Surgical treatment of hepatocellular carcinoma.(Dr Juan Carlos Meneu Diaz). Oncocir. Clinica Ruber

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Hepatocellular cancer …

Hepatocellular cancer
Resection
Hepatobiliary Unit

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  • 1. University Hospital 12 de Octubre, Madrid, Spain • Capital City Madrid (pop. 4,512,500) (2006 est.) .The Madrid metro area now exceeds 5.9 million ~1200 beds ~1.000.000 population Juan Carlos Meneu-Diaz MD PhD Chief Hepatobiliary Unit and Transplantation Surgical treatment of hepatocellular carcinoma. Partial liver resection vs liver transplantation.
  • 2. University Hospital 12 de Octubre, Madrid, Spain
  • 3. University Hospital 12 de Octubre, Madrid, Spain
  • 4. LIVER TRANSPLANTATION ACTIVITY (1986-2007) 0 10 20 30 40 50 60 70 80 90 100 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 University Hospital 12 de Octubre, Madrid, Spain N=1394
  • 5. University Hospital 12 de Octubre, Madrid, Spain
  • 6. Surgical treatment of hepatocellular carcinoma. Partial liver resection vs liver transplantation. Juan Carlos Menéu-Diaz MD PhD Baltasar Perez Saborido MD PhD Almudena Moreno MD PhD Yiliam Fundora MD PhD Manuel Abradelo MD PhD, Alberto Gimeno MD PhD, Santos Jiménez Galanes Vanesa Barra Hepatobiliary Unit and Transplantation Part of the team
  • 7. Introduction: HCC Worldwide •Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide •More than half a million new cases yearly •In some areas of Asia and the Middle East, HCC ranks as the first cause of death due to cancer •The incidence of HCC is increasing in Europe and the United States, and it is currently the leading cause of death among cirrhotic patients.
  • 8. Major causes of HCC worldwide
  • 9. ParikhS.TheAmericanJournalofMedicine(2007) 120,194-202 Surveilleance for HCC Liver Nodule ?
  • 10. Non-cirrhotic liver  Affordable resection: 80 % of liver volume Functional reserve Hepatic Insufficience Hepatic failure Dead Limited resectionPreneoplastic condition Tumoral recurrence The problem Llovet JM. J Gastroenterol 2005; 40:225–235
  • 11. • Tumor variables • Hepatic function reserve • Tumor involvement • Patient status • Hospital posibilities Better survival Lower morbimortality Lower Recurrence HCC: Management depends on… Compagnon P. Transplantation. 2008 Oct 27;86(8):1068-76
  • 12. HCC: Management options Surgical therapy 1. Partial liver resection 2. Total liver resection and orthotopic liver transplantation Locoregional therapies 1. EPI 2. Acetic acid PI 3. Criotherapy 4. Microwaves 5. Radiofrecuency 6. Chemoembolization 7. Radiotherapy 8. Chemotherapy • Systemic • Transarterial 9. Hormonotherapy 10. Inmunotherapy 11. Genetic therapy Kim DY. World J Gastroenterol 2006 November 21; 12(43): 6992-6997
  • 13. Literature Review
  • 14. Liver transplant and HCC Wong LL. Am J Surg 2002 183:309-16
  • 15. Liver Transplant and HCC • Primary tumor along with… • Cirrhotic liver Reduce tumor recurrence! Waiting time Disease recurrence Inmunosuprresion therapy Tumor progression Tumor recurrence risk Infectous complications New tumors Chapman WC. Ann Surg. 2008 Oct;248(4):617-25.
