Surgery at the Borderline in HCC patient - EASL Conference - Vienna 2015
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Transcript of Surgery at the Borderline in HCC patient - EASL Conference - Vienna 2015
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Surgery at the Borderline
Eric Vibert, MD, PhD
Centre Hépato-Biliaire,
Hop. Paul Brousse
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The actual results of surgery in HCC
Authors Period N 90 days Mortality Underlying Parenchyma
Greco et al. 2001-2005 129 4.1% Abnormal LiverRosaye et al 2005-2011 2342 3.5% Abnormal LiverZhong et al 2000-2007 908 3.1% Abnormal LiverVigano et al 2000-2012 192 2.1% Abnormal Liver
Donadon et al 2004-2013 336 2% Abnormal Liver
Kim et al 2005-2010 454 0.7% Healthy LiverZhou et al 2006-2009 124 0.5% Healthy LiverFaber et a; 2000-2010 148 0% Healthy Liver
« Acceptable » post-operative mortality in cirrhotic patient is inferior to 5%
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BCLC B BCLC C
These guidelines were no more followed…
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2005-2011 : Cohort BRIDGE 8656 patients
70% No Surgery (n=6134 )
30% Surgery (n=2342 )70% Out BCLC Guidelines (n=1624)
30% In BCLC Guidelines (n=718 )
2% BCLC Guideline for Surg (n=123)
2015
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Overall survival in the 3 groups
35%
65%
90 Postoperative Mortality : 1.2% (In BCLC) vs 4.5% (Out BCLC)
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In BCLC A : Unique Or 3 nod ≤ 3 cm
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The location of HCC is very important…
LiverSP by SIGHT
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Same portal hypertension level and same nodule.. but different location…
Segmentectomy
Segmentectomy 8 by Laparotomy Resection in Segment 3 by Lap’
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X3 PO. Mortality: 6.1% (38/618) vs 2.8% (32/1274)
X2 PO. Liver Failure : 17% vs 7%
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2008
1994-2004 : 455 pts included 130 with PHT : No impact…
Child A / Sans HTP
56%
71%
Child A / Avec HTP
No early impact but lower longtime survival after resection of PHT
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Makuuchi et al., Semin Surg Oncol 1993
Ascites
None or controlled Not controlled
ICGR15 Limited resection Enucleation Not indicated for hepatectomy
Trisectorectomy bisectorectomy
Left-sided hepatectomyRight-sided
sectoriectomy
Segmentectomy Limited resection Enucleation
Normal 1.1 – 1.5 mg/dL 1.6 – 1.9 mg/dL > 2.0 mg/dL
Total bilirubin level
Normal 10% - 19% 30% - 39% > 40%20% - 29%
Adapted liver resection to liverhemodynamics assessed by ICG-R15
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Impact of portal hypertension dependsof the remnant liver volume
Volume of the Remnant Liver
Portal Hypertension
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Major Hepatectomy in cirrhotic patient
Truant et al. JACS 2008
MELD Score ≤ 10 and no clinical portal hypertension
Cucchetti et al. Liver Transpl 2006
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2003
PVE is an « effort test » for the pathological liver…
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2000-2010 : 231 pts including 134 maj. hepatectomies with only 3% of PVE
In such condition, major impact of préoperative platelet rate < 150.000 / mL
22%
6%
Global Post OperativeMortality : 9%
2011
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TACE PVE Major Hep.
Rational of TACE before PVE strategy
1. Avoiding increased HCC arterial vascularization after PVE2. Occlusion of tumoral arterioportal shunt to increase PVE efficacy
2003
After ArterialRepermeabilization
2 weeks 3 weeks
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2011
TACE then PVE in HCC inferior to 5 cm : Increased Liver Volume and Tumoral Necrosis
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Correlation is linear…
YesNo
Post
hep
atec
tom
y P
VP
(m
mH
g)
22.5 mmHg
15 mmHg
P < 0.001
Liver failure « 50-50 » criteria
Portal pressure at the end of liver resection
An independent predictor of liver failure and mortalityafter major resection (N = 277) in humans1
1. Allard….. Vibert - Ann Surg. 2013 Nov;258(5):822-9
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Intraoperative Portal Flow modulation
MODHEP-1 : Phase I/II in Human(Hop. Paul Brousse – Villejuif)
1. Splenic Artery Ligation fisrt
2. Portal Caval Shunt (8 mm Goretex)
Today… Tomorrow…
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First Message
Portal hypertension is not, per se, a contra-indication to resection if the extent of hepatectomy is adapted to degree of portal hypertension….
