- Email: [email protected]
66. Tailoring breast cancer reconstruction
ABSTRACTS
751
restrictions were accepted then less than 10% of patients with liver only disease would come to hepatectomy. As a result, barely 3% of all patients with stage 4 disease were alive 5 years after diagnosis. The current definition of resectability is metastatic disease in the liver (even in the presence of resectable extra-hepatic disease) which can be resected while preserving 25-30% of viable disease free liver with a vascular inflow and vasculo-biliary outflow. As such, more than 20% of these patients are now considered resectable at presentation. The only barrier to such surgery is now anaesthetic fitness to undergo the liver surgery (2). Furthermore, more patients can now be brought physically to liver resection by using a number of techniques including:
Portal vein embolisation to increase the size of the future remnant liver Two stage hepatectomy Combination of surgery with ablation (3) Employing techniques from liver transplantation
As such, a further 10% of patients become surgical candidates without recourse to the use of induction chemotherapy. It has been clear for some time that there are patients with liver-limited but unresectable disease who can be converted to resectability following
induction chemotherapy, either on intention to treat or following a dramatic response, even when thought initially not feasible (the ‘accidental’ hepatectomy). Combining cytotoxic chemotherapy with biologics (especially the EGF-receptor antibody cetuximab in patients whose tumours are kras wild-type) might now bring up to 40% of patients with unresectable liver-limited disease to liver surgery with potentially curative intent (4). Using chemotherapy and biologics to bring patients to such surgery must only be employed within the setting of a highly specialised hepatobiliary multi-disciplinary team (5). Injudicious and excessive use of these agents leads to liver parenchymal damage, so causing increased morbidity and mortality after liver surgery, and also runs the risk of making the lesions morphologically disappear, so becoming undetectable at surgery, while remaining pathologically viable. 1. 2. 3. 4. 5.
Morris E et al. Brit J Surgery 2010; 97: 1110-8 Adam R et al. Brit J Surg 2010; 97: 366-376 Ruers T et al. Ann Oncol 2012 in press Folprecht G et al. Lancet Oncology 2010; 1: 38-47 National Institute of Health and Clinical Excellence. Technology Appraisal 176, August 2009
20 September 2012: 09:00 e 10:30 Symposium: How I do: Intraoperative decision-making and problem-solving in surgical oncology 63. Gastric cancer surgery: The unexpected positive oesophageal margin/direct invasion into colon or pancreas M. Pera1 1 Hospital Universitario del Mar, Section of Gastrointestinal Surgery, Barcelona, Spain UGI surgeons must be aware before the operation of those gastric cancer patients with a greater risk of having positive oesophageal margins after total gastrectomy. It has been shown that patients with larger tumour size, deeper wall penetration, more extensive gastric involvement, greater nodal involvement, higher stage and diffuse histology belong to this group at risk. In those cases, and once the pathologist confirms intraoperatively the oesophageal margin involvement, the surgeon should balance the potential benefit of achieving a negative margin against the risks of performing a more extensive resection. Physiological status of the patient and the stage of the disease, especially the extension of lymph node involvement, should be taken into account in these circumstances. Several studies have confirmed that a positive margin is associated with a worse outcome in patients with node-negative disease or early stages. All efforts should therefore be made to clear the oesophageal margin in these patients. In patients with more advance disease and extensive lymph node involvement, a more conservative approach should be taken. The value of extended organ resection for advanced gastric cancer has been debated for many years. Different studies have shown that additional organ resection is associated with an increase in morbidity and mortality. However, long-term survival following this kind of extended resection is possible. In these cases, similar to what happen with the issue of positive oesophageal margins, depth of invasion
and the extent of lymph node metastasis will finally have the most determinant impact on survival after additional organ resection and a R0 resection. 64. Hepatic cancer surgery: Surgical decision-making regarding the future liver remnant S. Lopez-Ben1, M.T. Albiol Quer1, A. Codina Barreras1, L. Falgueras Verdaguer1, E. Castro Gutierrez1, J. Figueras Felip1 1 Hospital Dr Josep Trueta, Seccion de Cirugıa Hepatobiliar y Pancreatica, Girona, Spain In the last years resectability criteria has been changing in liver neoplasm from data based on what has to be removed (namely, size and number of lesions, wide surgical margin, time from diagnosis,..) towards features of what we plan to be preserved. This is more true when we speak about colorectal liver metastases where the unique criteria of unresectability is the impossibility to preserve enough functioning liver after the surgical resection of the lesions. This pursuit of the "as large as possible" liver remnant is nowadays our main goal in liver surgical oncology and the different surgical options will be discussed, focusing in portal occlusion techniques, pharmacological adjuvant strategies and the different modalities of two-stage hepatectomies. 65. Pancreatic cancer surgery: The unexpected venous or arterial involvement Abstract not submitted.
20 September 2012: 09:00 e 10:30 Symposium: Breast cancer e Tailoring mastectomy 66. Tailoring breast cancer reconstruction Abstract not submitted.
