Metastasectomy

Last updated
Metastasectomy
Specialty surgical oncology

In oncology, metastasectomy is the surgical removal of metastases, which are secondary cancerous growths that have spread from cancer originating in another organ in the body.

Contents

In many cases, metastases are not treated surgically. There are two common reasons for this. Often, even with a successful surgery, the patient would have a poor prognosis. If the cancer is widely disseminated, it is likely that after the surgical removal of all known metastases, new ones will occur elsewhere. Sometimes, surgery itself has a low likelihood of success due to the location and/or extensiveness of the cancer. If complete surgical excision is feasible, however, removing both the primary cancer and its metastases may substantially improve the patient's prognosis. Some patients may even be cured. [1] [2]

The use of metastasectomy evolved in the field of liver resection for metastasised colorectal cancer, but has evolved to include resection of metastases from different primary cancers (such as breast cancer, melanoma, renal cell carcinoma, etc.) to the lungs, brain, and other organs. Not all of these applications are equally evidence-based, although with respect to some other primary cancers, metastasectomy may be underutilized.[ citation needed ]

Liver metastasectomy

Colorectal cancer

Among colorectal cancer patients, 15 to 25% will have liver metastases already when the colorectal cancer is discovered, and another 25 to 50% will develop them in the three years after resection of their primary cancer. [2] Of patients who die from metastasised colorectal cancer, 20% have metastasis in the liver alone. [2]

Surgical resection of liver metastases from colorectal cancer has been found to be safe and cost-effective. [3] Reports from several large retrospective patient series suggest that it has a 5-year overall survival rate (5y OSR) averaging 30 to 40% and a 10y OSR around 16%, [1] [2] [4] [5] whereas the highest 5y OSR for modern chemotherapy regimens is only 9% (with FOLFOX). [6] However, no randomized clinical trial has directly compared surgical management to chemotherapy or treatment with bevacizumab. Some have argued that the excellent results of liver metastasectomy for colorectal cancer are partially confounded by selection bias or reporting bias. [7] [8] Nevertheless, surgery for resectable metastases has become the standard of care, [9] probably making such a trial (ethically) infeasible. [2] [7]

Previously, liver metastasectomy was limited to patients with less than four sites of metastasis in the liver, with a tumour-free margin of at least 1 centimetre, and no cancer elsewhere. [10] [11] These criteria have been challenged, however, and today the main criteria are a tumour-free margin and enough functional liver tissue (70%) preserved after surgery. [12] [13] [14] Patients with initially unresectable liver metastases can be pre-treated with chemotherapy (this is called neoadjuvant chemotherapy). [9] This pre-treatment causes the tumors to shrink, resulting in a larger proportion of liver tissue that is functional, with broader margins.[ citation needed ]

Preoperative evaluation involves imaging of the liver and its metastases, for example with ultrasound, computed tomography or magnetic resonance imaging. Positron emission tomography can be useful to check the entire body for metastases, although the test can be falsely normal with small lesions or preoperative chemotherapy. [15] Baseline blood tests typically include liver function tests and tumour markers. [12] During surgery, intraoperative ultrasound can aid the surgeon to find additional metastases. [2] [16]

A clinical risk score first proposed by Fong et al. [17] is often used to assess the risk of recurrence after hepatic resection. The score assigns one point to each of the following:

The median survival for each score is:

Fong ScoreMedian Survival
074 months
151 months
247 months
333 months
420 months
522 months

Despite the score being highly predictive of long-term outcome, the clinical usefulness is often called into question because the chance of long-term survival is often enough to warrant surgery even in cases with high Fong Score. Some researchers have suggested that the Fong Score has become less useful with the advent of more effective neoadjuvant therapy. [18]

Pulmonary metastasectomy

Surgery is the mainstay of treatment for patients with isolated lung metastasis from colorectal cancer. [19] Again, no randomized clinical trials exist, and the scientific evidence is weak, limited only to case series. [20] The surgery can be performed with a low operative mortality. [19]

For patients in whom the primary tumour is controlled and metastases are limited to the lung, criteria for eligibility include the technical resectability of the metastases and the general fitness and lung function reserve of the patient. If there are both liver and lung metastases, a resection of both can be attempted. In general, only 10% of patients with pulmonary metastases from colorectal cancer are resectable. [2]

