Surgery in synchronous oligometastatic disease
Prof Peter Naredi - University of Gothenburg, Gothenburg, Sweden
This issue of surgery in synchronous oligometastatic disease, so you’ve got maybe primaries and metastases that you could operate on simultaneously, what is the big issue about this?
It shows off the multidisciplinarity that we are talking about at this conference because 20-30 years ago it was rather rare that patients were referred for surgery of metastatic disease. We have always said if it’s only liver metastases from colorectal cancer there’s a 30-40% chance of a long term five year survival and referrals have really improved. What has happened now is that we have got much more efficient systemic treatments like chemotherapy and biological drugs and we can today shrink the tumours, especially in the liver, in 75-80% of cases. We know that now from our national population based registers in Sweden. So the numbers you reach in clinical trials, we can actually reach them in the clinic.
Now liver metastases is one organ that you can look for mets and successfully operate on but what about other sites?
Lung has also become more common that you operate on. I would say it’s more rare that you have a disease where you have only lung metastases, it’s more often that you have both lung and liver metastases. But we don’t exclude a patient anymore. So oligometastatic means that you have a few metastases, so if you have two metastases in the liver and if you would have one in the lung we’d consider curative treatment as an option.
In fact, clinicians have talked about cure when they’re referring to surgery for metastatic disease. Is that a reality?
Yes it is. We are now getting the five year survival data from, again, the Swedish national liver register. So, looking at 2,000 cases that have been liver resected, which means liver resected and maybe something else also, we know we cover all patients operated, having done surgery in Sweden. We have a 50% five year survival, not the 20-30, we have a 50% five year survival and that is with the principle we have used chemotherapy to downsize, to shrink, the tumours and then do curative treatment. And it works in half of the cases.
Now this is why you stress the multidisciplinary team. How exactly should the team be working?
The most important thing is that every patient who has oligometastatic disease, and even those who have it in a very advanced stage, should be referred to a MDT board, this multidisciplinary board, where you have the expertise from the surgeons, it could be a colorectal surgeon, a liver surgeon, from the medical oncologist, the radiologist, very often a pathologist and the co-ordinating nurses. Then we also always want the doctor responsible for the treatment of the patient so we can discuss what is the view of the patient, the quality of life today and their performance. So this is the group and then the students, the residents, all those who have a fantastic learning experience by running an MDT.
So effectively chemotherapy and radiotherapy could be neoadjuvant treatment, so to speak, and then the surgeon comes in to deliver the final blow to the tumour?
Today I would say you’re almost right because definitely that’s the role of chemotherapy and biological drugs. But it’s fascinating because radiotherapy is now coming in as a surgical tool. You know we’ve been treating single metastases in the brain with what we call the surgical knife and this is now also becoming a reality for lung metastases and for liver metastases. So the first option, in my view, is surgery but sometimes it’s instead an ablative technique, heat with microwaves or radiofrequency, or radiotherapy. So let’s move radiotherapy into the curative part.
So what, then, is the brief summary, the take-home message for cancer doctors coming out of all of this?
If a patient has oligometastatic disease, metastasis in the liver or lung, refer them to an MDT, a multidisciplinary decision board, so that we can decide whether we should go for multidisciplinary treatment or not.
Thank you very much.