yashoda debate
TRANSCRIPT
Should chemotherapy given for all colorectal liver metastases before
resection
Chandramohan KAdditional Professor
Surgical OncologyRegional Cancer Centre
Trivandrum
Liver metastasis
Synchronous 15 All stages
Metachronous 13 All stages
30 Stage III
Survival 5yr 10yr
36 to 58 23to 36
perioperativemortality rates
lt 5
Response of Chemotherapy
0
10
20
30
40
50
60
70
5-fluorouracil 5FU+Irinotecan 5FU+Oxaliplatin withMonoclonal AB
Drugs
Series 1
Upfront Chemotherapy for all CRC LM
Resectable
Borderline
Unresectable
Is Neoadjuvant Chemotherapy Justified for Resectable Lesions
bull Issues with NAC
bull No increase in OS amp No Adjuvant arm
Nordlinger B Sorbye H Glimelius B et al Perioperative chemotherapy with FOLFOX4 and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC Intergroup trial 40983) a randomised controlledtrial Lancet 2008371(9617)1007ndash1016
Adam R Bhangui P Poston G et al Is perioperative chemotherapy useful for solitary metachronous colorectal liver metastases Ann Surg 2010252(5)774ndash787
Adjuvant ChemotherapyImproved survival whereas NAC had no impact on DFS and OS
Postoperative complications increased from 24to 37 in NAC Group
Blue Liver
Liver Toxicity
bull Oxaliplatin sinusoidal obstruction syndrome (SOS) (5-50)
bull Irinotetan chemotherapy-associated steatohepatitis (CASH)
Eur J Surg Oncol 2008 Jun34(6)609-14 Epub 2007 Aug 30Hepatic complications following preoperative chemotherapy with oxaliplatin oririnotecan for hepatic colorectal metastases
Morris-Stiff G1 Tan YM Vauthey JN
J Hepatobiliary Pancreat Surg 200916(2)137-44 doi 101007s00534-008-0016-zEpub 2008 Dec 18
Patterns of chemotherapy-induced hepatic injury and their implications forpatients undergoing liver resection for colorectal liver metastases
Khan AZ1 Morris-Stiff G Makuuchi M
bull In the EORTC trial 6 cycles of FOLFOX before surgery increased
bull the overall complication rate from 16 to 25 and the rate
bull of hepatic complications from 9 to 15
bull But mortality same
Annals of Surgery Volume 255 Number 2 February 2012 Chemotherapy Before Liver Resection
Annals of Surgery Volume 255 Number 2 February 2012 Chemotherapy Before Liver Resection
Esmo Guideline
NCCN
Upfront Chemotherapy for all CRC LM
Resectable
Borderline
Unresectable
Liver metastasis
Synchronous 15 All stages
Metachronous 13 All stages
30 Stage III
Survival 5yr 10yr
36 to 58 23to 36
perioperativemortality rates
lt 5
Response of Chemotherapy
0
10
20
30
40
50
60
70
5-fluorouracil 5FU+Irinotecan 5FU+Oxaliplatin withMonoclonal AB
Drugs
Series 1
Upfront Chemotherapy for all CRC LM
Resectable
Borderline
Unresectable
Is Neoadjuvant Chemotherapy Justified for Resectable Lesions
bull Issues with NAC
bull No increase in OS amp No Adjuvant arm
Nordlinger B Sorbye H Glimelius B et al Perioperative chemotherapy with FOLFOX4 and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC Intergroup trial 40983) a randomised controlledtrial Lancet 2008371(9617)1007ndash1016
Adam R Bhangui P Poston G et al Is perioperative chemotherapy useful for solitary metachronous colorectal liver metastases Ann Surg 2010252(5)774ndash787
Adjuvant ChemotherapyImproved survival whereas NAC had no impact on DFS and OS
Postoperative complications increased from 24to 37 in NAC Group
Blue Liver
