sensitivity
for detecting liver metastases less than 1 cm compared with standard extracellular
gadolinium studies.
It is useful to add diffusion-weighted acquisitions to increase diagnostic accuracy.
PET-CT
It is not routinely performed for the detection of liver metastases because other
techniques such as MRI have shown greater sensitivity.
It is done in some selected patients for the detection of extrahepatic disease not identified
by CT or MRI when resection is being considered.
INTRAOPERATIVE ULTRASOUND (Fig. 7 on page 25)
It is always performed. Intraoperative ultrasound is done jointly by radiologists and
surgeons in our hospital.
•
TREATMENT
PORTAL VEIN EMBOLIZATION (PVE) Fig. 8 on page 26
Page 13 of 34
The PVE is used before surgery to redistribute portal flow toward the future remaining
segments liver to increase their size. Thus, the future remnant results in hipertrophy
increasing a 10-15% of volume in 3-9 weeks, while in livers with chronic conditions can
be lower. It can be done before liver surgery or between a two-stage procedure.
The PVE can be percutaneously performed (ultrasound and fluoroscopic guidance) with
the patient under conscious sedation in the Interventional Radiology room.
Fig. 8: Figures a) and b) are X-ray acquisitions in portal embolization procedure.
Figures c) and d) show the end result in a MDCT control.
Page 14 of 34
References: RADIOLOGY, SESCAM, COMPLEJO HOSPITALARIO UNIVERSITARIO
ALBACETE - Albacete/ES
CT-GUIDED RADIOFREQUENCY
It is considered a palliative therapy that not replace surgical resection if this is technically
feasible. Their results in terms of long-term survival are lower than those of resection,
although recently they have obtained comparable survival to 3 years.
Radiofrequency only replace surgical resection if the general conditions of the patient
discourage the latter. It may be indicated in case of limited peritoneal metastases.
In some cases it may be associated with metastases surgical resection when complete
resectability is technically difficult or doubtful. This partnership entails lower survival than
complete surgical resection although lead to superior survival that the exclusive treatment
with RF and chemotherapy. This practice is under evaluation.
There are different techniques that ultimately induce coagulative necrosis, obtaining very
similar results. We use radiofrequency ablation (RFA), which induces heating of the soft
tissues in the vicinity of a monopole antenna that produces an alternating current.
Depending on the volume treated, recurrences are described in CRCLM between
12-31%, with a 2.8% rate of major complications and 17% of minor complications.
In patients with small tumoral volume, until a 50% survival at 5 years is described, while
most of the studies show percentages of approximately 35%.
After performing the CRCLM RFA, a thin marginal enhanced ring can be found during
late arterial phase until 4-5 months after the procedure.
The RFA procedure is considered adequate, if subsequent follow-up after this time shows
no enhancement in the portal phase and this ring is disappeared.
If there is an increase in the size of the lesion or progressive distortion of the lesion margin
after six weeks of the RFA, the existence of local progression should be considered.
INTRAOPERATIVE RADIOFREQUENCY Fig. 9 on page 27
Page 15 of 34
When possible, we prefer to perform the RFA in the operating room while surgical
resection in lesions that can not be resected, according to the decisions taken in our
committee.
Fig. 9: Ultrasound-guided radiofrequency ablation procedure in the operating room.
References: RADIOLOGY, SESCAM, COMPLEJO HOSPITALARIO UNIVERSITARIO
ALBACETE - Albacete/ES
INTRA-ARTERIAL CHEMOTHERAPY
In case of unresectable tumors, hepatic intra-arterial chemotherapy with floxuridine has
produced higher overall response rates but no consistent improvement in survival when
compared to systemic chemotherapy. In our hospital we have little experience with this
treatment.
OUR EXPERIENCE
Page 16 of 34
Between october 2009 and september 2013 we collected 42 patients with 50 surgical
procedures for resection of CRCLM. 7 patients required a second intervention by hepatic
recurrence. One patient underwent 3 surgeries for resection of liver metastases.
In our series, 35 resections were performed in men and 15 in women (Fig. 10 on page
28). The mean age of all patients was 63.2 years and the median 64 years (Fig. 11
on page 29). The maximum age was 78 years and minimum 27 years. In men, the
mean age was 64.2 years and the median 62 years. In women, the mean age was 61
years and the median 60 years.
The number of liver resections increased progressively as the unit of liver surgery has
gained more experience, from 3 patients operated in 2010 until 20 patients in 2012 (Fig.
