Surgical Treatment of Liver Metastases from Gastric Cancer

Gastric cancer is the fourth most common type of tumour, and the second cause of cancer-related death worldwide.

The incidence of gastric cancer liver metastases (GCLM) during the course of the disease varies between 30% and 50%. In particular, metachronous GCLM after curative gastrectomy are detected in up to 25% to 30% of patients, 80% of which appear within the first two post-operative years.

Surgical Treatment of Liver metastases from Gastric Cancer 

Surgical treatment of GCLM is currently reason of great debate. Hepatectomy is performed in only 0.4% to 1% of GCLM, because most GCLM are multiple, bilateral, and combined with peritoneal or lymph node metastases. Resection was initially indicated in patients with synchronous metastases who had no peritoneal dissemination or other distant metastases and in patients with metachronous metastases without any other detectable lesion, only if a complete resection of the metastases could be achieved without compromising liver function. Recent meta-analysis agrees that the best survival rates are associated with surgical treatment, which should be chosen whenever possible. In addition, the overall 5-year survival rate of metastatic gastric cancer ranges between 0% and 10%, whereas it rises up to 20% after hepatectomy. In Singapore, surgery for GCLM is not widely practiced – the following is an account of our first could be offered liver surgery. The availability of metabolic imaging (e.g. FDG-PET) now permits for the selection of a more appropriate treatment modality, by detecting distant metastases. Mr A’s PET scan was clean – except for the solitary liver lesion (Image 2). Taking into account local procedures for hepatic metastases, general consensus on management of GCLM includes adjuvant chemotherapy, molecular targeted therapy, or palliative supportive care. In metastatic disease, surgery offers an additional option of cure. In summary, despite the possible presence of a selection bias, recent studies still show improved survival for GCLM. Multidisciplinary discussion, patient selection, absence of additional secondary tumours or extra-hepatic metastases is essential components prior to offering surgery for GCLM. An individual clinician is obliged to remain open-minded about possible options in patients with GCLM, and each patient must be provided with information on advances in oncology to aid in making an informed decision, which is paramount to personalised cancer care. patient who underwent liver resection for GCLM.

Mr A is a 71-year-old gentleman with a history of hepatitis B infection and gastric cancer. He underwent total gastrectomy in July 2014 and is on regular follow-up since then. His scan in January 2016 showed a liver lesion and this was adjudged to be GCLM or a primary liver cancer (Image 1). Liver biopsy showed adenocarcinoma and was not able to differentiate between primary liver cancer versus GCLM. A PET scan was arranged and this showed a solitary lesion in the liver. A multidisciplinary tumour board meeting agreed that we could offer surgery for GCLM, if the patient is a fit candidate and if the surgeon deems that liver surgery would be a safe procedure. There was a possibility that this was a primary liver cancer and in such an instance, surgery was recommended. Patient was made aware of all this and he agreed to surgery. He underwent liver resection and his hospital stay was uncomplicated. He was discharged on the fifth post-operative day. His final histology report is similar to previous gastric cancer. His is a case of GCLM that underwent liver resection after being disease-free for 18 months. Mr A remains well after 4 months’ follow-up.

A parallel can be drawn is that fit and young patients with a small number of GCLM, and without extra-hepatic disease could be offered liver surgery. The availability of metabolic imaging (e.g. FDG-PET) now permits for the selection of a more appropriate treatment modality, by detecting distant metastases. Mr A’s PET scan was clean – except for the solitary liver lesion (Image 2). Taking into account local procedures for hepatic metastases, general consensus on management of GCLM includes adjuvant chemotherapy, molecular targeted therapy, or palliative supportive care. In metastatic disease, surgery offers an additional option of cure.

In summary, despite the possible presence of a selection bias, recent studies still show improved survival for GCLM. Multidisciplinary discussion, patient selection, absence of additional secondary tumours or extra-hepatic metastases is essential components prior to offering surgery for GCLM. An individual clinician is obliged to remain open-minded about possible options in patients with GCLM, and each patient must be provided with information on advances in oncology to aid in making an informed decision, which is paramount to personalised cancer care.

By Adjunct Assistant Professor Vishalkumar G Shelat, Consultant, Hepato-Pancreato-Biliary Surgery Service, Department of General Surgery, Tan Tock Seng Hospital