Liver Toxicity
bull Oxaliplatin sinusoidal obstruction syndrome (SOS) (5-50)
bull Irinotetan chemotherapy-associated steatohepatitis (CASH)
Eur J Surg Oncol 2008 Jun34(6)609-14 Epub 2007 Aug 30Hepatic complications following preoperative chemotherapy with oxaliplatin oririnotecan for hepatic colorectal metastases
Morris-Stiff G1 Tan YM Vauthey JN
J Hepatobiliary Pancreat Surg 200916(2)137-44 doi 101007s00534-008-0016-zEpub 2008 Dec 18
Patterns of chemotherapy-induced hepatic injury and their implications forpatients undergoing liver resection for colorectal liver metastases
Khan AZ1 Morris-Stiff G Makuuchi M
bull In the EORTC trial 6 cycles of FOLFOX before surgery increased
bull the overall complication rate from 16 to 25 and the rate
bull of hepatic complications from 9 to 15
bull But mortality same
Annals of Surgery Volume 255 Number 2 February 2012 Chemotherapy Before Liver Resection
Annals of Surgery Volume 255 Number 2 February 2012 Chemotherapy Before Liver Resection
Esmo Guideline
NCCN
Upfront Chemotherapy for all CRC LM
Resectable
Borderline
Unresectable
Response of Chemotherapy
0
10
20
30
40
50
60
70
5-fluorouracil 5FU+Irinotecan 5FU+Oxaliplatin withMonoclonal AB
Drugs
Series 1
Upfront Chemotherapy for all CRC LM
Resectable
Borderline
Unresectable
Is Neoadjuvant Chemotherapy Justified for Resectable Lesions
bull Issues with NAC
bull No increase in OS amp No Adjuvant arm
Nordlinger B Sorbye H Glimelius B et al Perioperative chemotherapy with FOLFOX4 and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC Intergroup trial 40983) a randomised controlledtrial Lancet 2008371(9617)1007ndash1016
Adam R Bhangui P Poston G et al Is perioperative chemotherapy useful for solitary metachronous colorectal liver metastases Ann Surg 2010252(5)774ndash787
Adjuvant ChemotherapyImproved survival whereas NAC had no impact on DFS and OS
Postoperative complications increased from 24to 37 in NAC Group
Blue Liver
Liver Toxicity
bull Oxaliplatin sinusoidal obstruction syndrome (SOS) (5-50)
bull Irinotetan chemotherapy-associated steatohepatitis (CASH)
Eur J Surg Oncol 2008 Jun34(6)609-14 Epub 2007 Aug 30Hepatic complications following preoperative chemotherapy with oxaliplatin oririnotecan for hepatic colorectal metastases
Morris-Stiff G1 Tan YM Vauthey JN
J Hepatobiliary Pancreat Surg 200916(2)137-44 doi 101007s00534-008-0016-zEpub 2008 Dec 18
Patterns of chemotherapy-induced hepatic injury and their implications forpatients undergoing liver resection for colorectal liver metastases
Khan AZ1 Morris-Stiff G Makuuchi M
bull In the EORTC trial 6 cycles of FOLFOX before surgery increased
bull the overall complication rate from 16 to 25 and the rate
bull of hepatic complications from 9 to 15
bull But mortality same
Annals of Surgery Volume 255 Number 2 February 2012 Chemotherapy Before Liver Resection
Annals of Surgery Volume 255 Number 2 February 2012 Chemotherapy Before Liver Resection
Esmo Guideline
NCCN
Upfront Chemotherapy for all CRC LM
Resectable
Borderline
Unresectable
Upfront Chemotherapy for all CRC LM
Resectable
Borderline
Unresectable
Is Neoadjuvant Chemotherapy Justified for Resectable Lesions
bull Issues with NAC
bull No increase in OS amp No Adjuvant arm
