resection early hcc
DESCRIPTION
Surgery vs ablation in HCCTRANSCRIPT
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Surgery for early HCC
Eric Vibert, MD, PhD
Centre Hépato Biliaire,
Hop. Paul Brousse (AP/HP) - Villejuif
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218 patients avec CHC < 2 cm
Suivi médian : 31 mois
26%
Nécrose radiologique complète : 98%
2008
20%
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22.4%
Février 2011
4977 patients(1998 – 2003)
50 % HVC30% HVB20% Other
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Prognosis was in Satellite Nodules
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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%
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Marge : 1 cm vs 2 cm
Suivi moyen : Marge 1 cm (39±17 mois) ; Marge 2 cm (43±15)
2007
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For RF needle that destroy a sphere of 3 cm diameter
Diamètretumoral
Nb de « ponction »
1 cm 1
1,75 cm 6
3 cm 14
2002
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No exploration of the liver surface
ICG camera
IOUS
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2013
CHC < 3 cm
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1200 à 1500 Greffons / an en France….
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Waiting list : 3 months to 1 year
Inscription
Transplantation
Palliative
Drop-out = 12%
No Drop-out
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When I plan a treatment to MisterDurand, I think to Mister Dupond…Who will be more beneficiated ofliver transplantation relatively toresection ?
Risk and Interest of oncologic hepatectomy ?
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MELD > 11Sensitivity = 82%Specificity = 89%
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100 – Specificity
MELD > 9Sensitivity = 87%Specificity = 63%
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100 – Specificity
Post operative liver failure
1997 - 2004 : 157 cirrhotic liver resections
Post operative complications
2006
Child A : 93% / Minor resection : 95% / Mortality 7%
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The Risk…
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Variables MELD score <9 (n=74) MELD score between 9 and 10 (n=56)
MELD score > 11 (n=24)
Postoperative liver failure 0 (0%) 2 (3.6%) 9 (37.5%)
Postoperative complications 6 (8.1%) 20 (35.7%) 20 (83.3%)
Refractory ascites 5 (6.8%) 15 (26.8%) 20 (83.3%)
Jaundice 2 (2.7%) 10 (17.9%) 19 (79.2%)
Alteration of coagulation factors 3 (4.1%) 12 (21.4%) 19 (79.2%)
Renal impairment 0 (0%) 4 (7.1%) 6 (25%)
Hospital stay (days) 8 (5-38) 9 (6-33) 25 (6-166)
1-year survival 100% 94% 74%
No liver resection in cirrhotic patientwith a MELD Score superior to 12
2006
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British Journal of Surgery 1997, 84, 1255 - 1259
Survivors (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 (µmol 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) 0.90
0
15
35
[IG
C]
mg
%
Survivors
Distribution of indocyanine green (ICG) retention at ? in for survivors and patients who died in hospital
Non-survivors
5
25
40
10
20
45
30
127 hepatectomies dont 91 Majeures Child A (n=121) / Child B (n=6)Mortalité Hospitalière : 14/127 (11%)
Valeur seuil d’ICG à 15 minutes
15% pour les Hep. Maj23% pour les Hep. Min.
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2008
1994-2004 : 455 pts opérés pour CHC / Suivi moy.: 46 mois 384 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
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2003
PVE is an « effort test » for the pathological liver…
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The interest…
To treat a problem and to plan the futur
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Into the parenchyma
Into the HCC
If recurrence
Salvage LT
Preemptive LT
Bridge LT
Early Recurrence
Late Recurrence
CI à la TH
?
Test of time…
Scatton et al. Liver Transpl. Fuks et al. Hepatology
SwissWatch
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Taux de transplantation secondaire en cas de récidive : 28%
2011
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1 - Peu différencié2 - Inv. Vasc. micro3 - Nodules satellites4 - Cirrhose (F4)5 - Diamètre > 3 cm
Récidive dans Milan 65% de TH Salvage
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Log rank p= 0.038
100%
56%
78%
41%
100%
81%
Living donor : 11
Cadaveric donor : 22
Salvage Transplantation for HCC on cirrhotic liver
Overall Survival (Paul Brousse Experience)
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MILAN IN (Specimen)
MILAN Out (Specimen)
Mai 2011
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5 Gènes : TAF9, RAMP3, HN1, KRT19, RAN
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N= 35 malades
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BCLC B BCLC C
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The location of HCC…
LiverSP by SIGHT
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In conclusion…
It was possible to cure a patient with early HCC by liverresection that contain a safety margin if the patient hadenough liver fonctional reserve to support surgery…
We did not plan the futur of the patientS by destruction of the present but by its carefulanalysis…
Thanks for your attention
eric.vibert.pbr@gmail. com This slides will be on slides share