A MULTIMODALITY APPROACH FOR LIVER OLIGOMETASTATIC PATIENTS FROM PRIMARY ESOPHAGEAL CANCER: A SYSTEMATIC REVIEW OF THE LITERATURE.
Damiano Gentile*1, Salvatore Marano1, Fabio Procopio2, Pietro Riva1, Silvia Basato1, Anna Da Roit1, Guido Torzilli2, Carlo Castoro1
1Department of Upper Gastro-Intestinal Surgery, Humanitas Research Hospital, Rozzano, Milano, Italy; 2Department of Hepatobiliary and General Surgery, Humanitas Research Hospital, Rozzano, Milan, Italy
Background: Esophageal cancer (EC) is still considered an aggressive disease associated with a poor prognosis due to its early metastatic spread at the time of diagnosis. Surgery represents the only curative treatment for EC, however stage IVB EC has not been treated with curative intent until now. The multimodality approach, consisting of neo-adjuvant therapy associated with surgery, has been established as an effective treatment for locally advanced EC, with a 3-year survival rate of 34.6%.In literature, oligometastatic disease has been defined as a concentration of metastatic spread to a specific organ, however details on the number of lesions in a single organ have not been defined so far.The primary aim of this study was to evaluate the long-term survival of liver oligometastatic patients from primary EC who underwent multimodality therapy and compare their oncological outcomes with patients who underwent palliative treatment alone.
Methods: A comprehensive systematic literature search was conducted using PubMed, EMBASE, Scopus and the Cochrane Library CENTRAL to identify relevant articles published from January 1998 to September 2018 evaluating diverse treatment strategies and comparing overall survival (OS) of liver oligometastatic patients from primary EC.No restriction was set for type of publication.Article language was limited to English.
Results: A total of 17 studies were analyzed, involving 1704 oligometastatic (liver, lymph nodes, lung) patients from primary EC. For further analysis, exclusively patients with liver metastases from esophageal or gastro-esophageal junction cancer (n=265) were taken into consideration. 110 patients (41.5% of the total) underwent palliative chemotherapy. 155 patients (58.5% of the total) underwent multimodality approach including hepatic resection. The surgical group was divided into metachronous (n=40) and synchronous (n=115) patients. 86 patients with synchronous disease underwent neo-adjuvant therapy before esophageal and hepatic resection. Mean interval between esophageal resection and diagnosis of liver metastases was 10.6 months (6-72 months). At a mean follow-up of 30.4 months (6-76) the OS of liver oligometastatic patients who underwent multimodality approach including liver resection was significantly better than liver oligometastatic patients treated with palliative chemotherapy alone: 31.3 months versus 15.9 months (p-value = .004).
Conclusion: A multimodality approach including neo-adjuvant therapy and liver resection could be proposed to highly selected liver oligometastatic patients who could have acceptable oncological outcomes with potentially long-term OS as an alternative to palliative chemotherapy only. Further, prospective, randomized, controlled trials performed in high volume centers are necessary to define surgical criteria for liver oligometastatic patients and confirm these results.
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