Minimally Invasive Liver Resection and Ablation For Malignancy

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Mills-Peninsula Health Services Cancer Symposium - Kimberly Moore Dalal, MD, FACS
Medical Director, Surgical Oncology Peninsula Medical Clinic Burlingame, CA

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  • Hepatobiliary cancers are highly lethal cancers.4 million Americans with Hepatitis C1.5 million Americans with Hepatitis B
  • Hepatobiliary cancers are highly lethal cancers.4 million Americans with Hepatitis C1.5 million Americans with Hepatitis B
  • Minimally Invasive Liver Resection and Ablation For Malignancy

    1. 1. Minimally Invasive Liver Resection and Ablation For Malignancy Advances in Oncology Dorothy E. Schneider Cancer Center Mills-Peninsula Health Services March 16, 2013 Kimberly Moore Dalal, MD, FACS Medical Director, Surgical Oncology Peninsula Medical Clinic Burlingame, CA
    2. 2. Liver cancer Historical Perspective “…the liver is so friable, so full of gaping vessels and so evidently incapable of being sutured that it seems impossible to successfully manage large wounds of its substance.” JW Elliot 1897
    3. 3. Liver cancer Historical Perspective “…20% of patients died in the operating room because of exsanguinating hemorrhage… Another 14% died post-operatively as a direct consequence of enormous blood loss during operation…15% died of liver failure caused by technical factors other than hemostasis, including 3 bile duct injuries…” Foster JH, Berman MM. Major Problems in Clinical Surgery 1977;1-342.
    4. 4. Liver cancer OR Team, Bagram, Afghanistan 2007
    5. 5. Liver cancer Liver Resection Today Author N Operative Mortality (%) Scheele „91 219 6 Rosen „92 280 4 Gayowski ‟94 204 0 Scheele „95 469 4 Normal livers Nordlinger ‟95 568 2 Jamison, „97 280 4 Fong ‟99 1001 3
    6. 6. Liver cancer Outline Laparoscopic liver resections for benign and malignant tumors – Benign lesions – Hepatocellular carcinoma – Colorectal cancer metastases Ablation for patients who are not operative candidates
    7. 7. Liver cancer Anatomy
    8. 8. Liver cancer Benign Hepatic Lesions Tumor Malignant Potential Spontaneous Hemorrhage Focal nodular hyperplasia No No Hemangioma No Rare Cystadenoma Yes No Adenoma Yes Yes
    9. 9. Liver cancer Case 1: Cystic Lesion of the Liver 51 year old woman 3.5 cm Liver Cyst, Seg 4, first noted on chest CT in 2001 Presented with 3 days RUQ pain RUQ ultrasound (2/07): complex cystic structure of the liver with layering Triple phase liver CT (2/07): Cystic lesion, Seg 4, 6x8x6 cm; Hounsfield units 6 (noncontrast), 11 (iv contrast)
    10. 10. Liver cancer Ultrasound Complex cystic structure of liver with layering
    11. 11. Liver cancer Triple phase liver CT: Cystic lesion, Seg 4, 6x8x6 cm
    12. 12. Liver cancer Case 2: Hepatic Adenoma 43 yo F with an incidentally discovered right liver mass detected on chest CT for workup of cough. AFP and CEA normal. LFTs normal. CT and MRI – 4.2x2.1x2.0 cm mass, Seg 7, consistent with a hepatic adenoma.
    13. 13. Liver cancer Triple phase liver CT: Seg 7, 4x2x2 cm
    14. 14. Liver cancer Traditional Open “Chevron” Incision
    15. 15. Liver cancer Exposure in an Open Resection
    16. 16. Liver cancer Laparoscopic Port Placement for Right Liver Lesions Cho JY, et al., Arch Surg 2009; 144(1):25-29.
    17. 17. Liver cancer Laparoscopic View of the Liver Machado MA, et al., Surg Endosc, 2009; 23:2615-2619.
