resection early hcc

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Surgery vs ablation in HCC

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  • 1. Surgeryfor earlyHCCEricVibert, MD, PhDCentre Hpato Biliaire,Hop. Paul Brousse (AP/HP) -Villejuif

2. 218 patients avec CHC < 2 cmSuivi mdian : 31 mois26%Ncrose radiologique complte : 98%200820% 3. 22.4%Fvrier 20114977 patients(1998 2003)50 % HVC30% HVB20% Other 4. Prognosiswasin Satellite Nodules 5. 201316 / 132 pts (12%)Satellites Nod.1990 2009 : New York + Milan-NY : Child A / No Portal Hypertension-Milan : Child A : ICG < 20%132 pts / Mortalit Pst op 0.7% 6. Marge : 1 cm vs 2 cmSuivi moyen : Marge 1 cm (3917 mois) ; Marge 2 cm (4315)2007 7. For RF needlethatdestroy a sphereof 3 cm diameterDiamtretumoralNb de ponction1 cm11,75cm63 cm142002 8. No exploration of the liversurfaceICG cameraIOUS 9. 2013CHC < 3 cm 10. 1200 1500 Greffons / an en France. 11. Waiting list : 3 months to 1 yearInscriptionTransplantationPalliativeDrop-out = 12%No Drop-out 12. WhenIplanatreatmenttoMisterDurand,IthinktoMisterDupond Whowillbemorebeneficiatedoflivertransplantationrelativelytoresection?Riskand Interestof oncologichepatectomy? 13. MELD >11Sensitivity = 82%Specificity = 89%020406080100020406080100Sensitivity100 SpecificityMELD >9Sensitivity = 87%Specificity = 63%020406080100020406080100Sensitivity100 SpecificityPost operative liver failure1997 -2004 : 157 cirrhotic liver resectionsPost operative complications2006Child A : 93% / Minor resection : 95% / Mortality 7% 14. The Risk 15. VariablesMELD score 11 (n=24)Postoperative liver failure0 (0%)2 (3.6%)9 (37.5%)Postoperative complications6 (8.1%)20 (35.7%)20 (83.3%)Refractory ascites5 (6.8%)15 (26.8%)20 (83.3%)Jaundice2 (2.7%)10 (17.9%)19 (79.2%)Alteration of coagulation factors3 (4.1%)12 (21.4%)19 (79.2%)Renal impairment0 (0%)4 (7.1%)6 (25%)Hospital stay (days)8 (5-38)9 (6-33)25 (6-166)1-year survival100%94%74%No liver resection in cirrhotic patientwith a MELD Score superior to 122006 16. British Journal of Surgery 1997, 84, 1255 - 1259Survivors (n = 113) Non-survivors (n = 14) P *All ICG retention at 15 min (%) 11 (3 - 50) 18 (4 - 29) 0.008Aminopyrine breath test (%) 4-4 (1.3 - 9.6) 4.3 (2.8 8.3) 0.69Amino acid clearance test (1 m-2 min-1) 0.21(1.7 to 4.3) 0.15 (-0.2 to 0.9) 0.35Albumin (g l-1) 42 (31 - 53) 41 (29 - 46) 0.40Total bilirubin (mol l-1) 9 (3 - 70) 14 (7 - 32) 0.05Aspartate aminotransferase (units l-1) 59 (17 - 365) 97 (39 - 340) 0.02Alanine aminotransferase (units l-1) 53 (9 - 480) 53 (21 - 322) 0.9001535[IGC] mg %SurvivorsDistribution of indocyanine green (ICG) retention at? in for survivors and patients who died in hospitalNon-survivors5254010204530 127 hepatectomies dont 91 Majeures Child A (n=121) / Child B (n=6) Mortalit Hospitalire : 14/127 (11%) Valeur seuil dICG 15 minutes15% pour les Hep. Maj23% pour les Hep. Min. 17. 20081994-2004 : 455 pts oprs pour CHC / Suivi moy.: 46 mois 384 pts avec fibroscopie pr-opratoireChild A / Sans HTP56%71%Child A / Avec HTPDfinition de lHTP : VO et/ouplq < 100 000/ml + Splnomgalie 18. 2003PVE isan effort test for the pathologicalliver 19. The interestTo treata problemand to plan the futur 20. Into the parenchymaInto the HCCIf recurrenceSalvage LTPreemptive LTBridge LTEarly RecurrenceLate RecurrenceCI la TH ?Test of timeScatton et al. Liver Transpl.Fuks et al. HepatologySwissWatch 21. Taux de transplantation secondaire en cas de rcidive : 28%2011 22. 1 -Peu diffrenci2 -Inv. Vasc. micro3 -Nodules satellites4-Cirrhose (F4)5 -Diamtre > 3 cmRcidive dans Milan65% de TH Salvage 23. Log rank p= 0.038100%56%78%41%100%81%Living donor : 11Cadaveric donor : 22Salvage Transplantation for HCC on cirrhotic liverOverall Survival (Paul Brousse Experience) 24. MILAN IN (Specimen)MILAN Out (Specimen)Mai 2011 25. 5 Gnes : TAF9, RAMP3, HN1, KRT19, RAN 26. N= 35 malades 27. BCLC BBCLC C 28. The location of HCCLiverSPby SIGHT 29. In conclusionIt waspossible to cure a patient withearlyHCCby liverresectionthatcontaina safetymarginif the patient hadenoughliverfonctionalreserveto support surgeryWedidnot plan the futurof the patientSby destruction of the presentbut by itscarefulanalysisThanksfor [email protected] comThis slides willbeon slides share