  • 16. Surgical treatment algorithm
  • 17. HCC: Management options Locoregional therapies 1. EPI 2. Acetic acid PI 3. Criotherapy 4. Microwaves 5. Radiofrecuency 6. Chemoembolization 7. Radiotherapy 8. Chemotherapy • Systemic • Transarterial 9. Hormonotherapy 10. Inmunotherapy 11. Genetic therapy Kim DY. World J Gastroenterol 2006 November 21; 12(43): 6992-6997
  • 18. LRT for HCC. Pathologic response
  • 19. LRT for HCC. Survival benefit
  • 20. LRT for HCC. Survival benefit
  • 21. Liver Transplantation for HCC at The Uniiversity Hospital 12 de Octubre Milan Criteria  LT LDLT /Split liver transplantation/NHBD MELD priority (MELD 22 for stage II) Locoregional treatment TACE RFA Europe EEUU Spain~ 7 months Waiting list drop-outs time Perez B, Meneu-Diaz JC, M Elola A et al. Tumor recurrence after liver transplantation for hepatocellular carcinoma: recurrence pathway and prognostic factors. Transplant Proc. 2007 Sep;39(7):2304-7.
  • 22. Patients and method • Retrospective, case-control study (April´86-December´01)Retrospective, case-control study (April´86-December´01)  Follow-up: 2003Follow-up: 2003  164 HCC patients164 HCC patients Surgically treatedSurgically treated  Two groupsTwo groups:: • Resection GroupResection Group:: 93 pts93 pts  Solitary HCCSolitary HCC  Good functional status (Child A/ICG <15%)Good functional status (Child A/ICG <15%) • OLT GroupOLT Group:: 71 pts (8,3% of total liver trasnplants)71 pts (8,3% of total liver trasnplants)  Child B-CChild B-C  From 1996From 1996  Mazzaferro´s (Milan) criteriaMazzaferro´s (Milan) criteria » Solitary tumor less than 5 cmSolitary tumor less than 5 cm » Less than 3 nodules less than 3 cmLess than 3 nodules less than 3 cm Perez B, Meneu-Diaz JC, M Elola A et al. Liver transplantation for hepatocellular carcinoma: our experience from 1986. Transplant Proc. 2003 Aug;35(5):1825
  • 23. LT Technique  Vena cava preservationVena cava preservation  Arterial anastomosis (GDA-GDA)Arterial anastomosis (GDA-GDA)  End-to-end porto-portal anastomosisEnd-to-end porto-portal anastomosis  Biliary reconstruction: duct-to-ductBiliary reconstruction: duct-to-duct  85.7 % blood operative transfussion85.7 % blood operative transfussion
  • 24. Partial liver resection technique  Minor/Mayor resection: 51.6%/48.4%Minor/Mayor resection: 51.6%/48.4%  Pringle maneuver: 34.4%Pringle maneuver: 34.4%  (mean time: 13.35 minutes)(mean time: 13.35 minutes)  CUSA: 24.7%CUSA: 24.7%  53.8% without transfussion53.8% without transfussion  (Mean transfussion: 894 cc)(Mean transfussion: 894 cc)  Operative US as neededOperative US as needed
  • 25. Follow up  US+AFP level every 3 months first yearUS+AFP level every 3 months first year  every 6 months second yearevery 6 months second year  every yearevery year  Histological confirmation is not neededHistological confirmation is not needed  Mean follow-up time:Mean follow-up time: – PLR: 34.56PLR: 34.56 ± 29 months± 29 months – LT: 44.66 ± 45 monthsLT: 44.66 ± 45 months
