Traitement Chirurgical HCC Conf Zurich
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Transcript of Traitement Chirurgical HCC Conf Zurich
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Liver Resection For HCC
Eric Vibert, MD, PhD
Centre Hépato-Biliaire,
Hop. Paul Brousse
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10 years Recurrence Free Survival
22.4%
Février 2011
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2006
HCC < 2 cm
54 pts HBV versus 285 pts HCV
Différence à plus de 2 ans
28%
62%
15%
43%
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2000 – 2009 : 127 pts avec CHC sur cirrhose C / Résection R0
Diab. équilibré
Diab. non équilibré
Treatment of co-factor as diabete is also mandatory to decrease recurrence
En préop : BMI et plaquette plus élevés chez les diabétiques
RFS à 3 ans : 66% vs 27%
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2013
CHC < 3 cm
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1200 à 1500 Liver Graft / year in France….
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Which type of hepatectomy ?
AnatomicNon anatomic
Unique and inferior to 5 cm
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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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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%
Surgery > Local Destruction ifPlatelet > 150 000
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2005
Not the same liver, not the same resection…
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Recurrence free-survival was similar except in poor differenciated HCC
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Kinetics of AFP (Doubling time < 1 month) is more important than level to detect agressive HCC that required margin
No correlation between level
and kinetic (Dbl time)
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Very good accuracy to evaluate tumoral grading for CHC < 5 cm
81 Patients operated for unique CHC unique with preop. Percut. Biopsy
2011
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First Message
Agressive HCC (Satellite nod, AFP kinetic and poordifferentiated HCC) must be treated aggressively
with margin AND anatomical resection
Is feasible ?
The location is higlydeterminant
No choice Choice
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Minor hepatectomy
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2006
1997 – 2004 : 157 hepatectomies on cirrhosis
Child A : 93% / Minor resection 95% / Mortalité 7%
Insuf. Hépatique post-operatoire
Complications post-operatoires
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2006
No liver resection on cirrhosis if MELD > 11
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29 patients operated for HCC on Child A cirrhosis
Only hepatic venous pressure gradient > 10 mmHg was significant in multivariate analysis for decompensated cirrhosis after hepat.
Risk factor in univariate analysis
Bilirubin rateUrea rateRate of plateletICG ClearenceHepatic venous pressure gradiant,
1996
Ascite at 3 months po
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BCLC B BCLC C
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2008
1994-2004 : 455 pts opérés pour CHC / Suivi moy.: 46 mois384 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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Makuuchi et al., Semin Surg Oncol 1993
Ascites
None or controlled Not controlled
ICGR15 Limited resection Enucleation Not indicated for hepatectomy
Trisectorectomy bisectorectomy
Left-sided hepatectomyRight-sided
sectoriectomy
Segmentectomy Limited resection Enucleation
Normal 1.1 – 1.5 mg/dL 1.6 – 1.9 mg/dL > 2.0 mg/dL
Total bilirubin level
Normal 10% - 19% 30% - 39% > 40%20% - 29%
Assessment of ICG preoperatively
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Hépatectomie mineure Hépatectomie majeure
AUC 0,78 [0,66-0,90]Valeur seuil: 12,75
Sensibilité: 74%Spécificité: 71%
AUC: 0,66 [0,66-0,87]Sensibilité: 50%Spécificité: 88%
p=0,33
2012-2014 : 89 pts operated for HCC on cirrhosisMort : 2% - Liver Decomp : 34% (Ascite 93%)
ICG is the only preoperative data to predict Liver Decomp.
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90 pts including including 17 major hep. : 30% of liver decompensation (20% ascite)
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> 16 kpA: Ascite and/or POLF
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No evident difference between Laparoscopy and Laparotomy
70%
40%
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Foie Non Tumoral
Foie Tumoral
Si Récidive
SalvageRehépatectomie ?
De Principe
Bridge
Récidive Précoce
Récidive Tardive
CI à la TH
?
