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AUBHO CONFERNECE
8/2015
P R E S E N T E D B Y :
T H O M A S A L O I A , M D
A S S O C P R O F O F S U R G I C A L O N C O ...
Topics
1. Resectable hilar cholangiocarcinoma: Resection or OLT
2. Node-positive intrahepatic cholangiocarcinoma
3. Unrese...
Resectable Hilar Cholangiocarcinoma
 55 y/o F presented to an OSH with epigastric fullness and abnormal LFTs.
 Workup in...
Treatment Options?
A. Chemoradiotherapy followed by OLT
B. Resection
C. Chemotherapy
Resectable Hilar Cholangiocarcinoma
 Patient seen by Transplant Team
 Told that survivals better after transplant
 Star...
Resectable Hilar Cholangiocarcinoma
 Multiphasic liver CT:
 Now What?
Resectable Hilar Cholangiocarcinoma
 Multiphasic liver CT:
 Referred to medical oncology for Gemcitabine and Cisplatin
...
Hilar Cholangiocarcinoma
 38 patients
 Unresectable
 Neoadjuvant 5-FU and external beam radiation
 Preoperative stagin...
Hilar Cholangiocarcinoma
 12 transplant centers, 287 patients.
 53% 5 year survival and 65% recurrence free survival.
 ...
Hilar Cholangiocarcinoma
 Should resectable CCA be referred to OLT?
 Patients with clearly resectable de novo HC should ...
Topics
1. Resectable hilar cholangiocarcinoma: Resection or OLT
2. Node-positive intrahepatic cholangiocarcinoma
3. Unrese...
Node-positive Intrahepatic Cholangiocarcinoma
 57 y/o F presented to the ED with epigastric pain
 CT scan:
Node-positive Intrahepatic Cholangiocarcinoma
 Biopsy: adenocarcinoma positive for CK7 and CK 20
 CT suggested regional ...
Treatment Options?
A. Radiotherapy
B. Resection
C. Continued chemotherapy
Node-positive Intrahepatic Cholangiocarcinoma
 Biopsy: adenocarcinoma positive for CK7 and CK 20
 CT suggested regional ...
Portal Node Dissection
Cholangiocarcinoma
 Adenocarcinoma
 Rich lymphatic plexus
 =Early metastatic disease
Cholangiocarcinoma Lymphatic Drainage
Node-positive Intrahepatic Cholangiocarcinoma
 Complete surgical resection provides the best option for long-term surviva...
Topics
1. Resectable hilar cholangiocarcinoma: Resection or OLT
2. Node-positive intrahepatic cholangiocarcinoma
3. Unrese...
Unresectable IHCC
 54 yo man presents with left liver cholangio, portal
and gastric LAD, and a small right liver metastas...
Treatment Options?
 Options?
A. Low dose radiation
B. High dose radiation with bowel perforation risk 20%
C. Experimental...
Non-target Radiation Risk
Left Liver
Cholangio
overlying
stomach
Alloderm Envelope with Clips
Alloderm Spacer in Place
Clip Suture
MIS Alloderm Placement
MIS Alloderm Placement
duodenum
colon
3 cm
Envelope
Envelope
tumor
“Ablative” IMRT 67.5 Gy /15 fractions
Results
 12 patients
 Mean dose of radiation delivered was 76.1 Gy (58.1-100 Gy).
 Mean follow-up after completion of R...
Topics
1. Resectable hilar cholangiocarcinoma: Resection or OLT
2. Node-positive intrahepatic cholangiocarcinoma
3. Unrese...
Large HCC in Early Cirrhosis
 60 y/o gentleman with chronic hepatitis B was diagnosed with a right liver
mass (biopsy: we...
Treatment Options?
A. TACE alone
B. Resection
C. OLT
D. Chemotherapy
E. PVE
F. Combination
Large HCC in Early Cirrhosis
 60 y/o gentleman with chronic hepatitis B was diagnosed with a right liver
mass (biopsy: we...
Large HCC in Early Cirrhosis
 Preoperative imaging:
 FLR 36%
 KGR 2%-age points/week
Case Presentation
• 61 yo male
– EtOH Child’s A cirrhosis
– Large central HCC
• ERILS
– Premeds
– No narcotics
– Steroids
...
Case Presentation
• 61 yo male
– EtOH Child’s A cirrhosis
– Large central HCC
• Post Op: ERILS
– No NG
– No Narcotics
– PO...
Large HCC in Early Cirrhosis
 16 patients underwent TACE followed by PVE with a 2 week hypertrophy of 22%.
 Concluded: p...
Suggested Algorithm: HCC in Early Cirrhosis
Low
FLR
T<5 cm
TACE
PVE
T>5 cm
?Y90
PVE
???????????