  • 26. Preoperative variables Comparative LT/PLR VariableVariable RESECTIONRESECTION TRANSPLANTATIONTRANSPLANTATION pp Male/FemaleMale/Female 78.5%/21.5%78.5%/21.5% 79%/21.1%79%/21.1% nsns Mean ageMean age 59.459.4 ± 13 y± 13 y 5454 ± 8.7 y± 8.7 y 0.0040.004 CirrhosisCirrhosis 82%82% 100%100% nsns VHC cirrhosVHC cirrhos 48.7%48.7% 64.8%64.8% 0.040.04 VHB cirrhosVHB cirrhos 22.4%22.4% 8.5%8.5% 0.020.02 Child A/B-CChild A/B-C 87.1%/87.1%/12.9%12.9% 21.1%/21.1%/78.9%78.9% 0.00010.0001 Okuda I/II-IIIOkuda I/II-III 80.6%/80.6%/19.4%19.4% 19.7%/19.7%/80.3%80.3% 0.00010.0001
  • 27. Pathology Comparative LT/PLR VariableVariable RESECTIONRESECTION TRANSPLANTATIONTRANSPLANTATION pp SolitarySolitary 82.8%82.8% 63.4%63.4% 0.0050.005 < 3 cm< 3 cm 17.2%17.2% 52.1%52.1% 0.00010.0001 Both lobulesBoth lobules 4.3%4.3% 9.9%9.9% nsns MD-PDMD-PD 21.5%21.5% 12.7%12.7% nsns Vascular InvVascular Inv 16.1%16.1% 16.9%16.9% nsns EncapsulatedEncapsulated 23.7%23.7% 64.8%64.8% 0.00010.0001 SattelitosisSattelitosis 16.1%16.1% 11.3%11.3% nsns pTNM IVpTNM IV 6.5%6.5% 22.5%22.5% 0.0030.003 MazzaferroMazzaferro 48.3%48.3% 73.2%73.2% 0.010.01
  • 28. Postoperative course Comparative LT/PLR RESECTIONRESECTION TRANSPLANTATIONTRANSPLANTATION pp HospitalHospital mortalitymortality 6.5%6.5% 11%11% nsns MorbidityMorbidity 60%*60%* 71%#71%# nsns TransfussionTransfussion 46.2%46.2% 85.7%85.7% 0.0010.001 Mean postopMean postop staystay 16.5 days16.5 days 26.4 days26.4 days 0.0090.009 **Surgical complications more frequent # Medical complications more frequent
  • 29. Crude patient Survival Follow-up status PLRLT Count 100 90 80 70 60 50 40 30 20 10 0 STATUS Alive Dead 3754 63 46 p=0.03 p =0.03
  • 30. Actuarial patient survival Kaplan-Meier survival Follo-up time (months) 10896847260483624120 Cumsurvival 1,0 ,8 ,6 ,4 ,2 0,0 p = 0.047 LT PLR 40% p = 0,047 58.9 %
  • 31. Mortality causes Follow-up mortality causes PLRLT Count 100 90 80 70 60 50 40 30 20 10 0 Medical causes New tumors Liver disease Tumoral recurrence 528 14 16 21 78 38 p=0.0001
  • 32. Tumor recurrence Tumoral recurrence incidence PLRLT % 100 90 80 70 60 50 40 30 20 10 0 Recurrence Yes No 6219 38 81 p=0.0001 Liver 0 % Extrahepatic 66,7 % Both 33,3 % 43.4 % first year 75 % first year Liver 78.2 % Extrahepatic 16.4 % Both 5.5 %
  • 33. Disease-free survival Disease-free survival Follow-up without recurrence (months) 96847260483624120 Cumsurvival 1,0 ,8 ,6 ,4 ,2 0,0 p = 0.0006 LT PLR 59,8% 22,4 %
  • 34. ParikhS.TheAmericanJournalofMedicine(2007) 120,194-202 Surveilleance for HCC Liver Nodule ?
  • 35. Needle biopsy and DFS 156.68 ± 23.16 months 48.79 ± 9.28 months
  • 36. Conclusions  LT can achieve better survival rates than PLR in a patientLT can achieve better survival rates than PLR in a patient with liver cirrhosis and HCCwith liver cirrhosis and HCC  Recurrence rate is lower with LT than PLRRecurrence rate is lower with LT than PLR  However in the presence of poor pathological factorsHowever in the presence of poor pathological factors (larger than 5 cm, more than 3 nodules, bilateral, MD-PD,(larger than 5 cm, more than 3 nodules, bilateral, MD-PD, vascular invasion, sattelite nodules or pTNM stage IV) LTvascular invasion, sattelite nodules or pTNM stage IV) LT does not offer a benefit over PLRdoes not offer a benefit over PLR So, LT is better curative option than PLR to be offer to aSo, LT is better curative option than PLR to be offer to a patient with liver cirrhosis and HCCpatient with liver cirrhosis and HCC
  • 37. Thank you! Come and visit MADRID, SPAIN