Traitement Chirurgical HCC Conf Zurich
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Transcript of Traitement Chirurgical HCC Conf Zurich
Liver Resection For HCC
Eric Vibert, MD, PhD
Centre Hépato-Biliaire,
Hop. Paul Brousse
10 years Recurrence Free Survival
22.4%
Février 2011
2006
HCC < 2 cm
54 pts HBV versus 285 pts HCV
Différence à plus de 2 ans
28%
62%
15%
43%
2000 – 2009 : 127 pts avec CHC sur cirrhose C / Résection R0
Diab. équilibré
Diab. non équilibré
Treatment of co-factor as diabete is also mandatory to decrease recurrence
En préop : BMI et plaquette plus élevés chez les diabétiques
RFS à 3 ans : 66% vs 27%
2013
CHC < 3 cm
1200 à 1500 Liver Graft / year in France….
Which type of hepatectomy ?
AnatomicNon anatomic
Unique and inferior to 5 cm
Marge : 1 cm vs 2 cm
Suivi moyen : Marge 1 cm (39±17 mois) ; Marge 2 cm (43±15)
2007
Prognosis was in Satellite Nodules
2013
16 / 132 pts (12%) Satellites Nod.
1990 – 2009 : New York + Milan- NY : Child A / No Portal Hypertension- Milan : Child A : ICG < 20%
132 pts / Mortalité Pst op 0.7%
Surgery > Local Destruction ifPlatelet > 150 000
2005
Not the same liver, not the same resection…
Recurrence free-survival was similar except in poor differenciated HCC
Kinetics of AFP (Doubling time < 1 month) is more important than level to detect agressive HCC that required margin
No correlation between level
and kinetic (Dbl time)
Very good accuracy to evaluate tumoral grading for CHC < 5 cm
81 Patients operated for unique CHC unique with preop. Percut. Biopsy
2011
First Message
Agressive HCC (Satellite nod, AFP kinetic and poordifferentiated HCC) must be treated aggressively
with margin AND anatomical resection
Is feasible ?
The location is higlydeterminant
No choice Choice
Minor hepatectomy
2006
1997 – 2004 : 157 hepatectomies on cirrhosis
Child A : 93% / Minor resection 95% / Mortalité 7%
Insuf. Hépatique post-operatoire
Complications post-operatoires
2006
No liver resection on cirrhosis if MELD > 11
29 patients operated for HCC on Child A cirrhosis
Only hepatic venous pressure gradient > 10 mmHg was significant in multivariate analysis for decompensated cirrhosis after hepat.
Risk factor in univariate analysis
Bilirubin rateUrea rateRate of plateletICG ClearenceHepatic venous pressure gradiant,
1996
Ascite at 3 months po
BCLC B BCLC C
2008
1994-2004 : 455 pts opérés pour CHC / Suivi moy.: 46 mois384 pts avec fibroscopie pré-opératoire
Child A / Sans HTP
56%
71%
Child A / Avec HTP
Définition de l’HTP : VO et/ouplq < 100 000/ml + Splénomégalie
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%
Assessment of ICG preoperatively
Hépatectomie mineure Hépatectomie majeure
AUC 0,78 [0,66-0,90]Valeur seuil: 12,75
Sensibilité: 74%Spécificité: 71%
AUC: 0,66 [0,66-0,87]Sensibilité: 50%Spécificité: 88%
p=0,33
2012-2014 : 89 pts operated for HCC on cirrhosisMort : 2% - Liver Decomp : 34% (Ascite 93%)
ICG is the only preoperative data to predict Liver Decomp.
90 pts including including 17 major hep. : 30% of liver decompensation (20% ascite)
> 16 kpA: Ascite and/or POLF
No evident difference between Laparoscopy and Laparotomy
70%
40%
Foie Non Tumoral
Foie Tumoral
Si Récidive
SalvageRehépatectomie ?
De Principe
Bridge
Récidive Précoce
Récidive Tardive
CI à la TH
?
