the Harwood Academic Publishers imprint, part of The Gordon and Breach Publishing Group. Printed in Malaysia. Clinical Series Liver Resections for Metastases from Intraabdominal

This paper discusses liver resection for intraabdominal leiomyosarcoma metastases as a therapy for carefully selected patients. Of the 83 hepatectomies performed from 1992 to 1996, five were resections for liver metastases due to intraabdominal leiomyosarcoma, in 3 patients. The surgical indication was single liver metastases, without any evidence of extrahepatic disease. No mortality occurred during surgery and the longest survival was 38 months. We concluded that liver resection for leiomyosarcoma metastases can be performed, allowing a long term survival in an occasional patient.

This paper discusses liver resection for intraabdominal leiomyosarcoma metastases as a therapy for carefully selected patients. Of the 83 hepatectomies performed from 1992 to 1996, five were resections for liver metastases due to intraabdominal leiomyosarcoma, in 3 patients. The surgical indication was single liver metastases, without any evidence of extrahepatic disease. No mortality occurred during surgery and the longest survival was 38 months. We concluded that liver resection for leiomyosarcoma metastases can be performed, allowing a long term survival in an occasional patient.
Keywords: Leiomiosarcoma, liver metastases, liver resection, non-colorectal liver metastases Metastatic dissemination occurs by haematogenous spread, mainly to the lungs and liver, and only occasionally to regional lymph nodes [2]. Liver metastases are usually observed in the reccurrence of visceral and retroperitoneal sarcomas they are often multiple and bilobar [3,4].

INTRODUCTION
Leiomyosarcomas are malignant tumors of smooth muscles, occurring most commonly in the uterus, retroperitoneal.region and extremities. These lesions correspond to 7% of the soft tissue tumors, most often affecting adult, female patients [1].

PATIENTS AND METHODS
During the period from 1992 to 1997, 83  for metastases due to leiomyosarcoma, performed in three patients. This group consisted of two men and one woman whose ages ranged from 41 to 56 (mean, 46.6), all of them caucasian.
The site of the primary tumor, the time of diagnosis of liver metastases and their location are summarized in Table I.
All the patients were submitted to a preoperative assessment which consisted of routine lab tests, liver function tests and imaging (ultrasonography-US and computed tomography-CT).
Liver resection was indicated for a single metastasis from leiomyosarcoma, without any evidence of disease at another site.
Hepatectomy was performed by a bilateral subcostal incision, with afferent vascular exclusion in four resections and selective clamping in one hepatectomy (patient 3, the first resection). Subhepatic silicone drains were used in all patients. One patient required chest drainage (patient 3).
Surgical mortality was defined by death up to the 30th day post-surgery. Time of survival was computed in months (from date of liver resection up to the latest visit). Reccurrence was defined by abnormalities in computed tomography, ultrasonography, biopsy or bone radionuclide scanning. Post-resection survival and evolution of liver metastases due to leiomyosarcoma 1-Patient alive, without reccurrence at present, after re-hepatectomy at 25months due to hepatic reccurrence; 2-Died. Extra-hepatic reccurrence at 4 months post-hepatectomy; 3-Died. Submited to re-hepatectomy at 12months due to hepatic reccurrence and, at 24 months, presented new hepatic reccurrence.
is alive and asyrnptomatic, having adjuvant chemotherapy after the second resection, with a survival of 37 months.
Left lobectomy was performed in patient 2, who was submitted to radiation therapy and chemotherapy five months after liver resection, due to bone metastasis.
Bi-segrnentectorny was performed in patient 3. He survived for 38 months with reccurrence in the liver after the second operation.
No mortality occurred in surgery, and the transfusion of blood products required ranged from 0 to 1000 ml (mean, 250 rnl).
The presence or absence of reccurrence after liver resection, the course and survival of patients are illustrated in Figure [3]. Leiomyosarcomas constitute 7% of the histological types, often affecting the uterus, stomach and small bowel. The most undifferentiated tumors, with the worst prognosis, are found in the retroperitoneal sites [1,3].
Recent studies indicate the liver as a preferential site for metastases from visceral and retroperitoneal leiomyosarcomas [3,4,14]. Most of these metastases are multiple and bilobar [12], and 50% of the patients who developed them did so in the first year after diagnosis. This is the period during which one must carefully assess the liver of patients with intra-abdominal leiomyosarcoma [3,4]. Once the diagnosis of liver metastases has been established, the type and histological grade, as well as disease-free time after resection of the primary tumor do not appear to influence patient survival [3].
Chemotherapy, systemic or intra-arterial, does not have a substantial impact on the treatment of liver metastases from soft tissue sarcomas [3,4,15]. However, Mavligit et al. [4] report their experience with 14 patients who had gastrointestinal leiomyosarcoma, treated by hepatic chemoembolization, using a mixture of polyvinyl alcohol with cisplatinum powder (150mg), followed by intrahepatic arterial infusion of vinblastin (10mg/m2). In this series, all the patients had unresectable liver metastases; however, one patient had a dramatic regression of the tumor, which enabled its resection.
Based on these findings, we operated on 3 patients with liver metastases from leiomyosarcoma, and obtained a survival ranging from 24 to 38months. Two patients presented with re-ccurrence of the disease in the liver, and both of them were operated on again, corroborating the data from the literature which reports a high rate of reccurrence of this type of tumor in the liver [3,6,13]. The worst prognosis, was in the case of the patient with a metastasis of non-digestive origin, who presented with an extrahepatic reccurrence less than 6 months after hepatectomy.
Thus, we concluded that the resection of liver metastases due to leiomyosarcoma could be performed, allowing a long-term survival in an occasional patient. Invited commentary to: Kalil AN, de Lourdes Pereira B, Brenner MCL, Pereira-Lima L. Liver resections for metastases from intraabdominal leiomyosarcoma. HPB Surgery resection of metastatic intra-abdominal leiomyosarcoma. A few other authors have reported similar findings with an occasional 5-year survivor, although none of 10 patients with liver metastases from visceral leiomyosarcoma survived for 5 years in the largest single series [1]. It should be emphasized that spread to the liver is the main factor determining survival for visceral sarcomas but not for sarcomas originating at other locations, with the exception of retroperitoneal sarcomas that spread as often to the liver as to the lungs [1]. The pattern of spread, and the likelihood of having metastases only in the liver, is of course influenced by the portal venous drainage of gastrointestinal organs.
Definite indications do not exist, but it would appear that a patient with isolated and resectable hepatic metastases from gastrointestinal leiomyosarcoma should undergo resection [2]. A prerequisite is that the resection can be undertaken with low morbidity and low mortality (well under 5%). Considering the relative inefficiency of chemotherapy for leiomyosarcoma, it is also important to be able to ensure clear resection margins. The difficulty to be confident about indications and prognostic factors is true for hepatic resection of all other non-colorectal secondaries and should, hopefully, lead to an international registry for patients undergoing liver resection for non-colorectal secondaries.

INVITED COMMENTARY
The incidence of isolated hepatic metastases from cancers of the colon or rectum is frequent enough to justify hepatic resection in selected patients. For other malignancies metastases to the liver only is quite a rare phenomen, which explains why the literature contains relatively few and almost anecdotal reports of long-term survival following hepatic resection of metastases from non-colorectal malignancies, such as intra-abdominal leiomycoscarcoma.
The present study has shown that long-term survival (at least for 3 years) is possible following