controversies in hepato-biliary surgery
TRANSCRIPT
AUBHO CONFERNECE8/2015
P R E S E N T ED BY:T H O M A S A L O I A , M DA SS O C P R O F O F S U R G I C A L O N C O L O G YM D A N D E R SO N C A N C ER C EN T E R
Controversies in HPB Surgery
Topics
1. Resectable hilar cholangiocarcinoma: Resection or OLT
2. Node-positive intrahepatic cholangiocarcinoma3. Unresectable intrahepatic cholangiocarcinoma4. Large HCC in early cirrhosis
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.
MassMass
Treatment Options?
A. Chemoradiotherapy followed by OLTB. ResectionC. Chemotherapy
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.
Resectable Hilar Cholangiocarcinoma
Multiphasic liver CT:
Now What?
Resectable Hilar Cholangiocarcinoma
Multiphasic liver CT:
Referred to medical oncology for Gemcitabine and Cisplatin Re-evaluate in 3 – 6 months.
Hilar Cholangiocarcinoma
38 patients Unresectable Neoadjuvant 5-FU and external beam radiation Preoperative staging 5 year survival 82%, recurrence rate 13%
Hilar Cholangiocarcinoma
12 transplant centers, 287 patients. 53% 5 year survival and 65% recurrence free survival. 71 patients dropped out.
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.
Topics
1. Resectable hilar cholangiocarcinoma: Resection or OLT
2. Node-positive intrahepatic cholangiocarcinoma3. Unresectable intrahepatic cholangiocarcinoma4. Large HCC in early cirrhosis
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 adenopathy
EGD and colonoscopy – normal
PET scan: large intensely hypermetabolic mass in the left liver.
10 cycles of Gemcitabine and Cisplatin – stable disease.
Treatment Options?
A. RadiotherapyB. ResectionC. Continued chemotherapy
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
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 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.
Topics
1. Resectable hilar cholangiocarcinoma: Resection or OLT
2. Node-positive intrahepatic cholangiocarcinoma3. Unresectable intrahepatic cholangiocarcinoma4. Large HCC in early cirrhosis
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
Treatment Options?
Options?A. Low dose radiationB. High dose radiation with bowel perforation risk
20%C. Experimental protocol chemotherapy
Non-target Radiation RiskLeft Liver
Cholangio
overlying stomach
Alloderm Envelope with Clips
Alloderm Spacer in PlaceClip 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 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
Topics
1. Resectable hilar cholangiocarcinoma: Resection or OLT
2. Node-positive intrahepatic cholangiocarcinoma3. Unresectable intrahepatic cholangiocarcinoma4. Large HCC in early cirrhosis
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 righthepatectomy = 28%.
Treatment Options?
A. TACE aloneB. ResectionC. OLTD. ChemotherapyE. PVEF. Combination
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 righthepatectomy = 28%.
TACEPVE
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– Lidocaine– Epidural
• Inflow Occlusion– 4 x 15– EBL: 225cc– No transfusions
• C-Gram• Air Leak Test
– 4 parenchymal bile duct repairsAloia, JACS, 2015 & Zimmitti, JACS, 2013
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
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.
Suggested Algorithm: HCC in Early Cirrhosis
Low FLR
T<5 cm
TACE
PVE
T>5 cm
?Y90
PVE
???????????
Thomas A. Aloia, MD E: [email protected] T: @mdahpbaloia