Controversies in hepato-biliary surgery
- 1. AUBHO CONFERNECE 8/2015 P R E S E N T E D B Y : T H O M A S A L O I A , M D A S S O C P R O F O F S U R G I C A L O N C O L O G Y M D A N D E R S O N C A N C E R C E N T E R Controversies in HPB Surgery
- 2. Topics 1. Resectable hilar cholangiocarcinoma: Resection or OLT 2. Node-positive intrahepatic cholangiocarcinoma 3. Unresectable intrahepatic cholangiocarcinoma 4. Large HCC in early cirrhosis
- 3. Resectable Hilar Cholangiocarcinoma 55 y/o F presented to an OSH with epigastric fullness and abnormal LFTs. Workup included an MRI which demonstrated a small perihilar mass. No vascular involvement. ERCP identified a stricture with brushings suspicious for adenocarcinoma. EUS revealed a 1.2 cm hypoechoic mass with no lymphadenopathy. Mass Mass
- 4. Treatment Options? A. Chemoradiotherapy followed by OLT B. Resection C. Chemotherapy
- 5. Resectable Hilar Cholangiocarcinoma Patient seen by Transplant Team Told that survivals better after transplant Started on chemoradiation per the Mayo protocol. Taken to OR for transplantation, however, procedure aborted secondary to portal lymph node involvement. Developed jaundice and repeat ERCP was performed 2 metal stents were placed extending deep into right and left liver. Referred to MD Anderson for a second opinion.
- 6. Resectable Hilar Cholangiocarcinoma Multiphasic liver CT: Now What?
- 7. Resectable Hilar Cholangiocarcinoma Multiphasic liver CT: Referred to medical oncology for Gemcitabine and Cisplatin Re-evaluate in 3 – 6 months.
- 8. Hilar Cholangiocarcinoma 38 patients Unresectable Neoadjuvant 5-FU and external beam radiation Preoperative staging 5 year survival 82%, recurrence rate 13%
- 9. Hilar Cholangiocarcinoma 12 transplant centers, 287 patients. 53% 5 year survival and 65% recurrence free survival. 71 patients dropped out.
- 10. Hilar Cholangiocarcinoma Should resectable CCA be referred to OLT? Patients with clearly resectable de novo HC should be treated with resection. Patients with B-C type IV HC might be best treated with transplantation if they are excellent transplant candidates.
- 11. Topics 1. Resectable hilar cholangiocarcinoma: Resection or OLT 2. Node-positive intrahepatic cholangiocarcinoma 3. Unresectable intrahepatic cholangiocarcinoma 4. Large HCC in early cirrhosis
- 12. Node-positive Intrahepatic Cholangiocarcinoma 57 y/o F presented to the ED with epigastric pain CT scan:
- 13. Node-positive Intrahepatic Cholangiocarcinoma Biopsy: adenocarcinoma positive for CK7 and CK 20 CT suggested regional adenopathy EGD and colonoscopy – normal PET scan: large intensely hypermetabolic mass in the left liver. 10 cycles of Gemcitabine and Cisplatin – stable disease.
- 14. Treatment Options? A. Radiotherapy B. Resection C. Continued chemotherapy
- 15. Node-positive Intrahepatic Cholangiocarcinoma Biopsy: adenocarcinoma positive for CK7 and CK 20 CT suggested regional adenopathy EGD and colonoscopy – normal PET scan: large intensely hypermetabolic mass in the left liver. 10 cycles of Gemcitabine and Cisplatin – stable disease. Extended left hepatectomy + caudate and lymphadenectomy. Moderately differentiated cholangiocarcinoma with negative margins. 1 lymph node positive. T2a N1
- 18. Cholangiocarcinoma Adenocarcinoma Rich lymphatic plexus =Early metastatic disease
- 20. Node-positive Intrahepatic Cholangiocarcinoma Complete surgical resection provides the best option for long-term survival ⁽¹⁾. Factors with prognostic significance after ICC resection are the presence of vascular invasion, multiple tumors, and LNM ⁽²⁾. Some authors suggest that an LND should be performed in all patients with ICC in order to appropriately stage individuals and guide perioperative management. LN+ also constitutes an indication for neoadjuvant therapy. NCCN guidelines: Recommend considering a lymphadenectomy in resectable disease for accurate staging. Lymph node metastases beyond the porta hepatis (M1) contraindicates resection. 1 Herman J M and Pawlik T M, Hepatocellular Carcinoma, Gallbladder Cancer, and Cholangiocarcinoma, in Radiation Oncology: An Evidence-Based Approach, J.J. Lu and L.W. Brady, Editors. 2008. p. 221–243. 2 Cho S Y, Park S J, Kim S H, Han S S, Kim Y K, Lee K W, Lee S A, Hong E K, Lee W J, and Woo S M. Survival analysis of intrahepatic cholangiocarcinoma after resection. Annals of Surgical Oncology 2010; 17:1823–1830.