Le test of time…
Scatton et al. Liver Transpl. Fuks et al. Hepatology
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N= 35 malades
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Second Message
Minor hepatectomy is feasible if MELD < 12 andFibroScan < 17-20 kPa (or ICG-15’ < 13%)
Laparoscopy facilitates subsequent liver transplantation and must be used if oncological rules are respected
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Major hepatectomy
< 20% of standard liver volume or 0.5% body weight on non cirrhotic liver
Liver Surgical Planner (Available on iTunes)
Truant et al. JACS 2008Ribeiro, Vauthey et al. BJS 2007
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2003
PVE is an « effort test » for the pathological liver…
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2000-2010 : N= 231 pts (US) / 3 Centres
Plaquette Préop < 150.000 / mLCourbe ROC / Maj. Compl.
134 Maj. Hep / 3% PVE
JACS, Avril 2011
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Be careful… Hepatofugal flow…
No effect of portal vein embolization and risk of portal thrombosis
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TACE PVE Major Hep.
Rational of this strategy
1 PVE increases arterial flow and increases HCC vascularization2 Intra tumoral arterioportal shunt decrease PVE efficacy3 Blockage of intra-operative portal metastases
2003
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2011
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2009
PVE only or upfront hepatectomy…
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2006
Circulating Cells
Ant App. decreaseMassive Hemorrhage
(> 2 l) : 28% vs 7%
But no impact of recurrence…
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2000 – 2011 : 62 pts – 84% diabete32 (52%) Majors hepatectomies
TACE/PVE (n=8) et PVE (n=1)
38 (61%) abnormal liver parenchyma- F1/F2 ou Stéatohépatite (n=20)- F3/F4 (n=18)
15% des CHC réséqués en 2010
18% postop. mortality
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Non transplantable patient (Med 70 years) and CHC > 10 cm (75%)
Liver biopsy is mandatory to evaluated precisely parenchymaProtection of the liver parenchyma…. Clamping seems deleterious
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Third Message
No major hepatectomy in abnormalparenchyma without preoperative PVE,
especially before Right Hepatectomy
TACE before PVE in HCC < 5 cm improved survival
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Surgery is Usefull or not ?
Macroscopic Vascular Invasion
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BCLC B BCLC C
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Early tumor : ≤5 cm AND ≤3 nod AND no vascular invasion
Intermediate tumor : ≤5 cm AND >3 nod OR with vascular invasion>5 cm AND ≤3 nod AND no vascular invasion
Locally advanced tumor : ≤5 cm AND >3 nod AND with vascular invasion>5 cm AND >3 nod AND/OR vascular invasion
ECOG Performance Status1- Général status of pts:
Score de Child-Pugh2- Function reserve:
3 – Tumoral status:
4 - Envahissement extra-hépatique : Vasculaire et/ou métastatique
3856 ps – 79% HVB 38% resection, LT or ablation25% TACE as 1st treatment
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HKLC I
HKLC IIaHKLC IIb
HKLC Va (TH)
HKLC IIIa
HKLC IIIbHKLC IVa
HKLC Vb
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2046 patients including 297 pts BCLC C / Mort. 2.7%
25%
50%
2013
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Chir (n=70) vs Nexavar (n=44) in BCLC C in 4 Centers in France (Bondy, Creteil, Grenoble, Paul Brousse)
N=17
N=16
p=0.17
Propensity score to compare 2 populations
Constantin et al. Submitted to EASL
Globally no difference….
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But perhaps a role of adjuvant treatment
p=0.011
N=34N=44
25.2 m9.4 m
Constantin et al. Submitted to EASL
To explore…. Which treatment…
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Conclusions and Perspectives
• Oncological HCC resection imposed margin
– Prognostic value of margin according to diameter and genetic of HCC ?
• The location of HCC defined the type of surgery
– Staging of HCC must included also location
• Underlying liver parenchyma is the key
– Elastometry will replaced all and notably liver biopsy ?
• Surgical treatment of HCC BLCL C is feasible
– Adjuvant and perhaps neoadjuvant must be explored