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Chemotherapy does not impair parenchymal sparing surgery to treat colorectal liver metastases

Interview with Prof. Serge Evrard

Prof. Serge Evrard – Digestive Tumours Unit, Institute Bergonié, Bordeaux, France

ECCO 2017 Poster 441: Chemotherapy does not impair parenchymal sparing surgery to treat colorectal liver metastases -  Download poster - ECCO 2017 abstract

Video summary:

Prof. Serge Evrard, Surgical Oncologist from Bordeaux, France spoke about his team’s current focus on the metastases and to protect the normal liver. His was amongst the first teams who launched the concept of combining resection and intra-operative ablation which is now an accepted evidence-based practice. They proposed to make a small resection focused on the lesions and intra-operative ablation, for example when there are deep lesions, especially in the parenchyma, in spite of removing a lot of liver, they just inserted the needle with ultrasound control and destroyed the lesions. RAF23000 study has also demonstrated on a prospective basis that this approach is equivalent in terms of recurrences, local recurrences and the expectation of survival. The poster presented at ECCO2017 mentions a lot of chemotherapy can be given as when you remove some segments of the liver, mainly you remove tumour burden, not normal liver so it is easy to understand that even if you make a major resection, you make it because you have a lot of metastases inside and so it’s more compatible with chemotherapy.. The impact of chemotherapy is good if you protect the normal liver from the resection but if you remove a lot of normal liver you will have some problems like vascular lesions. The PSS (parenchymal-sparing approach) is compatible with the administration of chemotherapy both in the neoadjuvant and adjuvant setting. As surgery is getting more and more safe there are some indications for other non-colorectal cancers. 

Video transcript:

How has the landscape of liver resection for colorectal liver metastases changed over the last two decades?

So I’m Serge Evrard, Surgical Oncologist from Bordeaux, France.  I am a member of the ESSO, the European Society of Surgical Oncology association and the EORTC too and we have a collaboration between ESSO and EORTC which is the SURCARE platform.

So my talk on parenchymal sparing surgery is to say that there is an evolution in the thinking of how we have to design the surgery of colorectal liver mets.  In the past there was a trend to propose extensive hepatectomies because we had the knowledge of the liver transplant, for example and it was said that the biggest resection, the biggest amount of micro metastases we could remove but it is not a good concept because you let some micro metastases in the liver remain, so now more and more we are pushing the idea that the normal liver is not a target. 

We have to focus on the metastases and to protect the normal liver.  In order to make iterative surgery, to operate once, two times, three times, it’s a trial and because clearly the parenchyma is not a target, so we have to demonstrate this and we were among the first teams launching the concept of combining resection and intra-operative ablation which is now accepted by most teams but it was not the case ten years ago. 

And so we propose to make the smallest resection focussed on the lesions and intra-operative ablation, for example when you have deep lesions, deep in the parenchyma, in spite of removing a lot of liver, you just put the needle in the ultrasound control and you destroy these lesions, and we have demonstrated on a prospective basis RAF23000 study that it was equivalent in terms of recurrences, local recurrences and the expectation of survival.

So now we have to demonstrate that this approach is also compatible with chemotherapy because one of the criticisms of extended surgery was that it was not so compatible with chemotherapy if you give more than the 12 cycles of chemo and you did after a big extensive hepatectomy, you have a high rate of mortality.

We have shown in this poster that you can do a lot of chemotherapy by the fact that when you remove some segments of the liver, mainly you remove tumour burden, not normal liver so it is easy to understand that even if you make a major resection, you make it because you have a lot of metastases inside and so it’s more compatible with chemotherapy.

So it has been very interesting to see that you can do a lot of chemo before and after by the fact that you respect the liver, the normal liver so it’s a very interesting concept and completely integrating the notion of the multidisciplinary approach.  The surgeon is important but chemotherapy is also very important.  You can do also ablation, etc., etc., so that’s I think the new concept to deal in the modern way with colorectal liver mets.

Is liver resection for metastases a safe procedure? Does chemotherapy before liver resection make the operation more difficult for the surgeon or dangerous for the patient?

We have not so much impact of chemotherapy if you protect the normal liver from the resection but of course if you remove a lot of normal liver you will have some problem because oxaliplatin is inducing the syndrome of vascular lesions, and ?irinotecan is leading to ?store hepatocytes, etc., so if you give a number of cycles which sometimes is necessary, of course you can have some cumulative toxicity but most of the time in a routine way, the PSS, the parenchymal-sparing approach, is compatible with the administration of chemo both on the neoadjuvant setting and in the adjuvant setting.

How does the experience with liver surgery for colorectal cancer metastases translate to other diseases like e.g. gastric cancer or pancreatic cancer?

So we had a multidisciplinary staff discussion in this meeting this morning with Gunnar Folprecht, with some other friends of mine about this discussion.  The problem is can we push the limits of the surgery or should we say ‘Okay, now we have to stop to make some barriers’?

So clearly for liver-only metastases, when the patient has only metastases in the liver and nothing else, I would say we have to push the limit because we have no demonstration that surgery is always doing better than chemo only, but for patients having liver and extra-hepatic localisation like lung, …, etc., more and more you have medical oncologists saying it is not demonstrated that you are giving some additional chance to the patients so Gunnar Folprecht is wanting to have a randomised study in this topic.

So I clearly understand that the progress of chemotherapy is now at 25, 30 months so mechanically the progress of medicine will join in all the residual surgery, so there will be a limit to surgical indications but once again for liver-only disease, I think there is a big place for surgery.

How does the experience with liver surgery for colorectal cancer metastases translate to other diseases like e.g. gastric cancer or pancreatic cancer?

As surgery is getting more and more safe there are some indications for other non-colorectal cancers.  First was neuroendocrine tumours, but the problem is that with the progress of MRI we see that in the past we used to say that when you see five non-endocrine metastases, when you operate you have ten or 20 because you have a lot of very small metastases and now with the progress of MRI, especially diffusion-weighted MRI, we see more and more before operating and so we have less indication because we know that most of the time we are in the perioperative setting.

But at the same time for gastric cancer, for example, for some indications like pancreatic cancer sometimes a patient has a specific evolution, three years after the start of the treatment he is always alive and you have one or two mets not so growing so you have to discuss in the MDT indications, and I know that in Japan they discuss more and more indications for gastric carcinoma, for example, and there is a project both in Japan and at the EORTC to have some prospective databases to record these cases because they are not so frequent so you cannot say we can analyse because we have not enough patients in this type of evolution so the good response will probably be prospective databases to see what we really offer to the patient in terms of quality of life and expectation of life, too.

- Ends -

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