Anselmo A. Cirrosi Epatica e Tumori del Fegato: dalla Resezione al Trapianto. ASMaD 2015
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The document discusses cirrhosis and liver tumors, from resection to transplantation. It covers: - The epidemiology of liver cancer, including risk factors, global incidence, and age-specific incidence. - The pathogenesis and risk factors involved in the development of hepatocellular carcinoma (HCC). - The clinical features, diagnosis, and management of HCC according to guidelines from EASL and other sources. - Treatment options for HCC including resection, transplantation, and prevention.
![CT-scan
• Sensitivity and specificity by CT
67.5% and 92.5%
• Lesion is larger than 2 cm in diameter- 100% specificity
• Lesions of 1 to 2 cm - a second type of dynamic imaging
(magnetic resonance imaging [MRI] or contrast
ultrasonography)](https://image.slidesharecdn.com/remedi1dr-150331035003-conversion-gate01/85/Anselmo-A-Cirrosi-Epatica-e-Tumori-del-Fegato-dalla-Resezione-al-Trapianto-ASMaD-2015-31-320.jpg)
Anselmo A. Cirrosi Epatica e Tumori del Fegato: dalla Resezione al Trapianto. ASMaD 2015
- 1. "Cirrosi epatica e tumori del fegato: dalla resezione al trapianto" Alessandro Anselmo MD, Ph.D, FEBST UOC Chirurgia dei Trapianti Fondazione Policlinico Tor Vergata
- 2. • Introduction • Epidemiology • Pathophysiology • Clinical features • Management • Prevention
- 3. Introduction • Commonest primary malignant tumor of the liver • 6th most common cancer in the world • Third leading cause of cancer related death • More than 600,000 people die from HCC each year
- 4. Epidemiology • Men are more susceptible than women (male-to-female ratio 3.7 : 1.0) • Incidence increases with advancing age in all populations • Cirrhosis is a primary risk factor • Hepatitis and excessive alcohol are leading causes
- 5. • Hepatitis B virus - most frequent underlying cause world wide • 85% of HCC cases- Eastern and Southeastern Asian and Sub Saharan Africa (endemic HBV infection)
- 7. Journal of Hepatology 2012 vol. 56 j 908–943
- 8. Age-Specific Incidence Liver cancer program ,American Liver Foundation, Dec,2008
- 9. Liver cancer program ,American Liver Foundation, Dec,2008
- 10. Risk factors • Chronic hepatitis B or C virus infection. • Cirrhosis (any etiology) • Nonalcoholic steatohepatitis. • Diabetes (metabolic syndrome - likely risk process) • Europe, North America, and Japan- established cirrhosis
- 12. Origin of HCC • Cirrhotic liver(All causes) • Noncirrhotic liver Hepatitis B Fibrolamellar variant Metabolic diseases (eg, glycogenosis, porphyria) Hepatitis C
- 13. Incidence related to etiology of cirrhosis High incidence (>15%) HBV related HCV related Alcoholic Hemochromatosis Intermediate incidence (5-15%) NAFLD Low incidence (<5%) Primary biliary cirrhosis Wilsons disease Autoimmune hepatitis
- 14. Pathogenesis A stepwise process • Sequential genetic mutations • Oncogene activation • Tumor suppressor gene inactivation
- 15. Key mechanisms in development of HCC Liver cirrhosis following tissue damage - Mutations occurring in 1 or more oncogenic or tumor suppressor genes -Abnormalities in cellular signaling pathways Raf/MEK/ERK –PI3K/AKT/mTOR/β-catenin – Angiogenic signaling
- 21. Clinical features Small tumour: • Often asymptomatic • No physical signs • Signs related to the chronic liver disease and/or underlying cirrhosis Advanced disease: • Palpable mass in the upper abdomen, • Hard, irregular liver surface • Tenderness in the upper right abdominal quadrant • Splenomegaly, ascites • Hepatic arterial bruit (heard over the tumor) WGO practice