12 on page 30).
Also, the experience of radiologists involved in the management of patients has been
increasing in the same way, on the one hand regarding the updating of protocols and
secondly, to perform more diagnostic procedures (volumetries, MRI with Primovist®) and
treatment (ultrasound and intraoperative RFA, PVE). Fig. 13 on page 31
Many patients were operated at first with a single test image (MDCT), mainly due to a lack
of coordination and communication between the Department of Surgery and Radiology
and the limited experience of the physicians involved. The appearance of a discrepancy
between the findings of a single test and those obtained in the operating room forced us
to rethink the presurgical imaging algorithms, accelerating our learning curve in both the
management of this condition and the workflow of a multidisciplinary team.
All cases were operated with at least one MDCT scan and intraoperative ultrasonography.
In 9 cases (18%) MRI was performed with gadolinium to confirm the diagnosis of
metastases.
In 19 cases (38%) MRI was performed with Primovist® as a preoperative study to confirm
the number and location of metastases. These cases have steadily increased over the
years and in 2013 70% had this study before surgery.
4 patients (9%) underwent PVE to increase liver remnant, being evaluated with a liver
volumetry pre- and post treatment to control growth of the future remnant.
In 4 patients an intraoperative RFA was performed, all in 2013.
Page 17 of 34
Fig. 10
References: RADIOLOGY, SESCAM, COMPLEJO HOSPITALARIO UNIVERSITARIO
ALBACETE - Albacete/ES
Page 18 of 34
Fig. 11
References: RADIOLOGY, SESCAM, COMPLEJO HOSPITALARIO UNIVERSITARIO
ALBACETE - Albacete/ES
Page 19 of 34
Fig. 12
References: RADIOLOGY, SESCAM, COMPLEJO HOSPITALARIO UNIVERSITARIO
ALBACETE - Albacete/ES
Page 20 of 34
Fig. 13
References: RADIOLOGY, SESCAM, COMPLEJO HOSPITALARIO UNIVERSITARIO
ALBACETE - Albacete/ES
Images for this section:
Page 21 of 34
Fig. 2: The surgeon examinates a resected liver metastases with free macroscopic
margin in the operating room.
Page 22 of 34
Fig. 3: Survival data in patients who have undergone CRC liver metastases resection.
Page 23 of 34
Fig. 5: Liver volumetry held in the workstation of our General Electric MDCT, in a patient
after CRCLM resection (see metal clips). Two new metastatic lesions were found and a
new surgical resection was planned.
Page 24 of 34
Fig. 6: Only one CRCLM was found in this patient: a) MDCT after iv contrast; b) MR, STIR
transversal image; c) MR, T1-weighted image and d) MR, Fat supression T1-weighted
image after 30 minutes of iv Primovist® injection.
Page 25 of 34
Fig. 7: Ultrasound equipment used in the operating room.
Page 26 of 34
Fig. 8: Figures a) and b) are X-ray acquisitions in portal embolization procedure. Figures
c) and d) show the end result in a MDCT control.
Page 27 of 34
Fig. 9: Ultrasound-guided radiofrequency ablation procedure in the operating room.
Page 28 of 34
Fig. 10
Page 29 of 34
Fig. 11
Page 30 of 34
Fig. 12
Page 31 of 34
Fig. 13
Page 32 of 34
Conclusion
Surgical management of patients with CRCLM has begun in the last five years in our
center.
We treate these patients within a multidisciplinary team (hepatobiliary pathology
committee). The management of CRCLM should be customized and, where possible,
reviewed by a multidisciplinary team to take the best therapeutic option for patients.
With the formation of this multidisciplinary team we have supplied deficiencies that
previously existed in our hospital related to the management of these patients. We have
been able to solve problems that previously implied to refer many of these patients to
other spanish hospitals in near regions such as Madrid, Murcia and Valencia.
The accumulated experience of the participants, makes us consider it one of the best
tools at our disposal to get the most of our resources in the service of the best care we
are able to provide our patients.
The implementation of this Committee has meant hours of extra work and effort for its
members, thrilled by performing a job well done even in these times of economic crisis
that has hit the public health system in Spain and specifically Castilla-La Mancha, and
satisfaction after checking every week that this effort translates into a better patient care
that attempts increase their quality day after day.
The radiologist plays an important role in the diagnosis and follow-up of CRC, with an
increasingly relevant role in the interventional treatment of these patients.
Personal information
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