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Chan SM, Cornman-Homonoff J, Lucatelli P, Madoff DC. Image-guided percutaneous strategies to improve the resectability of HCC: Portal vein embolization, liver venous deprivation, or radiation lobectomy? Clin Imaging 2024; 111:110185. [PMID: 38781614 DOI: 10.1016/j.clinimag.2024.110185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 04/20/2024] [Accepted: 05/08/2024] [Indexed: 05/25/2024]
Abstract
Despite considerable advances in surgical technique, many patients with hepatic malignancies are not operative candidates due to projected inadequate hepatic function following resection. Consequently, the size of the future liver remnant (FLR) is an essential consideration when predicting a patient's likelihood of liver insufficiency following hepatectomy. Since its initial description 30 years ago, portal vein embolization has become the standard of care for augmenting the size and function of the FLR preoperatively. However, new minimally invasive techniques have been developed to improve surgical candidacy, chief among them liver venous deprivation and radiation lobectomy. The purpose of this review is to discuss the status of preoperative liver augmentation prior to resection of hepatocellular carcinoma with a focus on these three techniques, highlighting the distinctions between them and suggesting directions for future investigation.
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Affiliation(s)
- Shin Mei Chan
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA; Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA
| | - Joshua Cornman-Homonoff
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA
| | - Pierleone Lucatelli
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - David C Madoff
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA; Department of Medicine, Section of Medical Oncology, Yale School of Medicine, New Haven, CT, USA; Department of Surgery, Section of Surgical Oncology, Yale School of Medicine, New Haven, CT, USA.
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Hu R, Xu J, Wang H, Wang J, Lei K, Zhao X, Zhang H, You K, Liu Z. Impact of preoperative transcatheter arterial chemoembolization (TACE) on postoperative long-term survival in patients with nonsmall hepatocellular carcinoma: a propensity score matching analysis. BMC Cancer 2024; 24:190. [PMID: 38336712 PMCID: PMC10858462 DOI: 10.1186/s12885-024-11978-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 02/07/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND The purpose of this propensity score matching (PSM) analysis was to compare the effects of preoperative transcatheter arterial chemoembolization (TACE) and non-TACE on the long-term survival of patients who undergo radical hepatectomy. METHODS PSM analysis was performed for 387 patients with hepatocellular carcinoma (HCC) (single > 3 cm or multiple) who underwent radical resection of HCC at our centre from January 2011 to June 2018. The patients were allocated to a preoperative TACE group (n = 77) and a non-TACE group (n = 310). The main outcome measures were progression-free survival (PFS) and overall survival (OS) since the treatment date. RESULTS After PSM, 67 patients were included in each of the TACE and non-TACE groups. The median PFS times in the preoperative TACE and non-TACE groups were 24.0 and 11.3 months, respectively (p = 0.0117). The median OS times in the preoperative TACE and non-TACE groups were 41.5 and 29.0 months, respectively (p = 0.0114). Multivariate Cox proportional hazard regression analysis revealed that preoperative TACE (hazard ratio, 1.733; 95% CI, 1.168-2.570) and tumour thrombosis (hazard ratio, 0.323; 95% CI, 0.141-0.742) were independent risk factors significantly associated with OS. CONCLUSIONS Preoperative TACE is related to improving PFS and OS after resection of HCC. Preoperative TACE and tumour thrombus volume were also found to be independent risk factors associated with OS.
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Affiliation(s)
- Run Hu
- The Second Affiliated Hospital of Chongqing Medical University, 74# Linjiang Road, Yuzhong District, Chongqing, 400000, China
| | - Jie Xu
- The Second Affiliated Hospital of Chongqing Medical University, 74# Linjiang Road, Yuzhong District, Chongqing, 400000, China
| | - Hongxiang Wang
- The Second Affiliated Hospital of Chongqing Medical University, 74# Linjiang Road, Yuzhong District, Chongqing, 400000, China
| | - Jiaguo Wang
- The Second Affiliated Hospital of Chongqing Medical University, 74# Linjiang Road, Yuzhong District, Chongqing, 400000, China
| | - Kai Lei
- The Second Affiliated Hospital of Chongqing Medical University, 74# Linjiang Road, Yuzhong District, Chongqing, 400000, China
| | - Xiaoping Zhao
- The Second Affiliated Hospital of Chongqing Medical University, 74# Linjiang Road, Yuzhong District, Chongqing, 400000, China
| | - Huizhi Zhang
- The Second Affiliated Hospital of Chongqing Medical University, 74# Linjiang Road, Yuzhong District, Chongqing, 400000, China
| | - Ke You
- The Second Affiliated Hospital of Chongqing Medical University, 74# Linjiang Road, Yuzhong District, Chongqing, 400000, China
| | - Zuojin Liu
- The Second Affiliated Hospital of Chongqing Medical University, 74# Linjiang Road, Yuzhong District, Chongqing, 400000, China.