Nordlinger B Sorbye H Glimelius B et al Perioperative chemotherapy with FOLFOX4 and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC Intergroup trial 40983) a randomised controlledtrial Lancet 2008371(9617)1007ndash1016
Adam R Bhangui P Poston G et al Is perioperative chemotherapy useful for solitary metachronous colorectal liver metastases Ann Surg 2010252(5)774ndash787
Adjuvant ChemotherapyImproved survival whereas NAC had no impact on DFS and OS
Postoperative complications increased from 24to 37 in NAC Group
Blue Liver
Liver Toxicity
bull Oxaliplatin sinusoidal obstruction syndrome (SOS) (5-50)
bull Irinotetan chemotherapy-associated steatohepatitis (CASH)
Eur J Surg Oncol 2008 Jun34(6)609-14 Epub 2007 Aug 30Hepatic complications following preoperative chemotherapy with oxaliplatin oririnotecan for hepatic colorectal metastases
Morris-Stiff G1 Tan YM Vauthey JN
J Hepatobiliary Pancreat Surg 200916(2)137-44 doi 101007s00534-008-0016-zEpub 2008 Dec 18
Patterns of chemotherapy-induced hepatic injury and their implications forpatients undergoing liver resection for colorectal liver metastases
Khan AZ1 Morris-Stiff G Makuuchi M
bull In the EORTC trial 6 cycles of FOLFOX before surgery increased
bull the overall complication rate from 16 to 25 and the rate
bull of hepatic complications from 9 to 15
bull But mortality same
Annals of Surgery Volume 255 Number 2 February 2012 Chemotherapy Before Liver Resection
Annals of Surgery Volume 255 Number 2 February 2012 Chemotherapy Before Liver Resection
Esmo Guideline
NCCN
Upfront Chemotherapy for all CRC LM
Resectable
Borderline
Unresectable
Is Neoadjuvant Chemotherapy Justified for Resectable Lesions
bull Issues with NAC
bull No increase in OS amp No Adjuvant arm
Nordlinger B Sorbye H Glimelius B et al Perioperative chemotherapy with FOLFOX4 and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC Intergroup trial 40983) a randomised controlledtrial Lancet 2008371(9617)1007ndash1016
Adam R Bhangui P Poston G et al Is perioperative chemotherapy useful for solitary metachronous colorectal liver metastases Ann Surg 2010252(5)774ndash787
Adjuvant ChemotherapyImproved survival whereas NAC had no impact on DFS and OS
Postoperative complications increased from 24to 37 in NAC Group
Blue Liver
Liver Toxicity
bull Oxaliplatin sinusoidal obstruction syndrome (SOS) (5-50)
bull Irinotetan chemotherapy-associated steatohepatitis (CASH)
Eur J Surg Oncol 2008 Jun34(6)609-14 Epub 2007 Aug 30Hepatic complications following preoperative chemotherapy with oxaliplatin oririnotecan for hepatic colorectal metastases
Morris-Stiff G1 Tan YM Vauthey JN
J Hepatobiliary Pancreat Surg 200916(2)137-44 doi 101007s00534-008-0016-zEpub 2008 Dec 18
Patterns of chemotherapy-induced hepatic injury and their implications forpatients undergoing liver resection for colorectal liver metastases
Khan AZ1 Morris-Stiff G Makuuchi M
bull In the EORTC trial 6 cycles of FOLFOX before surgery increased
bull the overall complication rate from 16 to 25 and the rate
bull of hepatic complications from 9 to 15
bull But mortality same
Annals of Surgery Volume 255 Number 2 February 2012 Chemotherapy Before Liver Resection
Annals of Surgery Volume 255 Number 2 February 2012 Chemotherapy Before Liver Resection
Esmo Guideline
NCCN
Upfront Chemotherapy for all CRC LM
Resectable
Borderline
Unresectable
Blue Liver
Liver Toxicity