- 21. Topics 1. Resectable hilar cholangiocarcinoma: Resection or OLT 2. Node-positive intrahepatic cholangiocarcinoma 3. Unresectable intrahepatic cholangiocarcinoma 4. Large HCC in early cirrhosis
- 22. Unresectable IHCC 54 yo man presents with left liver cholangio, portal and gastric LAD, and a small right liver metastasis Stable on induction systemic therapy, but mounting toxicities Able to radiate but bowel at risk
- 23. Treatment Options? Options? A. Low dose radiation B. High dose radiation with bowel perforation risk 20% C. Experimental protocol chemotherapy
- 24. Non-target Radiation Risk Left Liver Cholangio overlying stomach
- 25. Alloderm Envelope with Clips
- 26. Alloderm Spacer in Place Clip Suture
- 30. “Ablative” IMRT 67.5 Gy /15 fractions
- 31. Results 12 patients Mean dose of radiation delivered was 76.1 Gy (58.1-100 Gy). Mean follow-up after completion of RT was 19.5 months. 2 patients developed mild radiation-induced GI toxicity (RTOG grade 2). No GI bleeding, RILD or readmission. RT was able to control liver disease in 42.9%. Only 2 patients had isolated in- field progression of liver disease. Overall survival rate was 72% over a 2 year period. Ismael/Crane/Aloia, in prep, 2015
- 32. Topics 1. Resectable hilar cholangiocarcinoma: Resection or OLT 2. Node-positive intrahepatic cholangiocarcinoma 3. Unresectable intrahepatic cholangiocarcinoma 4. Large HCC in early cirrhosis
- 33. Large HCC in Early Cirrhosis 60 y/o gentleman with chronic hepatitis B was diagnosed with a right liver mass (biopsy: well differentiated HCC). INR 0.9, PLT 344,000, Bilirubin 0.6, Albumin 4.5. Presented to MD Anderson for a second opinion. Volumetry: FLR for extended right hepatectomy = 28%.
- 34. Treatment Options? A. TACE alone B. Resection C. OLT D. Chemotherapy E. PVE F. Combination
- 35. Large HCC in Early Cirrhosis 60 y/o gentleman with chronic hepatitis B was diagnosed with a right liver mass (biopsy: well differentiated HCC). INR 0.9, PLT 344,000, Bilirubin 0.6, Albumin 4.5. Presented to MD Anderson for a second opinion. Volumetry: FLR for extended right hepatectomy = 28%. TACEPVE
- 36. Large HCC in Early Cirrhosis Preoperative imaging: FLR 36% KGR 2%-age points/week
- 37. Case Presentation • 61 yo male – EtOH Child’s A cirrhosis – Large central HCC • ERILS – Premeds – No narcotics – Steroids – Lidocaine – Epidural • Inflow Occlusion – 4 x 15 – EBL: 225cc – No transfusions • C-Gram • Air Leak Test – 4 parenchymal bile duct repairs Aloia, JACS, 2015 & Zimmitti, JACS, 2013
- 38. Case Presentation • 61 yo male – EtOH Child’s A cirrhosis – Large central HCC • Post Op: ERILS – No NG – No Narcotics – POD1 Diet and Exercise – POD2 Foley out – POD3 Drain Bili=1.4 • Drain removed – POD4 Epidural out – POD5 DC – Lovenox x 23d – Path: T1, N0, Marg- Aloia, JACS, 2015
- 39. Large HCC in Early Cirrhosis 16 patients underwent TACE followed by PVE with a 2 week hypertrophy of 22%. Concluded: procedure contributes to both the broadening of surgical indications and the safety of performing major hepatectomies in HCC patients with chronic liver disease.
- 40. Suggested Algorithm: HCC in Early Cirrhosis Low FLR T<5 cm TACE PVE T>5 cm ?Y90 PVE
- 41. ??????????? Thomas A. Aloia, MD E: [email protected] T: @mdahpbaloia