Multidisciplinary Management of Hepatocellular Carcinoma

Zeljka Jutric MD Department of Surgery

Division of Hepatobiliary and Pancreas Surgery

February 29th, 2020

Introduction

• Management of HCC is challenging • Underlying liver disease Cirrhosis • Variations in expertise and local resources

• Multidisciplinary Approach • Leads to improved outcomes

Multidisciplinary Tumor Board

Diagnosis of HCC – All about imaging

* AASLD Criteria: Do not need biopsy with diagnostic imaging in patients with cirrhosis

LI-RADS CT/MRI

LI-RADS Working Group, Hepatology 2014

Barcelona Clinic Liver Cancer (BCLC)

Forner et al. Treatment of intermediate stage HCC. Nature Reviews. 2014Llovet et al. The Barcelona Approach. Liver Transplantation . 2004

Median OS > 60 mo OS 20 mo OS 11 mo OS < 3 mo

Liver Transplant

• Based on MELD scores • Points for HCC moving target • Milan Criteria• Expanded Criteria

Transplantation for HCC• Advantages

–Treatment of underlying liver disease–Better long-term patient survival–Removes synchronous tumors –Lower risk of positive margin

• Disadvantages–Donor organ availability region dependent –Long-term immuno-suppression–Higher cost

Liver Resection for HCC

• Valuable curative option for HCC patients • Historically, balance between operative

risk and oncologic prognosis limited selection

Factors Influencing Resection

Cauchey et al Best Practices Gastroenterolog. 2014

Resection vs.Transplantation for HCC

• 413 pts over 10 yrs in Miami (low MELD)• 106 resection• 270 transplant• 37 listed but not transplanted

• Median time to transplant = 48 days

Koniaris LG et al. Ann Surg 2015

Intention-to-treat

Koniaris LG et al. Ann Surg 2015

Refinement of Current Guidelines

• Sophisticated assessment of liver function• Postoperative liver failure

• Improvements in preoperative management• Use of volume modulation

• Refinements in surgical technique • Laparoscopy

Portal Vein Embolization

Portal Vein Embolization

Portal Vein Embolization

Portal Vein Embolization

Use of Laparoscopy

• 10-20% of all liver resections performed laparoscopically • Initial concerns with patient safety, adequate

oncologic results • Laparoscopic Approach is Safe in Expert

Centers • Decreased hospital length of stay• Less post operative complications • Decreased ascites

Ablation: Radiofrequency and Microwave

Ablation: Radiofrequency and Microwave

Used for primary treatment (smaller tumors) and

bridge to transplant

Chemoembolization Hepatic parenchyma derives 70% of bloodflow from

portal vein Primary hepatic malignancies derive 70% of bloodflow

from the hepatic artery

UCI HPB Surgeons