Hepatectomy for liver metastases from breast cancer.

Thirty-two selected patients underwent laparotomy in an attempt to resect one or more isolated liver metastases (LM) from breast cancer. Only 21 of them had hepatectomy and systematic lymph node picking of the hepatic pedicle. In six patients (19%), the discovery of diffuse metastatic disease contraindicated hepatectomy and in five patients (16%), the diagnosis of LM was erroneous, for lesions proved to be benign liver tumours. Nineteen of the resected cases received preoperative chemotherapy, 12 received post-operative chemotherapy and two had repeated hepatectomy. Eight patients (38%) had more than one LM and (24%) had positive hepatic lymph nodes. No post-operative mortality occurred. After the beginning of this combined treatment, median survival was 38.2 months and 2- and 5-year survival rates were, respectively, 78% and 24%. After the hepatectomy, median survival was 26 months and 2- and 5-year survival rates were, respectively, 50% and 9%. When a recurrence did occur (mean time to recurrence after hepatectomy was 14.8 months) the liver was involved in 75% of the cases and was the first place of recurrence in 56% of the patients. In this limited series, the number of LM, the number of positive pedicular lymph nodes, and a response to preoperative chemotherapy were not significant prognostic factors. However, patients with negative nodes tended to have a better prognosis, as did those with the first and only site of relapse being the liver. These selected patients, treated with hepatectomy, had a median survival at least three-fold that of patients treated with standard, non-surgical treatment. However, hepatectomy appeared to be mainly a cytoreductive procedure, and the efficiency of this combined treatment was mainly hampered owing to the inefficacy of current chemotherapy programmes. Only a prospective randomized study, in well-defined patients with isolated LM from breast cancer, comparing conventional treatment with or without hepatectomy, will demonstrate whether hepatectomy does indeed increase survival rates.

[Surgical interventions for erroneous diagnoses of liver metastases]. / Interventions chirurgicales pour diagnostics erronés de métastases hépatiques.

Among 635 laparotomies carried out for liver metastases (LM) between June 1983 and December 1992, twenty three operations (with 6 hepatectomies) were performed for a false positive diagnosis of LM. They represented 3.6% of the whole population, but only 2.8% if the 5 patients operated for persistent diagnostic doubt are excluded. The 6 hepatectomies represented 2.2% of the 276 hepatectomies carried out for LM. The 23 false positive diagnosis of LM could be classified as follows: 14 complete errors (operation for the diagnosis of LM), 4 partial errors (the operation was also indicated for a concomitant disease), and 5 cases of real diagnostic doubt. Two groups of patients were differentiated according to the survey: one group had a regular survey and had a modification of their initial morphologic examinations of the liver, and one group had no reference morphologic examinations of the liver. The errors were more frequent in the first group. Atypical angiomas were the most frequent lesion (n = 10), followed by atypical cysts (n = 4), and nodular focal hyperplasia (n = 4): they represented 78% of all false positive diagnosis of LM. These false positive lesions were mainly detected in three carcinomas: colorectal carcinomas (n = 10), breast cancers (n = 5) and melanomas (n = 3): they represented 78% of the incorrect diagnosis. The relative frequency was high for melanomas (36%) and breast cancers (14%), but low for colorectal cancers (2%). The retrospective study of these cases shows that some errors could be eliminated by a more extensive imaging and systematic radio-clinical confrontation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical approaches to segment I for malignant tumors (20 cases)]. / Approches chirurgicales du segment I pour tumeurs malignes (20 cas).

Seven complete and 13 partial resections of segment I (caudate lobe) were performed for malignant tumors. In all except one instance, removal of segment I was combined with other types of hepatic resection for technical or carcinologic reasons. Six were iterative hepatic resections for recurrent hepatic metastases. In two, the future remaining left lobe was hypertrophied by right portal venous embolization preoperatively. Hepatectomies were performed with intermittent portal triad clamping (mean total duration of 63 minutes, range of 20 to 120 minutes) and after preparation for total vascular exclusion. Associated partial resection of the inferior vena cava was necessary in three instances. Mean duration of operation was 285 minutes (range of 60 to 540 minutes) and mean blood loss was 1,749 milliliters (range of 200 to 5,200 milliliters). There was no postoperative mortality and the morbidity rate was low. Surprisingly, we discovered retrospectively that free margins were small (less than 5 millimeters) in 83 percent of the patients. Regardless of limited free margins and six iterative hepatectomies, eight patients were free of disease with a mean follow-up examination period of 19.2 months. Technical problems were different for each patient and a patient by patient adaptation was necessary. Left, right and central approaches were used accordingly. If resection of segment I associated with a right of left hepatectomy can currently considered as a standard hepatic resection, isolated complete resection of segment I remains a real technical challenge.

Surgical approach to segment I for malignant tumors of the liver.