The HCC location must be included in therapeutic guidelines….
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After Technical…Oncological limits
Image Ferrière : CHC Multiple
Adenopathie +
Macroscopic Vascular Invasion
Portal Invasion
Multiple Nodule
Huge Lesion
Ruptured HCC Hepatic Vein / Caval Invasion Ruptured HCC
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No impact of HCC diameter in T1 lesionT1 : No vascular invasion on the specimen
Vauthey et al. J. Clin Oncol 2002
203 patients
5-years Overall Survival : 55%
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Analysis of preoperative imagery
50%
Annals of Surgery 2009 Br. Journal of Surgery 2006
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Same Size but different aspect…
Large HCC on non-cirrhotic liver
30% of 5-years OS >50% of 5-years OS
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Extended Right HepatectomyWell Differenciated HCC – R1 Resection
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2006
Circulating Cells
Ant App. decreaseMassive Hemorrhage
(> 2 l) : 28% vs 7%
But no impact of recurrence…
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2009
PVE only or upfront hepatectomy…
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No TACE before hepatectomy for large HCC without macroscopic vascular invasion
Resectable… No more resectable…
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No impact of high Value of AFP
Surgery, 2015
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Large tumor in large and old patient….
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2000 – 2011 : 62 pts – CHC > 10 cm (75%) 52% of major hepatectomy
15% of pts in 2010
38 pts with liver abnormalities (32% F1/F2 / 29% F3/F4) 18% of post operative mortality
2013
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No tolerance of clamping…
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Protection of the liver and kidney duringlarge hepatectomy in fragile patients
Br. Journal of Surgery 2009Annals of Surgery 2005
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Mergental et al. , J. Hepatol 2012
ELTR : 105 patients in 10 years…
49%
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60%70%
Récidive < 12 mois
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Second Message
Size is not the problem to decideresection or not for huge HCC…
Tumor and Patient Morphology are more important….
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Surgery is Usefull or not ?
Macroscopic Vascular Invasion
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Impact of Portal Vein Extension
Vp1 Vp2
Vp3 Vp4
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5-year Survival around 10-15% in Vp3/Vp4
Author PeriodPortal VeinExtension
N. PtsPO.
Mort.Median
3-years OS
5-years OS
Matono et al. 1985-2005 Vp3/Vp4 29 3% 16.6 24% 17%
Ikai et al. 1990-2002 Vp3/Vp4 78 3.8% 8,8 21% 11%
Pawlick 1984-1999 Vp3 102 5.8% 11 17% 10%
Minigawa 1989-1998 Vp2/Vp3/Vp4 18 5.5% 18 42% 42%
Peng 2002-2007 Vp2 27 51% 37%
Vp3 68 17% 17%
Vp4 83 4% 4%
LeTreut 1988-2004 Vp2/Vp3/Vp4 26 11% 9 13%
Zhou Vp2/Vp3/Vp4 386 12%
Personnal Exp. 1992-201 Vp2/Vp3/Vp4 43 10% 7 19%
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Selection by TACE before Surgery
Vp2
N=9(50%)
Vp3
N=9(50%)
2001
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Surgery vs TACE in HCC with PVT
Vp1 Vp2
Vp3 Vp4
Peng et al. Cancer 2012
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Paul Brousse Experience
1992 – 2014 : 43 pts
Vp1/Vp2 : 8 ptsVp3/Vp4 : 35 pts
50%
30%
19%
35%
Atrophy of the liver on the side of the tumoral thrombus is the only prognostic factor
Atrophy is a surrogate factor of a slowly growing tumor
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Macroscopic Hepatic Vein
Microscopic or Peripherical Venous Invasion = Macroscopic Venous Invasion
2015
50%
Associated to Vp1/Vp2 >>> Vp3/Vp4
It is still intra hepatic lesion
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Third (and last..) Message…
• Surgery is an emergency for HCC with intrahepaticmacroscopic portal vein or hepatic vein extension….
• Upfront surgical treatment of HCC with macroscopicvascular extension into large portal branch (Vp3) or portal Trunk (Vp4) is more debetable…
• Neo-Adjuvant (or Adjuvant ?…) treatments in thesepatients must be developped
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Ruptured HCC
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33%13%
45%
Surgery or Local destruction are justified if they are not performed in emergency
Aoki et al. Ann Surg 2013 Yang et al. Br J Surg 2013
Loc. Dest = Surgery
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Conclusions and Perspectives
Therapeutic guidelines must nowinvolve the location of the tumor inthe liver and intra/extrahepaticmacroscopic vascular extension tostratify and treat correctly pts withHCC…