bull Oxaliplatin sinusoidal obstruction syndrome (SOS) (5-50)
bull Irinotetan chemotherapy-associated steatohepatitis (CASH)
Eur J Surg Oncol 2008 Jun34(6)609-14 Epub 2007 Aug 30Hepatic complications following preoperative chemotherapy with oxaliplatin oririnotecan for hepatic colorectal metastases
Morris-Stiff G1 Tan YM Vauthey JN
J Hepatobiliary Pancreat Surg 200916(2)137-44 doi 101007s00534-008-0016-zEpub 2008 Dec 18
Patterns of chemotherapy-induced hepatic injury and their implications forpatients undergoing liver resection for colorectal liver metastases
Khan AZ1 Morris-Stiff G Makuuchi M
bull In the EORTC trial 6 cycles of FOLFOX before surgery increased
bull the overall complication rate from 16 to 25 and the rate
bull of hepatic complications from 9 to 15
bull But mortality same
Annals of Surgery Volume 255 Number 2 February 2012 Chemotherapy Before Liver Resection
Annals of Surgery Volume 255 Number 2 February 2012 Chemotherapy Before Liver Resection
Esmo Guideline
NCCN
Upfront Chemotherapy for all CRC LM
Resectable
Borderline
Unresectable
Liver Toxicity
bull Oxaliplatin sinusoidal obstruction syndrome (SOS) (5-50)
bull Irinotetan chemotherapy-associated steatohepatitis (CASH)
Eur J Surg Oncol 2008 Jun34(6)609-14 Epub 2007 Aug 30Hepatic complications following preoperative chemotherapy with oxaliplatin oririnotecan for hepatic colorectal metastases
Morris-Stiff G1 Tan YM Vauthey JN
J Hepatobiliary Pancreat Surg 200916(2)137-44 doi 101007s00534-008-0016-zEpub 2008 Dec 18
Patterns of chemotherapy-induced hepatic injury and their implications forpatients undergoing liver resection for colorectal liver metastases
Khan AZ1 Morris-Stiff G Makuuchi M
bull In the EORTC trial 6 cycles of FOLFOX before surgery increased
bull the overall complication rate from 16 to 25 and the rate
bull of hepatic complications from 9 to 15
bull But mortality same
Annals of Surgery Volume 255 Number 2 February 2012 Chemotherapy Before Liver Resection
Annals of Surgery Volume 255 Number 2 February 2012 Chemotherapy Before Liver Resection
Esmo Guideline
NCCN
Upfront Chemotherapy for all CRC LM
Resectable
Borderline
Unresectable
bull In the EORTC trial 6 cycles of FOLFOX before surgery increased
bull the overall complication rate from 16 to 25 and the rate
bull of hepatic complications from 9 to 15
bull But mortality same
Annals of Surgery Volume 255 Number 2 February 2012 Chemotherapy Before Liver Resection
Annals of Surgery Volume 255 Number 2 February 2012 Chemotherapy Before Liver Resection
Esmo Guideline
NCCN
Upfront Chemotherapy for all CRC LM
Resectable
Borderline
Unresectable
Annals of Surgery Volume 255 Number 2 February 2012 Chemotherapy Before Liver Resection
Annals of Surgery Volume 255 Number 2 February 2012 Chemotherapy Before Liver Resection
Esmo Guideline
NCCN
Upfront Chemotherapy for all CRC LM
Resectable
Borderline
Unresectable
Annals of Surgery Volume 255 Number 2 February 2012 Chemotherapy Before Liver Resection
Esmo Guideline
NCCN
Upfront Chemotherapy for all CRC LM
Resectable
Borderline
Unresectable
Esmo Guideline
NCCN
Upfront Chemotherapy for all CRC LM
Resectable
Borderline
Unresectable
NCCN
Upfront Chemotherapy for all CRC LM
Resectable
Borderline
Unresectable
Upfront Chemotherapy for all CRC LM
Resectable
Borderline
Unresectable