Controversies in hepato-biliary surgery

AUBHO CONFERNECE8/2015

P R E S E N T ED BY:T H O M A S A L O I A , M DA SS O C P R O F O F S U R G I C A L O N C O L O G YM D A N D E R SO N C A N C ER C EN T E R

Controversies in HPB Surgery

Topics

1. Resectable hilar cholangiocarcinoma: Resection or OLT

2. Node-positive intrahepatic cholangiocarcinoma3. Unresectable intrahepatic cholangiocarcinoma4. Large HCC in early cirrhosis

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.

MassMass

Treatment Options?

A. Chemoradiotherapy followed by OLTB. ResectionC. Chemotherapy


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.


Multiphasic liver CT:

Now What?


Multiphasic liver CT:

Referred to medical oncology for Gemcitabine and Cisplatin Re-evaluate in 3 – 6 months.

Hilar Cholangiocarcinoma

38 patients Unresectable Neoadjuvant 5-FU and external beam radiation Preoperative staging 5 year survival 82%, recurrence rate 13%


12 transplant centers, 287 patients. 53% 5 year survival and 65% recurrence free survival. 71 patients dropped out.


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.

Topics



Node-positive Intrahepatic Cholangiocarcinoma

57 y/o F presented to the ED with epigastric pain CT scan:


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.

Treatment Options?

A. RadiotherapyB. ResectionC. Continued chemotherapy


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

Portal Node Dissection

Cholangiocarcinoma

Adenocarcinoma Rich lymphatic plexus =Early metastatic disease

Cholangiocarcinoma Lymphatic Drainage


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.

Topics



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

Treatment Options?

Options?A. Low dose radiationB. High dose radiation with bowel perforation risk

20%C. Experimental protocol chemotherapy

Non-target Radiation RiskLeft Liver

Cholangio

overlying stomach

Alloderm Envelope with Clips

Alloderm Spacer in PlaceClip Suture

MIS Alloderm Placement

MIS Alloderm Placement

duodenum

colon

3 cm

Envelope

Envelope

tumor

“Ablative” IMRT 67.5 Gy /15 fractions

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

Topics



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 righthepatectomy = 28%.

Treatment Options?

A. TACE aloneB. ResectionC. OLTD. ChemotherapyE. PVEF. Combination


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 righthepatectomy = 28%.

TACEPVE


Preoperative imaging: FLR 36% KGR 2%-age points/week

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 repairsAloia, JACS, 2015 & Zimmitti, JACS, 2013

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


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.

Suggested Algorithm: HCC in Early Cirrhosis

Low FLR

T<5 cm

TACE

PVE

T>5 cm

?Y90

PVE

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Thomas A. Aloia, MD E: [email protected] T: @mdahpbaloia

Education

Controversies in hepato-biliary surgery