Blalock reported the first lung resection for metastasis from colorectal cancer in 1944. [21]

Footnotes

  1. 1 2 Tomlinson JS, Jarnagin WR, DeMatteo RP, et al. (October 2007). "Actual 10-year survival after resection of colorectal liver metastases defines cure". J. Clin. Oncol. 25 (29): 4575–80. doi: 10.1200/JCO.2007.11.0833 . PMID   17925551.
  2. 1 2 3 4 5 6 7 Khatri VP, Petrelli NJ, Belghiti J (November 2005). "Extending the frontiers of surgical therapy for hepatic colorectal metastases: is there a limit?". J. Clin. Oncol. 23 (33): 8490–9. doi:10.1200/JCO.2004.00.6155. PMID   16230676.
  3. ↑ Gazelle GS, Hunink MG, Kuntz KM, et al. (April 2003). "Cost-Effectiveness of Hepatic Metastasectomy in Patients With Metastatic Colorectal Carcinoma: A State-Transition Monte Carlo Decision Analysis". Ann. Surg. 237 (4): 544–55. doi:10.1097/01.SLA.0000059989.55280.33. PMC   1514476 . PMID   12677152.
  4. ↑ Cummings LC, Payes JD, Cooper GS (February 2007). "Survival after hepatic resection in metastatic colorectal cancer: a population-based study". Cancer. 109 (4): 718–26. doi: 10.1002/cncr.22448 . PMID   17238180.
  5. ↑ Simmonds PC, Primrose JN, Colquitt JL, Garden OJ, Poston GJ, Rees M (April 2006). "Surgical resection of hepatic metastases from colorectal cancer: A systematic review of published studies". Br. J. Cancer. 94 (7): 982–99. doi:10.1038/sj.bjc.6603033. PMC   2361241 . PMID   16538219.
  6. ↑ Sanoff HK, Sargent DJ, Campbell ME, et al. (June 2007). "N9741: Survival update and prognostic factor analysis of oxaliplatin (Ox) and irinotecan (Iri) combinations for metastatic colorectal cancer (MCRC)". J. Clin. Oncol., 2007 ASCO Annual Meeting Proceedings Part I. 25 (18S): 4067.
  7. 1 2 Fey MF, Rauch D (2001). "Metastasectomy--a direct therapeutic effect or an illusion due to patient selection?". Ther Umsch. 58 (12): 726–31. doi:10.1024/0040-5930.58.12.726. PMID   11797535.
  8. ↑ Begg CB, Cramer LD, Hoskins WJ, Brennan MF (November 1998). "Impact of hospital volume on operative mortality for major cancer surgery". JAMA. 280 (20): 1747–51. doi:10.1001/jama.280.20.1747. PMID   9842949.
  9. 1 2 Nordlinger B, Sorbye H, Glimelius B, et al. (March 2008). "Perioperative chemotherapy with FOLFOX4 and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC Intergroup trial 40983): a randomised controlled trial". Lancet. 371 (9617): 1007–16. doi:10.1016/S0140-6736(08)60455-9. PMC   2277487 . PMID   18358928.
  10. ↑ Ekberg H, Tranberg KG, Andersson R, et al. (September 1986). "Determinants of survival in liver resection for colorectal secondaries". Br J Surg. 73 (9): 727–31. doi:10.1002/bjs.1800730917. PMID   3756436. S2CID   22309067.
  11. ↑ Hughes KS, Simon R, Songhorabodi S, et al. (August 1986). "Resection of the liver for colorectal carcinoma metastases: a multi-institutional study of patterns of recurrence". Surgery. 100 (2): 278–84. PMID   3526605.
  12. 1 2 Scheele J, Altendorf-Hofmann A (August 1999). "Resection of colorectal liver metastases". Langenbecks Arch Surg. 384 (4): 313–27. doi:10.1007/s004230050209. PMID   10473851. S2CID   33546325. Archived from the original on 2013-02-12.
  13. ↑ Poston GJ, Adam R, Alberts S, et al. (October 2005). "OncoSurge: a strategy for improving resectability with curative intent in metastatic colorectal cancer". J. Clin. Oncol. 23 (28): 7125–34. doi: 10.1200/JCO.2005.08.722 . PMID   16192596.
  14. ↑ O'Reilly DA, Chaudhari M, Ballal M, Ghaneh P, Wu A, Poston GJ (May 2008). "The Oncosurge strategy for the management of colorectal liver metastases - an external validation study". Eur J Surg Oncol. 34 (5): 538–40. doi:10.1016/j.ejso.2007.04.013. PMID   17560066.
  15. ↑ Wiering B, Krabbe PF, Jager GJ, Oyen WJ, Ruers TJ (December 2005). "The impact of fluor-18-deoxyglucose-positron emission tomography in the management of colorectal liver metastases". Cancer. 104 (12): 2658–70. doi: 10.1002/cncr.21569 . PMID   16315241.
  16. ↑ Wildi SM, Gubler C, Hany T, et al. (January 2008). "Intraoperative sonography in patients with colorectal cancer and resectable liver metastases on preoperative FDG-PET-CT". J Clin Ultrasound. 36 (1): 20–6. doi: 10.1002/jcu.20408 . PMID   17937421.
  17. ↑ Fong Y, Fortner J, Sun RL, Brennan MF, Blumgart LH (September 1999). "Clinical Score for Predicting Recurrence After Hepatic Resection for Metastatic Colorectal Cancer: Analysis of 1001 Consecutive Cases". Annals of Surgery. 230 (3): 309–18, discussion 318–21. doi:10.1097/00000658-199909000-00004. PMC   1420876 . PMID   10493478.
  18. ↑ Schreckenbach T, Malkomes P, Bechstein WO, Woeste G, Schnitzbauer AA, Ulrich F (January 2015). "The clinical relevance of the Fong and the Nordlinger scores in the era of effective neoadjuvant chemotherapy for colorectal liver metastasis". Surg Today. 45 (12): 1527–34. doi:10.1007/s00595-014-1108-9. PMID   25563588. S2CID   23101155.
  19. 1 2 Pfannschmidt J, Dienemann H, Hoffmann H (July 2007). "Surgical resection of pulmonary metastases from colorectal cancer: a systematic review of published series". Ann. Thorac. Surg. 84 (1): 324–38. doi:10.1016/j.athoracsur.2007.02.093. PMID   17588454.
  20. ↑ Treasure T (November 2007). "Pulmonary Metastasectomy: A Common Practice Based on Weak Evidence". Ann R Coll Surg Engl. 89 (8): 744–8. doi:10.1308/003588407X232198. PMC   2173173 . PMID   17999813.
  21. ↑ Saito H, Minamiya Y, Taguchi K, Nakagawa T, Ogawa J (January 2003). "[Surgical treatment for pulmonary metastases from colorectal cancer]". Kyobu Geka (in Japanese). 56 (1): 35–40. PMID   12607251.