67. Radiation therapy and breast reconstruction P. Poortmans1 1 Institute Verbeeten, Radiation Therapy, Tilburg, The Netherlands
751
restrictions were accepted then less than 10% of patients with liver only disease would come to hepatectomy. As a result, barely 3% of all patients with stage 4 disease were alive 5 years after diagnosis. The current definition of resectability is metastatic disease in the liver (even in the presence of resectable extra-hepatic disease) which can be resected while preserving 25-30% of viable disease free liver with a vascular inflow and vasculo-biliary outflow. As such, more than 20% of these patients are now considered resectable at presentation. The only barrier to such surgery is now anaesthetic fitness to undergo the liver surgery (2). Furthermore, more patients can now be brought physically to liver resection by using a number of techniques including:
Portal vein embolisation to increase the size of the future remnant liver Two stage hepatectomy Combination of surgery with ablation (3) Employing techniques from liver transplantation
As such, a further 10% of patients become surgical candidates without recourse to the use of induction chemotherapy. It has been clear for some time that there are patients with liver-limited but unresectable disease who can be converted to resectability following
induction chemotherapy, either on intention to treat or following a dramatic response, even when thought initially not feasible (the ‘accidental’ hepatectomy). Combining cytotoxic chemotherapy with biologics (especially the EGF-receptor antibody cetuximab in patients whose tumours are kras wild-type) might now bring up to 40% of patients with unresectable liver-limited disease to liver surgery with potentially curative intent (4). Using chemotherapy and biologics to bring patients to such surgery must only be employed within the setting of a highly specialised hepatobiliary multi-disciplinary team (5). Injudicious and excessive use of these agents leads to liver parenchymal damage, so causing increased morbidity and mortality after liver surgery, and also runs the risk of making the lesions morphologically disappear, so becoming undetectable at surgery, while remaining pathologically viable. 1. 2. 3. 4. 5.
Morris E et al. Brit J Surgery 2010; 97: 1110-8 Adam R et al. Brit J Surg 2010; 97: 366-376 Ruers T et al. Ann Oncol 2012 in press Folprecht G et al. Lancet Oncology 2010; 1: 38-47 National Institute of Health and Clinical Excellence. Technology Appraisal 176, August 2009
20 September 2012: 09:00 e 10:30 Symposium: How I do: Intraoperative decision-making and problem-solving in surgical oncology 63. Gastric cancer surgery: The unexpected positive oesophageal margin/direct invasion into colon or pancreas M. Pera1 1 Hospital Universitario del Mar, Section of Gastrointestinal Surgery, Barcelona, Spain UGI surgeons must be aware before the operation of those gastric cancer patients with a greater risk of having positive oesophageal margins after total gastrectomy. It has been shown that patients with larger tumour size, deeper wall penetration, more extensive gastric involvement, greater nodal involvement, higher stage and diffuse histology belong to this group at risk. In those cases, and once the pathologist confirms intraoperatively the oesophageal margin involvement, the surgeon should balance the potential benefit of achieving a negative margin against the risks of performing a more extensive resection. Physiological status of the patient and the stage of the disease, especially the extension of lymph node involvement, should be taken into account in these circumstances. Several studies have confirmed that a positive margin is associated with a worse outcome in patients with node-negative disease or early stages. All efforts should therefore be made to clear the oesophageal margin in these patients. In patients with more advance disease and extensive lymph node involvement, a more conservative approach should be taken. The value of extended organ resection for advanced gastric cancer has been debated for many years. Different studies have shown that additional organ resection is associated with an increase in morbidity and mortality. However, long-term survival following this kind of extended resection is possible. In these cases, similar to what happen with the issue of positive oesophageal margins, depth of invasion
and the extent of lymph node metastasis will finally have the most determinant impact on survival after additional organ resection and a R0 resection. 64. Hepatic cancer surgery: Surgical decision-making regarding the future liver remnant S. Lopez-Ben1, M.T. Albiol Quer1, A. Codina Barreras1, L. Falgueras Verdaguer1, E. Castro Gutierrez1, J. Figueras Felip1 1 Hospital Dr Josep Trueta, Seccion de Cirugıa Hepatobiliar y Pancreatica, Girona, Spain In the last years resectability criteria has been changing in liver neoplasm from data based on what has to be removed (namely, size and number of lesions, wide surgical margin, time from diagnosis,..) towards features of what we plan to be preserved. This is more true when we speak about colorectal liver metastases where the unique criteria of unresectability is the impossibility to preserve enough functioning liver after the surgical resection of the lesions. This pursuit of the "as large as possible" liver remnant is nowadays our main goal in liver surgical oncology and the different surgical options will be discussed, focusing in portal occlusion techniques, pharmacological adjuvant strategies and the different modalities of two-stage hepatectomies. 65. Pancreatic cancer surgery: The unexpected venous or arterial involvement Abstract not submitted.
20 September 2012: 09:00 e 10:30 Symposium: Breast cancer e Tailoring mastectomy 66. Tailoring breast cancer reconstruction Abstract not submitted.
67. Radiation therapy and breast reconstruction P. Poortmans1 1 Institute Verbeeten, Radiation Therapy, Tilburg, The Netherlands