Prospective Evaluation of Two-Stage Hepatectomy Combined with Selective Portal Vein Embolisation and Systemic Chemotherapy for Patients with Unresectable Bilobar Colorectal Liver Metastases

Abstract

Background: Liver resection is contraindicated in patients with multiple bilobar colorectal liver metastases because of the small liver remnant. An alternative strategy which may be curative is a two-stage hepatectomy in which the cancer is resected from one lobe and regeneration allowed prior to contralateral lobe resection. Objective: To assess the feasibility, risks, and outcomes in a prospectively applied strategy for two-stage hepatectomy. Methods: Over a 6-year period, 14 of 280 patients undergoing liver resection for colorectal liver metastases (5%) were considered for two-stage hepatectomy. Surgery was combined with chemotherapy in all (n = 14) and portal vein embolisation (PVE) selectively (n = 5). Median follow-up was 43 months. Results: Both stages were completed in 11 of 14 patients (78%). There were no deaths. Post-operative complication rates were 0% (1st hepatectomy) and 27% (2nd hepatectomy). The 5-year survival after the second hepatectomy was 50%. The mean disease-free survival was 25 ± 7.5 months. Conclusion: Two-stage hepatectomy combined with systemic chemotherapy and PVE can produce long-term survival in patients with multiple bilobar colorectal liver metastases.

Parenchymal-sparing hepatectomies (PSH) for bilobar colorectal liver metastases are associated with a lower morbidity and similar oncological results: A propensity score matching analysis

“…9,15,16 Based on this idea, a two-stage hepatectomy has largely gained consensus, achieving a satisfying 30-35% 5-year OS in these patients. [17][18][19][20][21][22] This strategy has some NON-PSH limitations due to the high risk of dropouts between the first and second stage 19,20 (30% of cases) due to tumor progression, re-discussing the role of resection margins as compared to a high dropout risk. In a recent study including 3000 CRLMs, Hamady et al 23 demonstrated that a 1 mm margin was sufficient to be considered curative and more extended margins did not lead to oncological benefits in terms of recurrence.…”

Two-Stage Hepatectomy Procedure to Treat Initially Unresectable Multiple Bilobar Colorectal Liver Metastases: Technical Aspects

“…Generally, almost all the patients scheduled for two-stage hepatectomy have been previously heavily treated with chemotherapy, while only a minority (less than 10%) of the initially unresectable patients became eligible for a curative two-stage hepatectomy after administration of neoadjuvant chemotherapy, which also provides some drawbacks such as missing metastases and chemotherapy-induced hepatotoxicity [5,6,7]. Furthermore, the feasibility rate of the initially planned two-stage hepatectomy was around two thirds of the patients, and the failure was mainly related to disease progression and/or to insufficient liver hypertrophy [5,8,9,10,11,12,13,14,15]. However, completion of this procedure allows to provide, for patients presenting with multiple and bilobar CLM, a similar survival benefit to that reported in patients with initially resectable liver metastases (table 1) [3].…”

“…The 2nd-stage hepatectomy (right or extended right) is performed 4–8 weeks after PVE. This strategy offers the patients a long-term survival similar to that obtained after liver resection in patients with initially resectable liver metastases and without the use of preoperative PVE (table 1) [5,8,9,10,11,12,13,14,15]. …”

Thermal ablation of colorectal liver metastases: a position paper by an international panel of ablation experts, the interventional oncology sans frontières meeting 2013

“…However, the survival results of resection following portal vein embolisation are only 25 % at 5 years [66]. Furthermore, nearly 40 % of patients undergoing portal vein embolisation never get to resection and many patients planned for staged resection also fail to complete the course of treatment [67,68]. Some, but not all, of these patients will have ablatable disease with comparable 5-year survival post-ablation but a higher chance of completing radical treatment to all sites of disease.…”