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Rajakannu M, Cherqui D, Cunha AS, Castaing D, Adam R, Vibert E. Predictive nomograms for postoperative 90-day morbidity and mortality in patients undergoing liver resection for various hepatobiliary diseases. Surgery 2023; 173:993-1000. [PMID: 36669938 DOI: 10.1016/j.surg.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 11/10/2022] [Accepted: 11/13/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Postoperative complications affect the long-term survival and quality of life in patients undergoing liver resection. No model has yet been validated to predict 90-day severe morbidity and mortality. METHODS The prospective recruitment of patients undergoing liver resection for various indications was performed. Preoperative clinical and laboratory data, including liver stiffness, indocyanine green retention, and intraoperative parameters, were analyzed to develop predictive nomograms for postoperative severe morbidity and mortality. Calibration plots were used to perform external validation. RESULTS The most common indications in 418 liver resections performed were colorectal metastases (N = 149 [35.6%]), hepatocellular carcinoma (N = 106 [25.4%]), and benign liver tumors (N = 60 [14.3%]). Major liver resections were performed in 164 (39.2%) patients. Severe morbidity and mortality were observed in 87 (20.8%) and 9 (2.2%) of patients, respectively, during the 90-day postoperative period. Post-hepatectomy liver failure was observed in 19 (4.5%) patients, resulting in the death of 4. The independent predictors of 90-day severe morbidity were age (odds ratio:1.02, P = .06), liver stiffness (odds ratio: 1.23, P = .04], number of resected segments (odds ratio: 1.28, P = .004), and operative time (odds ratio: 1.01, P = .01). Independent predictors of 90-day mortality were diabetes mellitus (odds ratio: 6.6, P = .04), tumor size >50 mm (odds ratio:4.8, P = .08), liver stiffness ≥22 kPa (odds ratio:7.0, P = .04), and operative time ≥6 hours (odds ratio: 6.1, P = .05). Nomograms were developed using these independent predictors and validated by testing the Goodness of fit in calibration plots (P = .64 for severe morbidity; P = .8 for mortality). CONCLUSION Proposed nomograms would enable a personalized approach to identifying patients at risk of complications and adapting surgical treatment according to their clinical profile and the center's expertise.
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Affiliation(s)
- Muthukumarassamy Rajakannu
- Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Inserm, Unité UMR-S 1193, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Daniel Cherqui
- Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Antonio Sa Cunha
- Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Denis Castaing
- Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Inserm, Unité UMR-S 1193, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - René Adam
- Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Inserm, Unité UMR-S 1193, Villejuif, France; Inserm, Unité UMR-S 776, Villejuif, France
| | - Eric Vibert
- Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Inserm, Unité UMR-S 1193, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France. https://twitter.com/Eric_Vibert
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Cassese G, Han HS, Lee B, Cho JY, Lee HW, Guiu B, Panaro F, Troisi RI. Portal vein embolization failure: Current strategies and future perspectives to improve liver hypertrophy before major oncological liver resection. World J Gastrointest Oncol 2022; 14:2088-2096. [PMID: 36438704 PMCID: PMC9694272 DOI: 10.4251/wjgo.v14.i11.2088] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/01/2022] [Accepted: 10/31/2022] [Indexed: 11/15/2022] Open
Abstract
Portal vein embolization (PVE) is currently considered the standard of care to improve the volume of an inadequate future remnant liver (FRL) and decrease the risk of post-hepatectomy liver failure (PHLF). PHLF remains a significant limitation in performing major liver surgery and is the main cause of mortality after resection. The degree of hypertrophy obtained after PVE is variable and depends on multiple factors. Up to 20% of patients fail to undergo the planned surgery because of either an inadequate FRL growth or tumor progression after the PVE procedure (usually 6-8 wk are needed before surgery). The management of PVE failure is still debated, with a lack of consensus regarding the best clinical strategy. Different additional techniques have been proposed, such as sequential transarterial chemoembolization followed by PVE, segment 4 PVE, intra-portal administration of stem cells, dietary supplementation, and hepatic vein embolization. The aim of this review is to summarize the up-to-date strategies to overcome such difficult situations and discuss future perspectives on improving FRL hypertrophy.
