Surgery for early HCC

Eric Vibert, MD, PhD

Centre Hépato Biliaire,

Hop. Paul Brousse (AP/HP) - Villejuif

218 patients avec CHC < 2 cm

Suivi médian : 31 mois

26%

Nécrose radiologique complète : 98%

2008

20%

22.4%

Février 2011

4977 patients(1998 – 2003)

50 % HVC30% HVB20% Other

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%

Marge : 1 cm vs 2 cm

Suivi moyen : Marge 1 cm (39±17 mois) ; Marge 2 cm (43±15)

2007

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

No exploration of the liver surface

ICG camera

IOUS

2013

CHC < 3 cm

1200 à 1500 Greffons / an en France….

Waiting list : 3 months to 1 year

Inscription

Transplantation

Palliative

Drop-out = 12%

No Drop-out

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 ?

MELD > 11Sensitivity = 82%Specificity = 89%

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siti

vity

100 – Specificity

MELD > 9Sensitivity = 87%Specificity = 63%

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Post operative liver failure

1997 - 2004 : 157 cirrhotic liver resections

Post operative complications

2006

Child A : 93% / Minor resection : 95% / Mortality 7%

The Risk…

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

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

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Survivors

Distribution of indocyanine green (ICG) retention at ? in for survivors and patients who died in hospital

Non-survivors

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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.

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

2003

PVE is an « effort test » for the pathological liver…

The interest…

To treat a problem and to plan the futur

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

Taux de transplantation secondaire en cas de récidive : 28%

2011

1 - Peu différencié2 - Inv. Vasc. micro3 - Nodules satellites4 - Cirrhose (F4)5 - Diamètre > 3 cm

Récidive dans Milan 65% de TH Salvage

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)

MILAN IN (Specimen)

MILAN Out (Specimen)

Mai 2011

5 Gènes : TAF9, RAMP3, HN1, KRT19, RAN

N= 35 malades

BCLC B BCLC C

The location of HCC…

LiverSP by SIGHT

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