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Aggressive
surgery improves cure rate of hepatic malignancy
By
Kathy Pearsall
TORONTO,
ON--For
the majority of hepatic malignancies confined to the liver, surgical
excision offers the best opportunity for long-term, disease-free
survival, said Paul D. Greig, MD, Professor of Surgery, University
of Toronto, and Head of the GI Transplant Group.
"We can do a liver resection with a need for blood transfusion
under 25 per cent. So extensive surgery is now, I believe, the standard,"
Dr. Greig said.
He discussed his team's approach to hepatocellular carcinoma, cholangiocarcinoma,
gall bladder carcinoma, and liver metastases at the fourth Princess
Margaret Hospital conference.
Hepatocellular
carcinoma
At the University Health Network in Toronto, hepatologists are screening
for hepatocellular carcinoma. Approximately six new patients with
the disease are seen each week and a multidisciplinary review board
meets weekly to ensure a consistent treatment approach.
Canadian guidelines state that resectable tumours should be resected.
However, while data from the literature show that resection offers
a 40 to 50 per cent survival at five years, transplantation offers
75 per cent survival. Dr. Greig said if the guidelines are strictly
followed, people who could potentially be cured will be denied transplantation.
"We believe there's an increasing role for transplantation.
The living donor liver transplant option is available to patients,"
Dr. Greig said.
Cholangiocarcinoma
In the past decade, more extensive surgery has improved the resectability
rates and survival for patients with cholangiocarcinoma.
"By improving
the incidence
of negative resection margins, we have improved five-year survival
from about 10 per cent to between 40 and 50 per cent. For those
with positive margins the results are not nearly as good,"
Dr. Greig said.
Gall
bladder carcinoma
Like cholangiocarcinoma, the treatment and results for gall bladder
cancer have improved substantially during the past 10 years.
Approximately
five gall bladder resections are done annually in Toronto. "We've
improved the cure rate from about 10 to 40 per cent for patients
with negative resection margins. We believe gall bladder carcinoma
can be well served with an aggressive R-zero resection."
Liver
metastases
In the past decade, the number of resections for metastatic colorectal
cancer has increased to 42 per year from seven per cent at Toronto's
University Health Network. The majority of these were major resections.
The overall five-year disease-free survival now stands at 45 per
cent, up from 30 per cent reported in 1993. "Interestingly,
we did not find the number of metastases was predictive of outcome.
We found size, resection margins and previous chemotherapy were
predictive.
"We have an aggressive approach to metastatic disease. There
is no absolute limit to the number, size, or location. These patients
should be assessed appropriately and carefully," he said.
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