- 22. Suspicion of HCC in patients with previously compensated cirrhosis: • Rapid deterioration of liver function • New-onset (or refractory) ascites • Acute intra-abdominal bleeding • Increased jaundice • Weight loss and fever • New-onset encephalopathy • Variceal bleeding
- 23. Laboratory findings • Usually nonspecific • Signs of cirrhosis: Thrombocytopenia — Hypoalbuminemia — Hyperbilirubinemia — Coagulopathy • Electrolyte disturbances • Liver enzymes- abnormal( but nonspecific) • Elevated alpha fetoprotein (AFP; requires definitions of levels and appropriate setting) • Elevated alkaline phosphatase (ALP)
- 24. Diagnosis
- 26. Tumor markers Marker Sensitivit y(%) Specificit y(%) Cut off Remarks AFP Widely available a)High incidence regions 80-90 90 >10ng/ml b)Low incidence regions 25-65 79-95 16- 200ng/ml DCP 28-89 87-95 10- 125mAU/ ml AFP-L3 71 63 >10% Supports AFP if 10- 200
- 27. Novel markers • Glypican 3, • Golgi protein 73, • Hepatocyte growth factor, • Insulin growth factor 1, • Transforming growth factor-β1 • Clear cutoff values and comparisons with other markers have not been established
- 28. Imaging Ultrasonography • Detects most hepatocellular carcinomas • May not distinguish from other solid lesions • Low sensitivity(48%) & high specificity(97%)
- 29. Imaging CT-scan • Multiphase( dynamic) helical computed tomography(CT) - imaging technique of choice • Diagnostic pattern : - enhancement in the arterial phase - loss of central nodule enhancement (washout) in portal venous phase - capsular enhancement in the portal venous and delayed phases
- 31. CT-scan • Sensitivity and specificity by CT 67.5% and 92.5% • Lesion is larger than 2 cm in diameter- 100% specificity • Lesions of 1 to 2 cm - a second type of dynamic imaging (magnetic resonance imaging [MRI] or contrast ultrasonography)
- 32. MRI • Findings on multiphase contrast enhancement are similar to those of CT • Signal intensity on T1-weighted images is low • Sensitivity and specificity - 80.6% and 84.8%
- 33. MRI
- 34. Morpholgy (Robbins Pathologic basis of disease)
- 35. Treatment (WGO practice guidelines,2009)
- 38. “Una ferita al fegato è fuori dalle nostre cure, anzi, per evitare che la gente ci possa ritenere responsabili della morte dei parenti, è bene declinare ogni invito a intervenire chirurgicamente.” Ruggero di Frugardo, chirurgo salernitano XIII sec.
- 39. Anatomy, Diagnosis and preoperatory Planning
- 40. QuickTime™ e un decompressore sono necessari per visualizzare quest'immagine.
- 41. Clampaggi vascolariClampaggi vascolari a) manovra dia) manovra di PringlePringle b) clampaggiob) clampaggio selettivoselettivo c) clampaggioc) clampaggio soprailaresoprailare d) clampaggiod) clampaggio intraepaticointraepatico e) esclusionee) esclusione vascolarevascolare totaletotale
- 45. GENERATORE MANIPOLO CON SET DI ASSEMBLAGGIO ASPIRATORE CUSA: CAVITATIONAL ULTRASONIC SURGICAL ASPIRATION
- 46. COAGULATORE AD ARGON Rappresenta uno dei principali ausili nella chirurgia del fegato per minimizzare le perdite ematiche e biliari post operatorie
- 47. Radiofrequenza della trancia di sezione SCOPO ONCOLOGICO SCOPO EMOSTATICO (pre e post resezione)
- 48. EMOSTATICI
- 49. Resezioni x HCC: Quando?Resezioni x HCC: Quando? In assenza di cirrosi sono suscettibili di terapia resettiva con intento radicale: HCC in stadio I HCC in stadio II HCC in stadio IIIa (N0) In assenza di cirrosi sono suscettibili di terapia resettiva con intento non radicale: HCC in stadio IIIb (N1) Non sono resecabili: HCC in stadio IV
