+

Caso Clnico
Tratamento adjuvante (4 ciclos
quimioterapia)
Cinquenta meses depois:
- Excelente estado geral
- Ausncia de recidiva

FCS,, Fev 2005

HEPATOCARCINOMA
Histria Natural

1 Milho novos casos/ano

Ressecabilidade 5-15%
Sobrevida espontnea (Mediana) - 10 meses
Sobrevida aps trat paliativo

(3 anos)

3-12%
FCS, Junho 2002

+ TUMORES HEPTICOS PRIMITIVOS

MALIGNOS
Sobrevida actuarial

vs tipo de tumor (log rank)

Survival Functions

1,2
1,0

n.s.

Linfoma

VAR00001
4

Cum Survival Sobrevida

,8

4-censored
,6

Hepatocarc.
,4

3-censored

Colangiocarc.

25% aos
3 anos
2

,2
0,0

2-censored

C. mistos

-,2
-0

43% aos 5 anos

1-censored
20

40

60

80

100

120

Meses

2004

SOBREVIDA ACTUARIAL (Kaplan Meier)

5
anos=52,19%
Survival
Function

3 anos=57,99%

1,1

1,0

,9

,8

C u m S u r v iv a l

TUMORES HEPTICOS PRIMITIVOS MALIGNOS

(n=72)

,7

,6

Survival Fu
,5

Censored
-0

20

40

60

80

100
FCS, Maio 2007

TUMORES HEPTICOS PRIMITIVOS MALIGNOS

(n=72)

Sobrevida actuarial vs tipo de cirurgia (log rank)

Survival Functions
p=0,0009
(64,2 vs 22%)

1,2

1,0

,8

Ress

V38

,6

Cum Survival

S/Ress

1-censored

,4

0
,2

0-censored
-0

20

40

60

80

100
FCS, Janeiro 2007

RE-HEPATECTOMIAS
( 26 Doentes, 56 Hepatectomias )
RESULTADOS

1 Hepatectomia

Mortalidade

Morbilidade

Hospitalizao

20%

8 1,1 dias (7 10)

ns
Re-hepatectomia

* Excluindo Tx Hep.

11,5%

8 2,4 dias (7 12)*

FCS, Maro 2008

Caso Clnico n5
S.R.H.,

61 anos

1999

Anorexia desde 12 meses

Alcoolismo crnico, HTA, Dislipidmia
-feto protena 1016 U/ml
Eco, TAC,
FCS, Paris, Mai 2004

Caso Clnico n5

FCS, Paris, Mai 2004

Caso Clnico n5

Interveno (22/10/99)
Segmentectomia VII
Bipsia heptica
(Transfuses 0)
Sem complicaes (Hospitalizao 7 dias)
Histologia: Hepatocarcinoma sobre cirrose(T3G 2)
FCS, Paris, Mai 2004

Caso Clnico n5

Follow-up (cada 3 meses):

Clinicamente bem;abstinncia alcolica

-feto - normal
Junho 2002
-feto-127 U/ml
Hpatomeglia
Biologia: estvel
FCS, Paris, Mai 2004

Caso Clnico n5

FCS, Paris, Mai 2004

Caso Clnico n5
2a Interveno (27/08/02)
Segmentectomia V
Colecistectomia
(Transfuses 0)
Infeco da ferida operatria
Hospitalizao 15 dias
Tamoxifeno
FCS, Paris, Mai 2004

Caso Clnico n5

Fevereiro 2004 (52 meses aps a 1a interveno):

Hrnia incisional
RM ndulo nos segmentos II/III
-feto- 4.1mg/ml

FCS, Paris, Mai 2004

Caso Clnico n5

FCS, Paris, Mai 2004

Caso Clnico n5

3a Interveno (19/03/04)
Lobectomia esquerda (II-III)
Laparoplastia
(Transfuses 0)
Ps-operatrio simples, salvo infeco da ferida
operatria (Hospitalizao 7 dias)
Junho 2004 Quimio-embolizao
Janeiro 2006 Recidiva heptica e extraheptica
Falecido com metstases dissminadas . 84
meses aps a 1 HEPATECTOMIA

FCS, Paris, Mai 2004

+
AT DCADA DE 80

Sinnimos de disseminao
da doena e de intractibilidade
mdico-cirrgica.
DCADA DE 90

A nica teraputica com

potencialidades curativas
a exrese cirrgica
FCS, Junho 2001

DADOS ESTATSTICOS

Metstases:

Sncronas: 15-25%
Metcronas: 20-30%

Sobrevida sem teraputica:

Global: 3-18 meses

Leso nica: 21-25 meses
Leses mltiplas: 15-17 meses
Leses difusas: 3-6 meses

Candidatos a exrese curativa 10%

20-25% recidivam no fgado

FCS, Junho 2001

SURGICAL TREATMENT OF CLR LIVER

METASTASES

CRLM TREATMENT
374 Patients
441 Operations
Female 36%
Male 64%

TREATMENT
374 PATIENTS, 441
OPERATIONS

Age: 62,610,2
years
Median: 63 years

Min: 34 years
Max: 85 years
<70 yrs: 71,3%
70 yrs: 28,7%

TREATMENT
374 PATIENTS, 441
OPERATIONS

Primary tumor
localization:

Right Colon:
21,7%
Left Colon: 8,7%
Sigmoid Colon:
30,7%
Rectum: 38,8%

TREATMENT
374 PATIENTS, 441
OPERATIONS

Presentation at
First Diagnosis
Synchronous:
54,6%
Metachronous:
45,4%

TREATMENT
374 PATIENTS, 441
OPERATIONS

Number of
metastases
Single: 42,7%
2-3 lesions:
35,6%
4-6 lesions:
11,8%
> 6 lesions: 9,9%

TREATMENT
374 PATIENTS, 441
OPERATIONS

Localization
Unilobar: 58,6%
Bilobar: 41,4%

TREATMENT
374 PATIENTS, 441
OPERATIONS

Synchronous vs
Metachronous
Ressection
(1st hepatectomy):
Synchronous:
16%
Metachronous:
84%

TREATMENT
374 PATIENTS, 441
OPERATIONS

Number of
metastases
Single: 42,7%
2-3 lesions:
35,6%
4-6 lesions:
11,8%
> 6 lesions: 9,9%

TREATMENT
374 PATIENTS, 441
OPERATIONS

1 Ressection vs
Rehepatectomy
1 Resection: 374
Rehepatectomy:
67
One: 61
Two: 6

CRLM
TREATMENT
374 PATIENTS, 441
OPERATIONS
Hepatic Resections
Pre/per op. portal
vein emb./ligation: 24
Laparoscopic: 18
Liver First: 9
Two Stage: 25
Rehepatectomies: 67
One: 61
Two: 6

SURGICAL TREATMENT OF CRC

LIVER METASTASES
Mortality:
2,9%

Morbidity:
23,4
%

TREATMENT
374 PATIENTS, 441
OPERATIONS

Post-operative hospitalization
(days):
median: 8
min: 1
max: 90

SURGICAL TREATMENT OF CRC

LIVER METASTASES
OVERALL SURVIVAL
RESECTED VS NON RESECTED

40,3%

24,2%

SURGICAL TREATMENT OF CRC

LIVER METASTASES

OVERALL SURVIVAL NUMBER OF

METASTASES
SINGLE VS MULTIPLE

52%

31,7%
25,2%

SURGICAL TREATMENT OF CRC

LIVER METASTASES
OVERALL SURVIVAL
RESECTED VS NON RESECTED

40,3%

24,2%

SURGICAL TREATMENT OF CRC

LIVER METASTASES
OVERALL SURVIVAL
SYNC/METACH PRESENTATION
METACHRONOUS VS
SYNCHRONOUS

42,6%
40,2%

SURGICAL TREATMENT OF CRC

LIVER METASTASES

45%

40%

287 Centers - 21697 Registered

SURGICAL TREATMENT OF CRC

LIVER METASTASES

METACHRONOUS VS SYNCHRONOUS
RESECTION

46,5%

33,1%

SURGICAL TREATMENT OF CRC

LIVER METASTASES

OVERALL SURVIVAL LOCATION

UNILATERAL VS BILATERAL

49,8%

28,9%

Metstases Hepticas

No Ressecveis 90%
Sobrevida aos 5 Anos <1%

Quimio

Emb.
Portal
Ressecveis 20-30%

Hep.I
RF

Ressecveis 10%

Sobrevida aos 5Anos

30-40%
FCS, Maro 2008

QUIMIOTERAPIA E MET. CANCRO COLO-RECTAL

5-Fluorouracil
Irinotecan

Lederfoline
Ant. Monoclonais
F.Anti-Angiognicos

Oxaliplatin

Xeloda
FCS,Maro 2008

FCS, Junho 2001

SURGICAL TREATMENT OF CRC

LIVER METASTASES
HEPATIC VEINS EMBOLIZATION

Caso Clnico n7
M.L.A.S.S.,

72 anos

Enfermeira, Testemunha de Jeov

Junho 2003: Hospital S. Marcos Braga
Hemicolectomia esquerda por neoplasia em
occluso (T3N2M1G1) 5 metstases no
lobo direito do fgado

Julho 2003:

Quimioterapia(Irinotecan + De Gramont)

Maro 2004:

Estabilizao das leses hepticas

Recusa de interveno com transfuso de sangue e
FCS, Paris, Mai 2004
derivados

Caso Clnico n7

FCS, Paris, Mai 2004

Caso Clnico n7
Abril 2004 Consulta em Coimbra
(FCS)
Administrao de:
Vitamina B12
Ferro por via oral
Eritropoitina recombinante

FCS, Paris, Mai 2004

Caso Clnico n7
Interveno a 12/05/2004:

Hepatectomia Dta
Sub-segmentectomia IV
Sub-segmentectomia II-III (angioma)
(Cell-Saver: Transfuso de 180cc)

Ps-operatrio
8dia

simples

com

alta

ao

FCS, Paris, Mai 2004

Caso Clnico n8
F.J.T.R.,

, 52 anos

Maio 2002 (Hospital Cova da Beira)

Resseco Anterior do Recto por cancro
( Histologia - T3N1M1, invaso vascular )
Radioquimioterapia: 40 Gy; 12 ciclos de Gramont
Follow-up: Clnica, bioqumica e imagiologia normais
Setembro 2003 (HUC Servio de Cirurgia III)
RMN: 11 ndulos no fgado (8 direita, 3 esquerda)
- Ausncia de leses distncia
FCS, Paris, Mai 2004

Caso Clnico n8
1 Interveno (17/10/03)

4 Subsegmentectomias hepticas: - IV ant.

- IV post.
- II/III
- IV/V
Laqueao (e injeco de lcool) do ramo portal
direito
Colecistectomia
Bipsia de adenopatia pedicular- positiva
(Transfuses 0)

Sem complicaes Hospitalizao -7 dias

Novembro 2003 Recomea quimioterapia

FCS, Paris, Mai 2004

Caso Clnico n8

FCS, Paris, Mai 2004

Caso Clnico n8
2a Interveno (20/02/04)
Hepatectomia direita alargada ao seg. IV
Subsegmentectomia I
(Transfuses 0)

Sem complicaes (Hospitalisao 6 dias)

Recomea quimioterapia (6 ciclos)
Catamenese no Servio de Cirurgia III
Maro de 2005 Bem, sem sinais de recidiva
aps

FCS, Paris, Mai 2004

Caso Clnico n8
Exrese de 18 metstases !

Falecido em Outubro 2006 com disseminao sistmica

FCS, 2007

SURGICAL TREATMENT OF CRC

LIVER METASTASES

OVERALL SURVIVAL TWO STAGE

YES VS NO

M, 67 years; Right
hemicolectomy for ADC
(T3N2M1)

CT - Bilobar liver metastases (>10), larger 3.5

cm
Ca 19.9: 4552.71
CEA: 295.75

 CT after 4 cycles of neoadjuvant chemotherapy

TC: Decrease the size of bilobares CR liver metastases

(larger 1,5 cm)
FLRV 16%
CEA: 12,41; Ca 19,9: 137,61

1st hepatectomy - 7 subsegmentectomies (Seg II, III and IVb)

cholecystectomy (Per-operative ultrasound)

TC (6th post-op day) - FLRV - 27%

Short Interval Two-Stage

Jornadas Internacionais de Cirurgia
Coimbra, 19 - 20 Abril 2013 Hepatectomy

Iterative Rigth Hepatectomy

16 days after the 1st Hepatectom
Plasma - 2U plasma, CE
Discharged on the 7th da

Short Interval Two-Stage Hepatectomy

Our Experience

80%

73 %

66 %

SURGICAL TREATMENT OF CRC

LIVER METASTASES

SSR
SG

??
?

ANN SURG, 248: 626-637, 200

SURGICAL TREATMENT OF CRC

LIVER METASTASES

OVERALL SURVIVAL LIVER FIRST

ALL PATIENTS

51,9%

SURGICAL TREATMENT OF CRC

LIVER METASTASES

OVERALL SURVIVAL LIVER FIRST

PRIMARY TUMOR RESECTED VS
NON RESECTED
80%

73 %

66 %

Adam et al. Ann Surg 2006

Patients and Methods

Location of the primary tumour:
Gastric
Breast
Gallbladder
Pancreas
Bile duct
Esophagus / EGJ
Small bowel
Other

14 (29,8 %)
11 (23,4 %)
5 (10,6 %)
4 (8,5 %)
4 (8,5 %)
4 (8,5 %)
3 (6,3 %)
2 (4,2 %)

Results
Mortality:

2 cases (4,2%)

Indication

Surgery

Complication

48 y. old female

Gallbladder
adenocarcinoma

Extended right hemihepatectomy

with bile duct resection and lymph
node dissection

Postoperative Liver Failure

grade C

68 y. old male

Adenocarcinoma of the
Esophagogastric junction

Total radical gastrectomy with

distal esophagectomy , D2 lymph
node dissection and segment 6
wedge resection

Intra-abominal sepsis from

anastomotic breakdown

Results
Overall survival
Median follow-up (months): 14
Median survival (months): 20
5-year survival: 19 %
19 %

Results
Resection: Better survival with metachronous

36 %

p<
0,001

Discussion
Good candidates for resection of NCRLM according to our results:
Metachronous diagnosis
Metachronous resection
Breast cancer LMs
Gastric cancer LMs in metachronous resection
Multinodular disease is not a contraindication
Clinical behavior after systemic therapy