Related Research Articles

<span class="mw-page-title-main">Metastasis</span> Spread of a disease inside a body

Metastasis is a pathogenic agent's spread from an initial or primary site to a different or secondary site within the host's body; the term is typically used when referring to metastasis by a cancerous tumor. The newly pathological sites, then, are metastases (mets). It is generally distinguished from cancer invasion, which is the direct extension and penetration by cancer cells into neighboring tissues.

<span class="mw-page-title-main">Osteosarcoma</span> Cancerous tumour in a bone

An osteosarcoma (OS) or osteogenic sarcoma (OGS) is a cancerous tumor in a bone. Specifically, it is an aggressive malignant neoplasm that arises from primitive transformed cells of mesenchymal origin and that exhibits osteoblastic differentiation and produces malignant osteoid.

<span class="mw-page-title-main">Gastrointestinal stromal tumor</span> Human disease (cancer)

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract. GISTs arise in the smooth muscle pacemaker interstitial cell of Cajal, or similar cells. They are defined as tumors whose behavior is driven by mutations in the KIT gene (85%), PDGFRA gene (10%), or BRAF kinase (rare). 95% of GISTs stain positively for KIT (CD117). Most (66%) occur in the stomach and gastric GISTs have a lower malignant potential than tumors found elsewhere in the GI tract.

<span class="mw-page-title-main">Cholangiocarcinoma</span> Bile duct adenocarcinoma

Cholangiocarcinoma, also known as bile duct cancer, is a type of cancer that forms in the bile ducts. Symptoms of cholangiocarcinoma may include abdominal pain, yellowish skin, weight loss, generalized itching, and fever. Light colored stool or dark urine may also occur. Other biliary tract cancers include gallbladder cancer and cancer of the ampulla of Vater.