- 50. Resezioni x HCC: Quando?Resezioni x HCC: Quando? In presenza di cirrosi oltre allo stadio della neoplasia deve essere considerato la gravità della epatopatia secondo la classificazione di Child-Pough Child A Child B Child C 1 2 3 Encephalopathy - Minimal Marked Ascites - Slight Moderate Bilirubin <35 35-50 >50 Albumin >35 28-35 <28 INR <1.4 1.4-2.0 >2.0• A – 5-6 points B – 7-9 points C – 10-15 points
- 51. Resezione e TrapiantoResezione e Trapianto In presenza di cirrosi sono suscettibili di terapia resettiva Child A Child B In presenza di cirrosi sono suscettibili di trapianto di fegato HCC unico ∅ < 5 cm Child C HCC mutiplo monolobare ∅ max < 5 cm Child C
- 52. Sopravvivenza post-resezioneSopravvivenza post-resezione In assenza di cirrosi il follow-up dopo resezione con intento curativo Surv. a 1 anno 71% libero da malattia Surv. a 3 aa. 50% “ Surv. a 5 aa. 43% “ Surv. a 10 aa. 19% “ In presenza di cirrosi il follow-up dopo resezione con intento curativo Surv. a 3 aa. 29% libero da malattia Surv. a 5 aa. 20% “
- 53. Sopravvivenza post-trapiantoSopravvivenza post-trapianto Il follow-up dopo OLTx per HCC surv attuariale a 5 aa: Stadio I 75% Stadio II 68% Stadio III 52,1% Stadio IV 11%
- 54. Resezione Epatica:Resezione Epatica: TerminologiaTerminologia - Resezione atipica - Resezione limitata: 1-3 segmenti (mono- bi- tri- segmentectomia) - Resezione maggiore: >3 segmenti (emiepatectomia dx/sx ± allargata) - Resezione estrema: >5 segmenti o ricostruzione vascolare - Epatectomia totale (→ Trapianto epatico)
- 64. Segmentectomie
- 65. 2D “conventional” Laparoscopy Advantages • Less surgical trauma • Less postop. pain • Shorter postop. ileus and prompt return to oral intake • Shorter hospital stay • Faster return to normal activities and work
- 66. “Hand assisted” Laparoscopy In hand-assisted laparoscopic surgery (HALS), the surgeon inserts a hand into the abdomen while pneumoperitoneum is maintained and uses the hand to assist the laparoscopic instruments directly.
- 67. QuickTime™ e un decompressore H.264 sono necessari per visualizzare quest'immagine.
- 70. Laparoscopy • 3D HD technology restores the surgeon’s natural 3-D vision with depth perception making the endoscopic surgical field-of-view appear open. • This results in optimized hand eye coordination, helping to increase surgical speed and accuracy, offering clinical and economic benefits to hospitals and patients globally. • This is obtained with the use of helmets or polarized lenses glasses
- 71. Laparoscopy
- 72. Laparoscopy
- 73. Laparoscopy
- 74. Laparoscopy
- 76. Hand Assisted Laparoscopy Left Nephrectomy for big Epithelioid Angiomyolipoma
- 77. Hand Assisted Laparoscopy Left Bisegmentectomy for big Hemangioma of the liver
- 78. Hand Assisted Laparoscopy Left Bisegmentectomy for big Hemangioma of the liver
- 79. Hand Assisted Laparoscopy Left Bisegmentectomy for big Hemangioma of the liver
- 80. Hand Assisted Laparoscopy Left Bisegmentectomy for big Hemangioma of the liver
- 81. Hand Assisted Laparoscopy Left Bisegmentectomy for big Hemangioma of the liver
- 82. Hand Assisted Laparoscopy Left Bisegmentectomy for big Hemangioma of the liver
- 83. • Better image quality • Depth of field • Tactile feedback • Better ergonomy • Better precision • Reduction of postop. complications • Less stress for the surgeon • Costs reduction • Faster postop. recovery QuickTime™ e un decompressore H.264 sono necessari per visualizzare quest'immagine. Laparoscopy Advantages
- 85. Robotic Surgery
- 87. Trapianto di FegatoTrapianto di Fegato
- 88. Thank you for your attention!