Seven complete and 13 partial resections of segment I (caudate lobe) were performed for malignant tumors. In all except one instance, removal of segment I was combined with other types of hepatic resection for technical or carcinologic reasons. Six were iterative hepatic resections for recurrent hepatic metastases. In two, the future remaining left lobe was hypertrophied by right portal venous embolization preoperatively. Hepatectomies were performed with intermittent portal triad clamping (mean total duration of 63 minutes, range of 20 to 120 minutes) and after preparation for total vascular exclusion. Associated partial resection of the inferior vena cava was necessary in three instances. Mean duration of operation was 285 minutes (range of 60 to 540 minutes) and mean blood loss was 1,749 milliliters (range of 200 to 5,200 milliliters). There was no postoperative mortality and the morbidity rate was low. Surprisingly, we discovered retrospectively that free margins were small (less than 5 millimeters) in 83 percent of the patients. Regardless of limited free margins and six iterative hepatectomies, eight patients were free of disease with a mean follow-up examination period of 19.2 months. Technical problems were different for each patient and a patient by patient adaptation was necessary. Left, right and central approaches were used accordingly. If resection of segment I associated with a right or left hepatectomy can be currently considered as a standard hepatic resection, isolated complete resection of segment I remains a real technical challenge.

Prognostic factors in patients with liver metastases from colorectal carcinoma treated with discontinuous intra-arterial hepatic chemotherapy.

48 patients with colorectal cancer metastatic to the liver were implanted with a subcutaneous access system allowing hepatic intra-arterial perfusion. Regional chemotherapy used 5-fluorouracil, while 17 patients also received low-dose mitomycin at the beginning of the study. Responses to the treatment occurred in 29 patients (60%) and median survival was 14.4 months. Toxicity included gastroduodenal erosions in 12.5% of the patients, leucopenia in 20.8%, catheter thrombosis in 42% and arterial thrombosis in 50%. 2 patients died of digestive haemorrhage probably related to treatment. When individually analysed, four factors were found to significantly affect survival: presence of hepatomegaly (defined as palpable liver edge exceeding the right costal margin by more than 5 cm) (P = 0.006), percentage of hepatic replacement superior to 50% (P = 0.003), more than four metastases (P = 0.025) and hypovascularised metastases at radionuclide liver scan with 99m technetium-labelled macroaggregate albumin (MAA) (P = 0.04). The effect of the four variables on the observed survival time was analysed using a Cox regression model. Two variables were found to have simultaneously influenced survival. Presence of hepatomegaly emerged as the more significant (P = 0.0001), the other being hypovascularised metastases at 99mTc-MAA.

[Epidermoid cancer of the esophagus. Does the efficacy of chemoradiotherapy justify surgical abstention?]. / Cancers épidermoïdes de l'oesophage. L'efficacité des traitements chimio-radiothérapiques autorise-t-elle l'abstention chirurgicale?

Nine inoperable patients with squamous esophageal cancer were selected from 112 patients treated with combination chemo-radiotherapy. The criteria of selection were: 1) localized cancer (T1 or T2 of the TNM classification), 2) complete response after neoadjuvant chemotherapy suggesting the possibility of a good survival, 3) and 65 Gy-irradiation in the previous tumor bed. Eight of these 9 carcinomas recurred locally after a median delay of 12.6 months after the end of the treatment (extremes: 2 and 30 months). Only one patient is free of disease 24 months after the end of the treatment. These results point out that this chemo-radiotherapeutic association is disappointing in the long term in terms of loco-regional tumoral control and survival, but appeared to be good palliative treatment. This is an argument against the attitude of physicians who currently recommended a non-surgical strategy and deny the value of surgery. The carcinologic surgical excision of esophageal cancers is still the best treatment today. It must be performed whenever it is feasible, possibly associated with complementary treatments (evaluated in prospective studies).

[Gastric adenocarcinoma surgically treated. A multivariate analysis of prognostic factors]. / Adénocarcinomes gastriques réséqués curativement. Analyse multifactorielle des facteurs pronostiques.

One hundred and twelve curatively resected gastric adenocarcinomas were studied retrospectively to appreciate the survival factors. Twenty different criteria (clinic, histologic and therapeutic parameters) were assessed using univariate and then multivariate analysis (semi parametric regression (COX's) model). Only three criteria were very important according to the multivariate analysis: 1) invasion of neighboring organs (p less than 0.006) with a relative risk score (RRS) of 4.26; 2) intravascular or intralymphatic tumor embols outside the tumor (p less than 0.004; RRS = 2.11); 3) invaded distal nodes (located at the origin of the vessels (p less than 0.04; RRS = 1.88). A prognosis index was described according to these results. A repartition of the patients in three prognostic groups according to these 3 criteria was proposed. Future, trials should consider these three different prognostic groups.