<span class="mw-page-title-main">Pancreaticoduodenectomy</span> Major surgical procedure involving the pancreas, duodenum, and other organs

A pancreaticoduodenectomy, also known as a Whipple procedure, is a major surgical operation most often performed to remove cancerous tumours from the head of the pancreas. It is also used for the treatment of pancreatic or duodenal trauma, or chronic pancreatitis. Due to the shared blood supply of organs in the proximal gastrointestinal system, surgical removal of the head of the pancreas also necessitates removal of the duodenum, proximal jejunum, gallbladder, and, occasionally, part of the stomach.

<span class="mw-page-title-main">Pelvic exenteration</span> Surgical removal of all pelvic organs

Pelvic exenteration is a radical surgical treatment that removes all organs from a person's pelvic cavity. It is used to treat certain advanced or recurrent cancers. The urinary bladder, urethra, rectum, and anus are removed. In women, the vagina, cervix, uterus, Fallopian tubes, ovaries and, in some cases, the vulva are removed. In men, the prostate is removed. The procedure leaves the person with a permanent colostomy and urinary diversion.

Hepatectomy is the surgical resection of the liver. While the term is often employed for the removal of the liver from a liver transplant donor, this article will focus on partial resections of hepatic tissue and hepatoportoenterostomy.

<span class="mw-page-title-main">Undifferentiated pleomorphic sarcoma</span> Medical condition

Undifferentiated pleomorphic sarcoma (UPS), also termed pleomorphic myofibrosarcoma, high-grade myofibroblastic sarcoma, and high-grade myofibrosarcoma, is characterized by the World Health Organization (WHO) as a rare, poorly differentiated neoplasm. WHO classified it as one of the undifferentiated/unclassified sarcomas in the category of tumors of uncertain differentiation. Sarcomas are cancers derived mesenchymal stem cells that typically develop in bone, muscle, fat, blood vessels, lymphatic vessels, tendons, and ligaments. More than 70 sarcoma subtypes have been described. The UPS subtype of these sarcomas consists of tumor cells that are poorly differentiated and may appear as spindle-shaped cells, histiocytes, and giant cells. UPS is considered a diagnosis that defies formal sub-classification after thorough histologic, immunohistochemical, and ultrastructural examinations fail to identify the type of cells involved.

Tegafur/uracil is a chemotherapy drug combination used in the treatment of cancer, primarily bowel cancer.

Hepatic arterial infusion (HAI) is a medical procedure that delivers chemotherapy directly to the liver. The procedure, mostly used in combination with systemic chemotherapy, plays a role in the treatment of liver metastases in patients with colorectal cancer (CRC). Although surgical resection remains the standard of care for these liver metastases, majority of patients have lesions that are unresectable.

<span class="mw-page-title-main">Metastatic liver disease</span> Medical condition

A liver metastasis is a malignant tumor in the liver that has spread from another organ affected by cancer. The liver is a common site for metastatic disease because of its rich, dual blood supply. Metastatic tumors in the liver are 20 times more common than primary tumors. In 50% of all cases the primary tumor is of the gastrointestinal tract; other common sites include the breast, ovaries, bronchus and kidney. Patients with Colorectal cancer will develop liver metastases during the disease

<span class="mw-page-title-main">Selective internal radiation therapy</span>

Selective internal radiation therapy (SIRT), also known as transarterial radioembolization (TARE), radioembolization or intra-arterial microbrachytherapy is a form of radionuclide therapy used in interventional radiology to treat cancer. It is generally for selected patients with surgically unresectable cancers, especially hepatocellular carcinoma or metastasis to the liver. The treatment involves injecting tiny microspheres of radioactive material into the arteries that supply the tumor, where the spheres lodge in the small vessels of the tumor. Because this treatment combines radiotherapy with embolization, it is also called radioembolization. The chemotherapeutic analogue is called chemoembolization, of which transcatheter arterial chemoembolization (TACE) is the usual form.

