A member asked about the advisability of removing liver mets: whether to do this while they are responding or only if they start growing.
I think if they all can be removed or ablated, then personally I would do it WHILE they are respondingand then stay on Gleevec. I do not see any evidence to argue against this. The trials are being doneto see if this works only for a select group with better status, but if YOU are IN such a group then DO IT!
There are several papers summarized about this in our website's TREATMENT section.
Here is a new one from CTOS 2011 just last month (thanks to Barbara Dore for attending on our part!)
Long Term Follow-Up of Patients with GIST Undergoing Metastasectomy In the Era of Imatinib an EORTC-STBSG Collaborative Analysis of Prognostic Factors
Sebastian Bauer MD, Alessandro Gronchi, Frits van Coevorden, Peter Hohenberger, Elena Fumagalli, Janusz Siedlecki, Buu-Phuk Nguyen, Martijn Kerst, Marco Fiore, Pawl Nyckowski, Mathias Hoiczyk, Annemik Cats, Paolo Casali, Jürgen Treckmann, Piotr Rukowski
This paper examines whether surgery to remove metastatic tumors improves survival , and looks for factors to identify patients who might benefit. Analysis was made on the results of surgery to remove metastases in the databases of 5 sarcoma centers, analyzing data for a total of 239 patients.
The following factors were examined:
• whether the patients received perioperative imatinib
• median overall survival (mOS)
• progression-free survival (PFS) and OS was calculated from time of first IM for metastatic disease until death or last follow-up.
• sex, status of resection,
• location of resected lesions, and remission status at time of metastasectomy.
• In 177 patients metastases were resected with macroscopically clear margins (R0+R1), and in 49 patients incompletely resected (R2).
Resection on patients in remission
Median time to progression after resection of residual disease was not reached in the patients with clear margins (R0/R1), and was 1.9 years in the R2 group of patients. Overall survival was not reached in the R0/R1 group, and 5.1 years in the R2 group.
Resection on patients in progression
Time to progression was 1.1 years for patients with clear margins, and 0.6 years with incomplete resection .
Median overall survival for patients with KIT exon 11 mutation was 8.7 years after complete and 5.2 years after incomplete resection.
Resection performed leaving clear margins (R0/R1)
Median overall survival was not reached for patients with only liver metastases, compared to 8.7 years in patients with only peritoneal, and 5.9 years with both peritoneal and liver metastases .
Resection performed leaving R2 margins
Median overall survival was 5.3 years for patients with R2 resection.
Those patients who did best were:
• only one metastasis (liver or peritoneum)
• surgery performed in remission
• patients with exon 11 mutation.
The authors conclude that for patients in whom clear margins (R0/R1) were obtained, it is likely that metastasectomy did confer improve overall survival benefit.
Incomplete resection, including debulking surgery does not seem to prolong survival. This analysis provides the strongest evidence to date of a potential benefit of surgery to remove metastases in selected GIST patients.
Another recent PubMed abstract is the following:
1. Cancer. 2011 Nov 15. doi: 10.1002/cncr.26650. [Epub ahead of print]
Hepatic resection for metastatic gastrointestinal stromal tumors in the tyrosine kinase inhibitor era.
Turley RS, Peng PD, Reddy SK, Barbas AS, Geller DA, Marsh JW, Tsung A, Pawlik TM, Clary BM.
Department of Surgery, Duke University Medical Center, Durham North Carolina. firstname.lastname@example.org.
BACKGROUND: Before the advent of tyrosine kinase inhibitors (TKIs), surgical resection was the primary treatment for hepatic gastrointestinal stromal tumor (GIST) metastases. Although TKIs have improved survival in the metastatic setting, outcomes after multimodal therapy comprised of hepatectomy and TKIs for GIST are unknown. The objective of this study was to determine whether combination therapy for hepatic GIST metastases is associated with improved overall survival compared with reported outcomes from surgery or TKI therapy alone. METHODS: Demographics, clinicopathologic tumor characteristics, treatments, and outcomes of patients who underwent hepatic resection at 3 high-volume centers from 1995 to 2010 were reviewed. RESULTS: In total, 39 patients underwent hepatectomy for metastatic GISTs, and 27 patients received postoperative TKI therapy. At a median follow-up of 39.7 months, 23 patients (59%) experienced recurrence at a median of 18 months. The 1-year, 2-year, and 3-year overall survival rates were 96.7%, 76.8%, and 67.9%, respectively. Median survival was not reached at 5 years. The rates of severe complication and mortality were 10.2% (4 patients) and 2.5% (1 patient), respectively. When controlling for confounders, postoperative TKI therapy was associated with improved survival (hazard ratio, 0.04; 95% confidence interval, 0.01-0.50; P = .006), and extrahepatic disease was associated with worse survival (hazard ratio, 9.51; 95% confidence interval, 1.63-55.7; P = .012). CONCLUSIONS: Overall survival after combination therapy exceeded previous reports for the treatment of metastatic GIST with hepatic resection or TKI therapy alone and was significantly enhanced by postoperative TKI therapy. The results from this study support findings that combination therapy for GIST liver metastases comprised of surgical resection and TKI therapy is more effective than surgery or TKI therapy alone. Cancer 2011;. © 2011 American Cancer Society.