Le test of time…
Scatton et al. Liver Transpl. Fuks et al. Hepatology
N= 35 malades
Second Message
Minor hepatectomy is feasible if MELD < 12 andFibroScan < 17-20 kPa (or ICG-15’ < 13%)
Laparoscopy facilitates subsequent liver transplantation and must be used if oncological rules are respected
Major hepatectomy
< 20% of standard liver volume or 0.5% body weight on non cirrhotic liver
Liver Surgical Planner (Available on iTunes)
Truant et al. JACS 2008Ribeiro, Vauthey et al. BJS 2007
2003
PVE is an « effort test » for the pathological liver…
2000-2010 : N= 231 pts (US) / 3 Centres
Plaquette Préop < 150.000 / mLCourbe ROC / Maj. Compl.
134 Maj. Hep / 3% PVE
JACS, Avril 2011
Be careful… Hepatofugal flow…
No effect of portal vein embolization and risk of portal thrombosis
TACE PVE Major Hep.
Rational of this strategy
1 PVE increases arterial flow and increases HCC vascularization2 Intra tumoral arterioportal shunt decrease PVE efficacy3 Blockage of intra-operative portal metastases
2003
2011
2009
PVE only or upfront hepatectomy…
2006
Circulating Cells
Ant App. decreaseMassive Hemorrhage
(> 2 l) : 28% vs 7%
But no impact of recurrence…
2000 – 2011 : 62 pts – 84% diabete32 (52%) Majors hepatectomies
TACE/PVE (n=8) et PVE (n=1)
38 (61%) abnormal liver parenchyma- F1/F2 ou Stéatohépatite (n=20)- F3/F4 (n=18)
15% des CHC réséqués en 2010
18% postop. mortality
Non transplantable patient (Med 70 years) and CHC > 10 cm (75%)
Liver biopsy is mandatory to evaluated precisely parenchymaProtection of the liver parenchyma…. Clamping seems deleterious
Third Message
No major hepatectomy in abnormalparenchyma without preoperative PVE,
especially before Right Hepatectomy
TACE before PVE in HCC < 5 cm improved survival
Surgery is Usefull or not ?
Macroscopic Vascular Invasion
BCLC B BCLC C
Early tumor : ≤5 cm AND ≤3 nod AND no vascular invasion
Intermediate tumor : ≤5 cm AND >3 nod OR with vascular invasion>5 cm AND ≤3 nod AND no vascular invasion
Locally advanced tumor : ≤5 cm AND >3 nod AND with vascular invasion>5 cm AND >3 nod AND/OR vascular invasion
ECOG Performance Status1- Général status of pts:
Score de Child-Pugh2- Function reserve:
3 – Tumoral status:
4 - Envahissement extra-hépatique : Vasculaire et/ou métastatique
3856 ps – 79% HVB 38% resection, LT or ablation25% TACE as 1st treatment
HKLC I
HKLC IIaHKLC IIb
HKLC Va (TH)
HKLC IIIa
HKLC IIIbHKLC IVa
HKLC Vb
2046 patients including 297 pts BCLC C / Mort. 2.7%
25%
50%
2013
Chir (n=70) vs Nexavar (n=44) in BCLC C in 4 Centers in France (Bondy, Creteil, Grenoble, Paul Brousse)
N=17
N=16
p=0.17
Propensity score to compare 2 populations
Constantin et al. Submitted to EASL
Globally no difference….
But perhaps a role of adjuvant treatment
p=0.011
N=34N=44
25.2 m9.4 m
Constantin et al. Submitted to EASL
To explore…. Which treatment…
Conclusions and Perspectives
• Oncological HCC resection imposed margin
– Prognostic value of margin according to diameter and genetic of HCC ?
• The location of HCC defined the type of surgery
– Staging of HCC must included also location
• Underlying liver parenchyma is the key
– Elastometry will replaced all and notably liver biopsy ?
• Surgical treatment of HCC BLCL C is feasible
– Adjuvant and perhaps neoadjuvant must be explored