<span class="mw-page-title-main">Bone metastasis</span> Medical condition

Bone metastasis, or osseous metastatic disease, is a category of cancer metastases that result from primary tumor invasions into bones. Bone-originating primary tumors such as osteosarcoma, chondrosarcoma, and Ewing sarcoma are rare; the most common bone tumor is a metastasis. Bone metastases can be classified as osteolytic, osteoblastic, or both. Unlike hematologic malignancies which originate in the blood and form non-solid tumors, bone metastases generally arise from epithelial tumors and form a solid mass inside the bone. Bone metastases, especially in a state of advanced disease, can cause severe pain, characterized by a dull, constant ache with periodic spikes of incident pain.

<span class="mw-page-title-main">Metastatic breast cancer</span> Type of cancer

Metastatic breast cancer, also referred to as metastases, advanced breast cancer, secondary tumors, secondaries or stage IV breast cancer, is a stage of breast cancer where the breast cancer cells have spread to distant sites beyond the axillary lymph nodes. There is no cure for metastatic breast cancer; there is no stage after IV.

<span class="mw-page-title-main">Brain metastasis</span> Cancer that has metastasized (spread) to the brain from another location in the body

A brain metastasis is a cancer that has metastasized (spread) to the brain from another location in the body and is therefore considered a secondary brain tumor. The metastasis typically shares a cancer cell type with the original site of the cancer. Metastasis is the most common cause of brain cancer, as primary tumors that originate in the brain are less common. The most common sites of primary cancer which metastasize to the brain are lung, breast, colon, kidney, and skin cancer. Brain metastases can occur months or even years after the original or primary cancer is treated. Brain metastases have a poor prognosis for cure, but modern treatments allow patients to live months and sometimes years after the diagnosis.

<span class="mw-page-title-main">Combined small-cell lung carcinoma</span> Medical condition

Combined small cell lung carcinoma is a form of multiphasic lung cancer that is diagnosed by a pathologist when a malignant tumor, arising from transformed cells originating in lung tissue, contains a component of;small cell lung carcinoma (SCLC), admixed with one components of any histological variant of non-small cell lung carcinoma (NSCLC) in any relative proportion.

<span class="mw-page-title-main">David Geller</span> American surgeon

Dr. David Geller is the Richard L. Simmons Professor of Surgery at the University of Pittsburgh School of Medicine, and co-director of the UPMC Liver Cancer Center. As a hepatobiliary Surgical Oncologist, his clinical interests center on the evaluation and management of patients with liver cancer. He has pioneered laparoscopic liver resections, and has performed more than 300 of these cases. Most of these patients are discharged home on the second post-operative day with four to five band-aid-sized incisions. He also specializes in performing laparoscopic radiofrequency ablations of liver tumors. Dr. Geller is a member of many professional and scientific societies including the American Surgical Association, Society of Surgical Oncology, Society of University Surgeons, and the American Society of Transplant Surgeons.

Prophylactic cranial irradiation (PCI) is a technique used to combat the occurrence of metastasis to the brain in highly aggressive cancers that commonly metastasize to brain, most notably small-cell lung cancer. Radiation therapy is commonly used to treat known tumor occurrence in the brain, either with highly precise stereotactic radiation or therapeutic cranial irradiation. By contrast, PCI is intended as preemptive treatment in patients with no known current intracranial tumor, but with high likelihood for harboring occult microscopic disease and eventual occurrence. For small-cell lung cancer with limited and select cases of extensive disease, PCI has shown to reduce recurrence of brain metastases and improve overall survival in complete remission.

Hyperthermic intrathoracic chemotherapy (HITOC) is part of a surgical strategy employed in the treatment of various pleural malignancies. The pleura in this situation could be considered to include the surface linings of the chest wall, lungs, mediastinum, and diaphragm. HITOC is the chest counterpart of HIPEC. Traditionally used in the treatment of malignant mesothelioma, a primary malignancy of the pleura, this modality has recently been evaluated in the treatment of secondary pleural malignancies.

Radiation lobectomy is a form of radiation therapy used in interventional radiology to treat liver cancer. It is performed in patients that would be surgical candidates for resection, but cannot undergo surgery due to insufficient remaining liver tissue. It consists of injecting small radioactive beads loaded with yttrium-90 into the hepatic artery feeding the hepatic lobe in which the tumor is located. This is done with the intent of inducing growth in the contralateral hepatic lobe, not dissimilarly from portal vein embolization (PVE).

This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.