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Affiliation(s)
- Gianluca Cassese
- Clinical Medicine and Surgery, Federico II University, Naples 80131, Italy
| | - Ho-Seong Han
- Department of Surgery, Seoul National University College of Medicine, Seongnam 13620, South Korea
| | - Boram Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam 13620, South Korea
| | - Jai Young Cho
- Department of Surgery, Seoul National University College of Medicine, Seongnam 13620, South Korea
| | - Hae Won Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam 13620, South Korea
| | - Boris Guiu
- Department of Medical Imaging and Interventional Radiology, St-Eloi University Hospital, Montpellier 34295, France
| | - Fabrizio Panaro
- Digestive Surgery and Transplantation, CHU de Montpellier, Montpellier 34295, France
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Botea F, Bârcu A, Kraft A, Popescu I, Linecker M. Parenchyma-Sparing Liver Resection or Regenerative Liver Surgery: Which Way to Go? MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1422. [PMID: 36295582 PMCID: PMC9609602 DOI: 10.3390/medicina58101422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/01/2022] [Accepted: 10/08/2022] [Indexed: 11/30/2022]
Abstract
Liver resection for malignant tumors should respect oncological margins while ensuring safety and improving the quality of life, therefore tumor staging, underlying liver disease and performance status should all be attentively assessed in the decision process. The concept of parenchyma-sparing liver surgery is nowadays used as an alternative to major hepatectomies to address deeply located lesions with intricate topography by means of complex multiplanar parenchyma-sparing liver resections, preferably under the guidance of intraoperative ultrasound. Regenerative liver surgery evolved as a liver growth induction method to increase resectability by stimulating the hypertrophy of the parenchyma intended to remain after resection (referred to as future liver remnant), achievable by portal vein embolization and liver venous deprivation as interventional approaches, and portal vein ligation and associating liver partition and portal vein ligation for staged hepatectomy as surgical techniques. Interestingly, although both strategies have the same conceptual origin, they eventually became caught in the never-ending parenchyma-sparing liver surgery vs. regenerative liver surgery debate. However, these strategies are both valid and must both be mastered and used to increase resectability. In our opinion, we consider parenchyma-sparing liver surgery along with techniques of complex liver resection and intraoperative ultrasound guidance the preferred strategy to treat liver tumors. In addition, liver volume-manipulating regenerative surgery should be employed when resectability needs to be extended beyond the possibilities of parenchyma-sparing liver surgery.
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Affiliation(s)
- Florin Botea
- Faculty of Medicine, “Titu Maiorescu” University, 031593 Bucharest, Romania
- “Dan Setlacec” Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Alexandru Bârcu
- Faculty of Medicine, “Titu Maiorescu” University, 031593 Bucharest, Romania
- “Dan Setlacec” Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Alin Kraft
- Faculty of Medicine, “Titu Maiorescu” University, 031593 Bucharest, Romania
| | - Irinel Popescu
- Faculty of Medicine, “Titu Maiorescu” University, 031593 Bucharest, Romania
- “Dan Setlacec” Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Michael Linecker
- Department of Surgery and Transplantation, UKSH Campus Kiel, 24105 Kiel, Germany
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Lerut J. Modern technology, liver surgery and transplantation. Hepatobiliary Pancreat Dis Int 2022; 21:307-309. [PMID: 35750600 DOI: 10.1016/j.hbpd.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 05/16/2022] [Indexed: 02/05/2023]
Affiliation(s)
- Jan Lerut
- Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Avenue Hippocrate 55 1200, Brussels, Belgium.