 Thomas A. Aloia, MD
 E: taaloia@mdanderson.org
 T: @mdahpbaloia
Controversies in hepato-biliary surgery
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Controversies in hepato-biliary surgery

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Controversies in hepato-biliary surgery. Dr Thomas Aloia

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Controversies in hepato-biliary surgery

  1. 1. AUBHO CONFERNECE 8/2015 P R E S E N T E D B Y : T H O M A S A L O I A , M D A S S O C P R O F O F S U R G I C A L O N C O L O G Y M D A N D E R S O N C A N C E R C E N T E R Controversies in HPB Surgery
  2. 2. Topics 1. Resectable hilar cholangiocarcinoma: Resection or OLT 2. Node-positive intrahepatic cholangiocarcinoma 3. Unresectable intrahepatic cholangiocarcinoma 4. Large HCC in early cirrhosis
  3. 3. Resectable Hilar Cholangiocarcinoma  55 y/o F presented to an OSH with epigastric fullness and abnormal LFTs.  Workup included an MRI which demonstrated a small perihilar mass.  No vascular involvement.  ERCP identified a stricture with brushings suspicious for adenocarcinoma.  EUS revealed a 1.2 cm hypoechoic mass with no lymphadenopathy. Mass Mass
  4. 4. Treatment Options? A. Chemoradiotherapy followed by OLT B. Resection C. Chemotherapy
  5. 5. Resectable Hilar Cholangiocarcinoma  Patient seen by Transplant Team  Told that survivals better after transplant  Started on chemoradiation per the Mayo protocol.  Taken to OR for transplantation, however, procedure aborted secondary to portal lymph node involvement.  Developed jaundice and repeat ERCP was performed  2 metal stents were placed extending deep into right and left liver.  Referred to MD Anderson for a second opinion.
  6. 6. Resectable Hilar Cholangiocarcinoma  Multiphasic liver CT:  Now What?
  7. 7. Resectable Hilar Cholangiocarcinoma  Multiphasic liver CT:  Referred to medical oncology for Gemcitabine and Cisplatin  Re-evaluate in 3 – 6 months.
  8. 8. Hilar Cholangiocarcinoma  38 patients  Unresectable  Neoadjuvant 5-FU and external beam radiation  Preoperative staging  5 year survival 82%, recurrence rate 13%
  9. 9. Hilar Cholangiocarcinoma  12 transplant centers, 287 patients.  53% 5 year survival and 65% recurrence free survival.  71 patients dropped out.
  10. 10. Hilar Cholangiocarcinoma  Should resectable CCA be referred to OLT?  Patients with clearly resectable de novo HC should be treated with resection.  Patients with B-C type IV HC might be best treated with transplantation if they are excellent transplant candidates.
  11. 11. Topics 1. Resectable hilar cholangiocarcinoma: Resection or OLT 2. Node-positive intrahepatic cholangiocarcinoma 3. Unresectable intrahepatic cholangiocarcinoma 4. Large HCC in early cirrhosis
  12. 12. Node-positive Intrahepatic Cholangiocarcinoma  57 y/o F presented to the ED with epigastric pain  CT scan:
  13. 13. Node-positive Intrahepatic Cholangiocarcinoma  Biopsy: adenocarcinoma positive for CK7 and CK 20  CT suggested regional adenopathy  EGD and colonoscopy – normal  PET scan: large intensely hypermetabolic mass in the left liver.  10 cycles of Gemcitabine and Cisplatin – stable disease.
  14. 14. Treatment Options? A. Radiotherapy B. Resection C. Continued chemotherapy
  15. 15. Node-positive Intrahepatic Cholangiocarcinoma  Biopsy: adenocarcinoma positive for CK7 and CK 20  CT suggested regional adenopathy  EGD and colonoscopy – normal  PET scan: large intensely hypermetabolic mass in the left liver.  10 cycles of Gemcitabine and Cisplatin – stable disease.  Extended left hepatectomy + caudate and lymphadenectomy.  Moderately differentiated cholangiocarcinoma with negative margins. 1 lymph node positive. T2a N1
  16. 16. Portal Node Dissection
  17. 17. Cholangiocarcinoma  Adenocarcinoma  Rich lymphatic plexus  =Early metastatic disease
  18. 18. Cholangiocarcinoma Lymphatic Drainage
  19. 19. Node-positive Intrahepatic Cholangiocarcinoma  Complete surgical resection provides the best option for long-term survival ⁽¹⁾.  Factors with prognostic significance after ICC resection are the presence of vascular invasion, multiple tumors, and LNM ⁽²⁾.  Some authors suggest that an LND should be performed in all patients with ICC in order to appropriately stage individuals and guide perioperative management.  LN+ also constitutes an indication for neoadjuvant therapy.  NCCN guidelines:  Recommend considering a lymphadenectomy in resectable disease for accurate staging.  Lymph node metastases beyond the porta hepatis (M1) contraindicates resection. 1 Herman J M and Pawlik T M, Hepatocellular Carcinoma, Gallbladder Cancer, and Cholangiocarcinoma, in Radiation Oncology: An Evidence-Based Approach, J.J. Lu and L.W. Brady, Editors. 2008. p. 221–243. 2 Cho S Y, Park S J, Kim S H, Han S S, Kim Y K, Lee K W, Lee S A, Hong E K, Lee W J, and Woo S M. Survival analysis of intrahepatic cholangiocarcinoma after resection. Annals of Surgical Oncology 2010; 17:1823–1830.