    18. 18. Liver cancer Case 2: Hepatic Adenoma, Segment 7 Laparoscopic Resection…9 Months Later
    19. 19. Liver cancer Laparoscopic Liver Surgery Established Diagnosis/Staging Fenestration of Simple Cysts Evolving Minor resections (≤ 2 segments) for tumor Major hepatic resections Tumor ablation
    20. 20. Liver cancer Laparoscopic Liver Resection Theoretical Advantages and Disadvantages Advantages: Disadvantages: Less post-operative pain Loss of tactile sense Margins Less post-operative Staging morbidity Limited access/ Shorter hospital stay instrumentation Improved cosmesis Exposure Control of major Quicker return to normal pedicles/hepatic veins activity Time and money Quicker initiation of adjuvant therapies
    21. 21. Liver cancer Laparoscopic Liver Resection Solutions Loss of tactile sense Margins Staging Laparoscopic Hand-assisted Ultrasound techniques
    22. 22. Liver cancer Laparoscopic Liver Resection Solutions • Hand-assisted techniques Limited access/instrumentation • Ligaments intact Exposure • Improved Control of major pedicles/hepatic veins retractors Fear of major hemorrhage Harmonic Vascular Ligasure Scalpel Stapler Device Tissuelink Argon Beam Coagulator Water Jet
    23. 23. Liver cancer Laparoscopic Hepatectomy MSKCC Results (n=44) •Segmental resection: 27 pts (61%) •1 segment: 17 pts (38%) •>1 segment: 10 pts 2 (22%) •Left lateral: 6 pts 5 8 7 (13%) 3 D‟Angelica, MD, et al., AHPBA 2006
    24. 24. Liver cancer Laparoscopic Hepatectomy MSKCC Results (n=44) Benign 21 pts (47%) Malignant 23 pts (53%) 23 pts: Negative margins (100%). No local recurrence. 1 tumor 36 pts (81%) > 1 tumor 8 pts (18%) D‟Angelica, MD, et al., AHPBA 2006
    25. 25. Liver cancer Laparoscopic Hepatectomy MSKCC Results: Comparison to Open Operative Outcome LLR OLR (n=44) (n=91) p OR time (minutes) 199 161 0.01 Pringle time (minutes) 31 22 0.04 Pringle 45% 75% <0.01 EBL (ml) 161 521 <0.01 Transfusion 2.2% 26% <0.01 D‟Angelica, MD, et al., AHPBA 2006
    26. 26. Liver cancer Laparoscopic Hepatectomy MSKCC Results: Comparison to Open Post-operative Outcome LLR OLR (n=44) (n=91) p Length of stay (days) 5.1 6.7 <0.01 Morbidity 13% 28% 0.08 Regular diet (days) 3 3 0.7 Oral analgaesia (days) 3.1 3.5 0.1 Mortality 0% 0% 0 D‟Angelica, MD, et al., AHPBA 2006
    27. 27. Liver cancer Outline Laparoscopic liver resections for benign and malignant tumors – Benign lesions – Hepatocellular carcinoma – Colorectal cancer metastases Ablation for patients who are not operative candidates
    28. 28. Liver cancer Epidemiology of Hepatobiliary Cancer Estimated U.S. incidence in 2013: 21,670 deaths in men and women 30,640 cases/year1 Annual incidence of HCC with Hepatitis C cirrhosis is 2-8%, Hepatitis B cirrhosis 2.5%. Siegel R, et al., CA Cancer J Clin, 2013; 63:11-30.
    29. 29. Liver cancer Diagnosis and Workup for HCC Often asymptomatic. Nonspecific symptoms: anorexia, weight loss, malaise, upper abdominal pain. Paraneoplastic syndromes: hypercholesterolemia, erythrocyto sis, hypercalcemia, hypoglycemia . Physical signs: jaundice, ascites AFP>200 ng/mL + liver mass =HCC Zhang BH et al., J Cancer Res Clin Oncol. 2004; 130:417-422.
    30. 30. Liver cancer Child-Pugh Class A Patients are Candidates for Resection 1 2 3 Encephalopathy None 1-2 3-4 Ascites None Slight Moderate Albumin (g/dL) >3.5 2.8-3.5 <2.8 Prothrombin time (sec) 1-4 4-6 >6 Bilirubin (mg/dL) 1-2 2-3 >3 Class A = 5-6 points Good operative risk Class B = 7-9 points Moderate operative risk Class C = 10-15 points Poor operative risk
    31. 31. Liver cancer Case 3: Hepatocellular Carcinoma 74 yo M with Hepatitis C x 30 years from a blood transfusion, treated with interferon for one year Developed pneumonia and asked PCP to investigate for cirrhosis. AFP: 4690. Abd US: 3.4 x 2.4 x 3.1 cm mass, left lateral segment of liver. Triple phase Liver CT: 3.5 x 2.5 cm mass, segment 3. (CT of abdomen and pelvis 3 months earlier negative).
    32. 32. Liver cancer Triphasic Liver CT: Segment III 3.5 cm mass
    33. 33. Liver cancer Principles of Surgery for HCC Mortality <5% Careful patient selection: Five-year survival rates > 50% – Comorbidities – 70% in patients with early – Tumor characteristics stage HCC and preserved – Size and function of future liver function. liver remnant Recurrence at 5 yrs>75% Liver transplantation for patients meeting UNOS criteria – Single lesion < 5cm – 2 or 3 lesions < 3 cm
    34. 34. Liver cancer Case 3: Hepatocellular Carcinoma Laparoscopic resection of segment III Length of stay 5 days Bone metastasis @ 7 mos
    35. 35. Liver cancer Outline Laparoscopic liver resections for benign and malignant tumors – Benign lesions – Hepatocellular carcinoma – Colorectal cancer metastases Ablation for patients who are not operative candidates
    36. 36. Liver cancer Epidemiology of Colorectal Cancer Estimated U.S. incidence of colorectal cancer: 142,820/year1 51,370 deaths 50% of patients will be diagnosed with liver metastases Liver resection->long-term survival – 5 year survival: 25-58% – Surgical techniques – Chemotherapy – Unresectable->resectable 1Siegel R, et al., CA Cancer J Clin, 2013; 63:11-30. 2 http://www.hopkinsmedicine.org.