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Abstract
Liver resection is the standard curative treatment for liver cancer. Advances in surgical techniques over the last 30 years, including the preoperative assessment of the future liver remnant, have improved the safety of liver resection. In addition, advances in nonsurgical multidisciplinary treatment have increased the opportunities for tumor downstaging. Consequently, the indications for resection of more advanced liver cancer have expanded. Laparoscopic and robot-assisted liver resections have also gradually become more widespread. These techniques should be performed in stages, depending on the difficulty of the procedure. Advances in preoperative simulation and intraoperative navigation technology may have also lowered the threshold for their performance and may have promoted their widespread use. New insights and experiences gained from laparoscopic surgery may be applicable in open surgery. Liver transplantation, which is usually indicated for patients with poor liver function, has also become safer with advances in perioperative management. The indications for liver transplantation in liver cancer are also expanding. Although the coronavirus disease 2019 pandemic has forced the postponement of liver resection and transplantation procedures, liver surgeons should appropriately tailor the surgical plan to the individual patient as part of multidisciplinary treatment. This review may provide an entry point for future clinical research by identifying currently unresolved issues regarding liver cancer, and particularly hepatocellular carcinoma.
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Affiliation(s)
- Harufumi Maki
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Marques F, Ghallab M, Vibert E, Boleslawski E, Soubrane O, Adam R, Farges O, Mabrut JY, Régimbeau JM, Cherqui D, Allard MA, Sa Cunha A, Samuel D, Pruvot FR, Golse N. Prognostic impact of surgical margins for hepatocellular carcinoma according to preoperative alpha-fetoprotein level. HPB (Oxford) 2022; 24:848-856. [PMID: 34785122 DOI: 10.1016/j.hpb.2021.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/17/2021] [Accepted: 10/22/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND HCC are known to have satellite nodules and microvascular invasions requiring sufficient margins. An alpha-fetoprotein (AFP) level >100 ng/mL is associated with worse pathological features in HCC. In practice, large resection margins, particularly >1 cm, are infrequently retrieved on the specimens. METHODS 397 patients from 5 centres were included from 2012 to 2017. The primary endpoint was time-to-recurrence in relation to AFP level (> or <100 ng/ml) as well as surgical margins (> or <1 cm). The secondary endpoint was overall survival (OS). RESULTS The median follow-up was 25 months. In Low AFP group, median time to recurrence (TTR) for patients with margins <1 cm was 36 months and for patients with margins ≥1 cm was 34 months (p = 0.756), and overall survival (OS) was not significantly different according to margins (p = 0.079). In High-AFP group, patients with margins <1 cm had a higher recurrence rate than patients with margins ≥1 cm (p = 0.016): median TTR for patients with margins <1 cm was 8 months whereas it was not reached for patients with margins ≥1 cm. Patients with margins <1 cm had a significantly worse OS compared to the patients with margins ≥1 cm (p = 0.043). CONCLUSION Preoperative AFP level may help determine margins to effectively treat high AFP tumours. For low-AFP tumours, margins didn't have an impact on TTR or OS.
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Affiliation(s)
- Frédéric Marques
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif, 94800, France
| | - Mohammed Ghallab
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif, 94800, France; The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Eric Vibert
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif, 94800, France; Université Paris-Saclay, UMRS 1193, Université Paris-Saclay, Inserm, Physiopathogénèse et Traitement des Maladies Du Foie, FHU Hepatinov, 94800, Villejuif, France
| | - Emmanuel Boleslawski
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, Hôpital Claude Huriez, Lille, France
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, Hôpital Beaujon, Assistance Publique Hôpitaux de Paris, Université Paris Clichy, INSERM, Unit 776, Villejuif F-94800, France
| | - René Adam
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif, 94800, France; Univ Paris-Sud, UMR-S 776, Villejuif, 94800, France
| | - Olivier Farges
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, Hôpital Beaujon, Assistance Publique Hôpitaux de Paris, Université Paris Clichy, INSERM, Unit 776, Villejuif F-94800, France
| | - Jean-Yves Mabrut
- Department of General Surgery and Liver Transplantation, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
| | - Jean-Marc Régimbeau
- Department of Digestive and Oncological Surgery, Amiens University Hospital, Amiens, France
| | - Daniel Cherqui
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif, 94800, France; Université Paris-Saclay, UMRS 1193, Université Paris-Saclay, Inserm, Physiopathogénèse et Traitement des Maladies Du Foie, FHU Hepatinov, 94800, Villejuif, France
| | - Marc-Antoine Allard
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif, 94800, France; Université Paris-Saclay, UMRS 1193, Université Paris-Saclay, Inserm, Physiopathogénèse et Traitement des Maladies Du Foie, FHU Hepatinov, 94800, Villejuif, France
| | - Antonio Sa Cunha
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif, 94800, France; Université Paris-Saclay, UMRS 1193, Université Paris-Saclay, Inserm, Physiopathogénèse et Traitement des Maladies Du Foie, FHU Hepatinov, 94800, Villejuif, France
| | - Didier Samuel
- Université Paris-Saclay, UMRS 1193, Université Paris-Saclay, Inserm, Physiopathogénèse et Traitement des Maladies Du Foie, FHU Hepatinov, 94800, Villejuif, France; Department of Hepatology, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif, 94800, France
| | - François-René Pruvot
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, Hôpital Claude Huriez, Lille, France
| | - Nicolas Golse
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif, 94800, France; Université Paris-Saclay, UMRS 1193, Université Paris-Saclay, Inserm, Physiopathogénèse et Traitement des Maladies Du Foie, FHU Hepatinov, 94800, Villejuif, France.