  20. 20. Topics 1. Resectable hilar cholangiocarcinoma: Resection or OLT 2. Node-positive intrahepatic cholangiocarcinoma 3. Unresectable intrahepatic cholangiocarcinoma 4. Large HCC in early cirrhosis
  21. 21. Unresectable IHCC  54 yo man presents with left liver cholangio, portal and gastric LAD, and a small right liver metastasis  Stable on induction systemic therapy, but mounting toxicities  Able to radiate but bowel at risk
  22. 22. Treatment Options?  Options? A. Low dose radiation B. High dose radiation with bowel perforation risk 20% C. Experimental protocol chemotherapy
  23. 23. Non-target Radiation Risk Left Liver Cholangio overlying stomach
  24. 24. Alloderm Envelope with Clips
  25. 25. Alloderm Spacer in Place Clip Suture
  26. 26. MIS Alloderm Placement
  27. 27. MIS Alloderm Placement
  28. 28. duodenum colon 3 cm Envelope Envelope tumor
  29. 29. “Ablative” IMRT 67.5 Gy /15 fractions
  30. 30. Results  12 patients  Mean dose of radiation delivered was 76.1 Gy (58.1-100 Gy).  Mean follow-up after completion of RT was 19.5 months.  2 patients developed mild radiation-induced GI toxicity (RTOG grade 2). No GI bleeding, RILD or readmission.  RT was able to control liver disease in 42.9%. Only 2 patients had isolated in- field progression of liver disease.  Overall survival rate was 72% over a 2 year period. Ismael/Crane/Aloia, in prep, 2015
  31. 31. Topics 1. Resectable hilar cholangiocarcinoma: Resection or OLT 2. Node-positive intrahepatic cholangiocarcinoma 3. Unresectable intrahepatic cholangiocarcinoma 4. Large HCC in early cirrhosis
  32. 32. Large HCC in Early Cirrhosis  60 y/o gentleman with chronic hepatitis B was diagnosed with a right liver mass (biopsy: well differentiated HCC).  INR 0.9, PLT 344,000, Bilirubin 0.6, Albumin 4.5.  Presented to MD Anderson for a second opinion. Volumetry: FLR for extended right hepatectomy = 28%.
  33. 33. Treatment Options? A. TACE alone B. Resection C. OLT D. Chemotherapy E. PVE F. Combination
  34. 34. Large HCC in Early Cirrhosis  60 y/o gentleman with chronic hepatitis B was diagnosed with a right liver mass (biopsy: well differentiated HCC).  INR 0.9, PLT 344,000, Bilirubin 0.6, Albumin 4.5.  Presented to MD Anderson for a second opinion. Volumetry: FLR for extended right hepatectomy = 28%. TACEPVE
  35. 35. Large HCC in Early Cirrhosis  Preoperative imaging:  FLR 36%  KGR 2%-age points/week
  36. 36. Case Presentation • 61 yo male – EtOH Child’s A cirrhosis – Large central HCC • ERILS – Premeds – No narcotics – Steroids – Lidocaine – Epidural • Inflow Occlusion – 4 x 15 – EBL: 225cc – No transfusions • C-Gram • Air Leak Test – 4 parenchymal bile duct repairs Aloia, JACS, 2015 & Zimmitti, JACS, 2013
  37. 37. Case Presentation • 61 yo male – EtOH Child’s A cirrhosis – Large central HCC • Post Op: ERILS – No NG – No Narcotics – POD1 Diet and Exercise – POD2 Foley out – POD3 Drain Bili=1.4 • Drain removed – POD4 Epidural out – POD5 DC – Lovenox x 23d – Path: T1, N0, Marg- Aloia, JACS, 2015
  38. 38. Large HCC in Early Cirrhosis  16 patients underwent TACE followed by PVE with a 2 week hypertrophy of 22%.  Concluded: procedure contributes to both the broadening of surgical indications and the safety of performing major hepatectomies in HCC patients with chronic liver disease.
  39. 39. Suggested Algorithm: HCC in Early Cirrhosis Low FLR T<5 cm TACE PVE T>5 cm ?Y90 PVE
  40. 40. ???????????  Thomas A. Aloia, MD  E: taaloia@mdanderson.org  T: @mdahpbaloia

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