    37. 37. Liver cancer Determinants of Outcome for CRC Liver Metastases: Fong Score• Extrahepatic disease• Positive margins• Node (+) colorectal primary• Disease-free interval < 1 year• More than 1 hepatic tumor• Largest hepatic tumor > 5 cm• CEA > 200 ng/mL Fong et al Ann Surg 1999;230:309 Fong Y, et al., Ann Surg. 1999 Sep;230(3):309-318.
    38. 38. Liver cancer Preoperative Portal Vein Embolization Can Increase the Future Liver Remnant Percent Resection PVE – FLR/TLV 0.20 (20%)1 >40% for cirrhotics, Child‟s A 1Chun YS, et al., J Gastrointest Surg. 2008 Jan;12(1):123-8.
    39. 39. Liver cancer Case 4: 61 year old Woman, Synchronous Colon Cancer Metastases to Liver Open sigmoid colectomy for obstructive sigmoid colon cancer 9/11 CEA 600 CT: bilateral metastases Xelox->cetuximab and xeloda
    40. 40. Liver cancer Case 4: Tremendous Response to Chemotherapy Sept 2011, CEA 600 Mar 2013, CEA 16 (up from 6)
    41. 41. Liver cancer Laparoscopic Resection of Two Colon Cancer Metastases to Liver Cirrhotic liver and gallbladder Adhesion to recurrent tumor Intraoperative ultrasound Post-ablation
    42. 42. Liver cancer >1 cm Margins are Preferred, but > 1 mm Margins are Favorable • Multivariate analysis (n=1019) • > 1 tumor • Size > 5 cm • Node positive primary • Bilateral resection • Margins Margin N (%) Median survival (mo) P Involved/<1mm 112 (11) 30 mos Ref 1 – 10 mm 563 (55) 42 mos <0.01 > 10 mm 344 (33) 55 mos <0.01 Are C, et al., Ann Surg. 2007 Aug;246(2):295-300.
    43. 43. Liver cancer Outline Laparoscopic liver resections for benign and malignant tumors – Benign lesions – Hepatocellular carcinoma – Colorectal cancer metastases Ablation for patients who are not operative candidates – Tumor size and function – Liver function – Comorbidities
    44. 44. Liver cancer Radiofrequency Ablation High-frequency alternating current flows from electrical probe through tissue to ground – Ionic agitation results in frictional heating and coagulation of surrounding tissue Probe Extension RF current insertion of prongs application
    45. 45. Liver cancer Radiofrequency Ablation Advantages Disadvantages – Performed – Poor performance percutaneously, near blood vessels laparoscopically, or at – One probe laparotomy Many tumors require – Low complication rate multiple, overlapping May be related to size ablations of ablation (<3 cm) – Slow
    46. 46. Liver cancer Microwave Ablation Theoretical advantages over RFA – Larger zone of active heating Possibly better performance near blood vessels – Hotter temperature – Use of multiple probes Lubner M, et al.,J Vasc Interv Radiol. 2010 Aug;21(8Suppl):S192-S203.
    47. 47. Liver cancer Case 5: Segment IV B 2.6 cm mass, Cirrhosis 77 year old woman Child‟s Pugh Class A cirrhosis due to autoimmune hepatitis AFP: 23 CT: 2.6x2.6 cm heterogeneously enhancing nodule segment IVB of liver FNA: HCC
    48. 48. Liver cancer Microwave Ablation Preop; AFP 23 1 month postop; AFP 7 10 months postop 1 months postop repeat AFP 24 AFP 6
    49. 49. Liver cancer Microwave Ablation Cirrhotic liver and gallbladder Adhesion to recurrent tumor Intraoperative ultrasound Post-ablation
    50. 50. Liver cancer Summary Laparoscopic liver resections are safe and oncologically sound in highly selected patients in the hands of surgeons with a laparoscopic skill set. Patients with malignant liver tumors can be considered for resection based on tumor characteristics, future liver remnant size and function, and patient comorbidities. Radiofrequency and microwave ablations are alternative ways to treat small liver tumors which are not amenable to resection.
    51. 51. Liver cancer Mills-Peninsula Multidisciplinary Gastrointestinal Tumor Board Second Tuesday of each month, Peninsula Hospital 12:30 pm-1:30 pm, CME + lunch Tailored approach to treatment plan Team: – Surgical oncologists, Interventional radiologists, Gastroenterologists – Medical oncologists, Radiation oncologist, Pathologist – GI nurse navigator, Clinical trials nurse, Physician liaison – YOU! We can provide state-of-the-art, cutting-edge care to our patients in their own backyard with a personalized touch!

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