Chemotherapyforpredominantlivermetastases

Prof.EricRaymond,MD,PhDeraymond@hpsj.fr

ChairofMedicalOncologyParisSaint-JosephHospitalGroup

France

Predominantlivermetastases•  ChemotherapystandsasthebackbonetreatmentformetastaGcdisease

•  Surgery&liver-directedtherapiesmakesenseifweconsiderthatthespreadofmetastasesremainslimitedtotheliverorthattumordebulkingmayparGcipatetoprolongindividualpaGentsurvival

•  ExperiencesdoexistinmanytumortypesbutprospecGvedatahavebeenprimarilygeneratedforcolorectalcancers

Indica=onsforsurgery&liver-directedtherapiesmayvarywithtumortypes

Unlikelytobeindicated

Breast

Lung

Pancreas

Gastric

Prostate

Bladder

Possiblyindicated

Colon

Endocrine

Sarcoma

Unknown

Ovarian

Uterine

Melanoma

Resectable

Borderline Resectable

Unresectable

10-15%

70%

Summaryofchemotherapyinlivermetasta=ccolorectalcancer

PREOPERATIVE TRIPLETS (followed by post-operative 3 months doublets) target a High response rate (60-70%)

SYSTEMIC DOUBLETS - Long-term duration (≥6 months) - Response rate 40-50% - Optimal tolerance

10-15%

PREOPERATIVE DOUBLET (followed by a post-operative 3 month doublet) for Short-term duration (≤6 months)

Clinicalpresenta=ondrivesmedicaldecisionsforlivermetastasesincolorectalcancer

Livermetastases

Metachronous

Isolated/small/longdiseasefree-interval

Considersurgery&liverdirectedtherapyfirst

Mul=ple/Large/extra-hepa=c/shortdisease-freeinterval

Considerneo-adjuvant

chemotherapy

Synchronous

Mul=ple Considerchemotherapy

Unique/small/primarysymptoma=c

Considersurgery&liverdirectedtherapyfirst

Expected Median Overall Survival following liver resection: 3.6 years (1.7-7.3)

Criteriaforselec=ngchemotherapyfirst

>1 liver metastases >3 cm tumor diameter Synchronous Highly elevated CEA Poor tumor grade Positive margins

Nordlinger et al, Ann Surg 2012 Kanas et al, Clinical Epidemiol 2012

Role of systemic therapy+++

Solitary nodule <5 cm diameter Metachronous

Adam et al, Ann Surg 2010

Role of chemotherapy +/- Interval of relapse

Age, performance status

Conclusions

•  Resectable:PerioperaGveFOLFOXismainstay(3+3,noprovedaddedvalueofopGmizingresponse)

•  Borderline:PreoperaGvetriplets(withatargetedagent)opGmizesthequalityofresponsebeforesurgery(thenadjuvantFOLFOX)

•  Neverresectable:Longtermdiseasecontroliskeyandlivertargetedtherapyshouldbediscussed

Thanks for your attention