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Papamichail M, Pizanias M, Heaton ND, M P, M P, Nd H. Minimizing the risk of small-for-size syndrome after liver surgery. Hepatobiliary Pancreat Dis Int 2022; 21:113-133. [PMID: 34961675 DOI: 10.1016/j.hbpd.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/06/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Primary and secondary liver tumors are not always amenable to resection due to location and size. Inadequate future liver remnant (FLR) may prevent patients from having a curative resection or may result in increased postoperative morbidity and mortality from complications related to small-for-size syndrome (SFSS). DATA SOURCES This comprehensive review analyzed the principles, mechanism and risk factors associated with SFSS and presented current available options in the evaluation of FLR when planning liver surgery. In addition, it provided a detailed description of specific modalities that can be used before, during or after surgery, in order to optimize the conditions for a safe resection and minimize the risk of SFSS. RESULTS Several methods which aim to reduce tumor burden, preserve healthy liver parenchyma, induce hypertrophy of FLR or prevent postoperative complications help minimize the risk of SFSS. CONCLUSIONS With those techniques the indications of radical treatment for patients with liver tumors have significantly expanded. The successful outcome depends on appropriate patient selection, the individualization and modification of interventions and the right timing of surgery.
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Affiliation(s)
- Michail Papamichail
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK.
| | - Michail Pizanias
- Department of General Surgery, Whittington Hospital, London N19 5NF, UK
| | - Nigel D Heaton
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
| | - Papamichail M
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK; Department of General Surgery, Whittington Hospital, London N19 5NF, UK; Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
| | - Pizanias M
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK; Department of General Surgery, Whittington Hospital, London N19 5NF, UK; Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
| | - Heaton Nd
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK; Department of General Surgery, Whittington Hospital, London N19 5NF, UK; Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
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10
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Del Basso C, Gaillard M, Lainas P, Zervaki S, Perlemuter G, Chagué P, Rocher L, Voican CS, Dagher I, Tranchart H. Current strategies to induce liver remnant hypertrophy before major liver resection. World J Hepatol 2021; 13:1629-1641. [PMID: 34904033 PMCID: PMC8637666 DOI: 10.4254/wjh.v13.i11.1629] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/08/2021] [Accepted: 10/11/2021] [Indexed: 02/06/2023] Open
Abstract
Hepatic resection is the gold standard for patients affected by primary or metastatic liver tumors but is hampered by the risk of post-hepatectomy liver failure. Despite recent improvements, liver surgery still requires excellent clinical judgement in selecting patients for surgery and, above all, efficient pre-operative strategies to provide adequate future liver remnant. The aim of this article is to review the literature on the rational, the preliminary assessment, the advantages as well as the limits of each existing technique for preparing the liver for major hepatectomy.