Copyright © 2011 American Cancer Society.
PMID: 22086856 [PubMed - as supplied by publisher]
CHEVRON INCISION in open liver surgery:
The most frequent incision utilized to open the abdomen for liver surgery is called a CHEVRON INCISION. In this incision a cut is made on the abdomen below the rib cage. The cut starts under the armpit below the ribs on the right side of the abdomen and continues all the way across the abdomen to the opposite arm pit thereby the whole width of the abdomen is cut to provide access to the liver. The average length of the incision is approximately 24 to 30 inches.
This is one of the longest incisions is utilized in abdominal surgery. The incision is frequently associated with significant discomfort after the surgery and in some patients the discomfort can continue for many months, particularly when some of the nerves in the abdominal wall have been cut during the surgery.
LAPRASCOPIC SURGERY provides advantages over open surgery for the liver since the chevron incision is completely avoided and the surgery is performed through tiny incisions. As a consequence the duration of stay in hospital, the amount and duration of post operative discomfort, and the length of recovery is much shorter after the laparoscopic procedure compared to open surgery. These procedures avoid the large chevron incision used in open liver surgery. Laparoscopic liver resection allows patients to go home earlier and recover quicker compared to open procedures.
LAPRASCOPIC WEDGE RESECTION of the liver:
In a WEDGE RESECTION of the liver, the tumor is removed with a surrounding margin of about half inch of normal liver. Wedge resection of the liver is preferred since only small amounts of liver tissue is removed during this procedure. A wedge resection is an option only for those tumors that are situated on the surface of the liver so that they can be safely removed without injury to the blood vessels of the liver. Cancers that are situated deep in the liver cannot be safely removed with a wedge resection due to a very high risk of injury and uncontrolled bleeding from the blood vessels within the substance of the liver.
Traditionally wedge resections have been performed through an open surgery , laparoscopic surgery was limited for the liver since removal of only the most superficial tumors was possible.
HAND-ASSISTED LAPRASCOPIC SURGERY:
With the availability of HAND-ASSISTED LAPRASCOPIC SURGERY surgeons are able to perform a WEDGE RESECTION on any part of the liver as long as the tumor is present on the surface of the liver. All the different parts of the liver are easily available for surgery.
Doctors can perform an INTRAOPERATIVE EXAMINATION of the liver with an ULTRASOUND PROBE during laparoscopic surgery to better stage the tumor and detect additional tumors that may have not been seen in the X-rays studies performed prior to the surgery.
LATERAL SEGMENTECTOMY of the liver:
The left lobe of the liver has two components: a MEDIAL SEGMENT and a LEFT LATERAL SEGMENT. The left lateral segment of the liver is often involved with metastatic disease and may require removal. In some patients the tumors may be confined only to the left lateral segment. Under these circumstances removal of the left lateral segment may provide an opportunity for cure.
The left lateral segment traditionally was removed through a large chevron opening. Doctors can now also offer a laparoscopic approach to removal of the left lateral segment. During this procedure small incisions are made for a VIDEO CHIP CAMERA and laparoscopic instruments. In addition to that, they can make a two inch incision to place a NEW LAPRASCOPIC DEVICE called A HAND PORT. The placement of a laparotomy hand-access device allows insertion of the surgeons hand into the abdomen for retraction and dissection of the liver from its surrounding attachments.
I had an 8 hour liver surgery on my 39th birthday.
I got what is called a "mercedes" incision...like the mercedes-benz logo. It heals up okay, but for a long time I felt like I had a piece of wire cinched around my torso, because the scar wasn't stretched out yet.
I was kept "knocked out" for a couple of days afterwards, so I have no stressful memories of the first part of the recovery except a few very foggy strange things.
I mostly remember having a very sore mid section, it was impossible to lie down on a flat mattress. An overstuffed recliner chair if not a hospital style bed is a must for the first couple of weeks. My arms and shoulders became sore from being used so much to hold up my body while my midsection was tender. The surgeon said I could get in the hot tube within a couple of weeks, which helped to reduce the force of gravity on my body. I also remember having drenching night sweats for a while, and so be prepared for that. I had a hard time regulating my body temperature, and so light layers of covers, a fan, towels on the pilllow, were helpful.
The worst part was getting the surgical drain tubes pulled at the end of the immediate recovery. There's a mile of tubing left inside--more than your imagination can imagine.... and it takes a firm tug to get these tubes out, and with an ouch.
Mostly, overall the experience wasn't particularly worse than my initial surgery to remove the GIST tumor but it was a bit different. You're pretty weak for a while. I remember thinking that the surgery was a reprieve from the dreaded and torturous weekly infusions of chemotherapy gemzar that I had been getting before the surgery. I wasn't actually nervous before the liver surgery, again because I thought of it as rescuing me from the chemotherapy infusions.