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Affiliation(s)
- Celeste Del Basso
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart 92140, France
| | - Martin Gaillard
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart 92140, France
| | - Panagiotis Lainas
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart 92140, France
| | - Stella Zervaki
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart 92140, France
| | - Gabriel Perlemuter
- Department of Hepato-Gastroenterology and Nutrition, Antoine Béclère Hospital, Clamart 92140, France
| | - Pierre Chagué
- Department of Radiology, Antoine Béclère Hospital, Clamart 92140, France
| | - Laurence Rocher
- Department of Radiology, Antoine Béclère Hospital, Clamart 92140, France
| | - Cosmin Sebastian Voican
- Department of Hepato-Gastroenterology and Nutrition, Antoine Béclère Hospital, Clamart 92140, France
| | - Ibrahim Dagher
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart 92140, France
| | - Hadrien Tranchart
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart 92140, France
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Hiramatsu K, Shindoh J, Hanaoka Y, Toda S, Ueno M, Matoba S, Kuroyanagi H. Postoperative Nutritional Status is Predictive of the Survival Outcomes in Patients Undergoing Resection of Stage III Colorectal Cancer. World J Surg 2021; 45:3198-3205. [PMID: 34143267 DOI: 10.1007/s00268-021-06202-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Preoperative nutritional status is reportedly associated with the clinical outcomes in patients with colorectal cancer (CRC), although it remains inconclusive whether the preoperative nutritional status that may improve after surgery is truly predictive of the survival outcomes of patients with CRC. METHODS Clinical records of patients with stage III CRC (n = 821) in whom curative resection had been achieved were retrospectively reviewed and the prognostic impact of nutritional status, determined by the controlling nutritional status (CONUT) score, was analyzed. RESULTS The CONUT undernutrition grade was significantly associated with the overall survival rate (OS) in the original population (P < 0.0001). By adopting a cut-off value of CONUT score of ≥ 2 and adjustment for clinical variables using the inverse probability treatment weighting methods, the group with a preoperative CONUT score of ≥ 2 showed a worse OS as compared to the groups with a preoperative CONUT score of < 2 (P = 0.037). However, sub-analysis based on the dynamic changes in the CONUT score revealed that sustained malnutrition in the postoperative period was more frequent among patients with preoperative CONUT score of ≥ 2, and that the OS and recurrence-free survival rate (RFS) were significantly correlated with the "postoperative" nutritional status, irrespective of the preoperative nutritional status. Patients who showed improvements of the nutritional status after surgery showed a significantly longer OS and RFS. CONCLUSIONS Sustained undernutrition or worsening of the nutritional status after colectomy may be associated with a worse OS and RFS after curative resection in patients with stage III CRC.
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Affiliation(s)
- Kosuke Hiramatsu
- Hepatobiliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Junichi Shindoh
- Hepatobiliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan.
- Okinaka Memorial Institute for Medical Disease, Tokyo, Japan.
| | - Yutaka Hanaoka
- Hepatobiliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Shigeo Toda
- Hepatobiliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Masashi Ueno
- Hepatobiliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Shuichiro Matoba
- Hepatobiliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Hiroya Kuroyanagi
- Hepatobiliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
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12
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Shao Z, Liu X, Peng C, Wang L, Xu D. Combination of transcatheter arterial chemoembolization and portal vein embolization for patients with hepatocellular carcinoma: a review. World J Surg Oncol 2021; 19:293. [PMID: 34598689 PMCID: PMC8487116 DOI: 10.1186/s12957-021-02401-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/15/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Transcatheter arterial chemoembolization has been widely used in patients with hepatocellular carcinoma. However, double blood supply and the existence of portal vein tumor thrombus influence the efficacy of transcatheter arterial chemoembolization. MAIN BODY Theoretically, portal vein embolization combined with transcatheter arterial chemoembolization may bring a breakthrough in the therapeutic effect of hepatocellular carcinoma. The feasibility, efficacy, long-term survival benefits, and side effects of the combined treatment have been explored in previous studies. Chemotherapeutic agents may also be added in the portal vein embolization procedure to further improve the treatment response. CONCLUSION In this study, we review the existing data and studies on the combined treatment in patients with hepatocellular carcinoma and provide an overall view of the strategy.
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Affiliation(s)
- Zhiying Shao
- Department of Interventional Ultrasound, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences , No. 1 East Banshan Road, Gongshu District, Hangzhou, 310022, People's Republic of China
| | - Xin Liu
- Department of Interventional Ultrasound, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences , No. 1 East Banshan Road, Gongshu District, Hangzhou, 310022, People's Republic of China
| | - Chanjuan Peng
- Department of Interventional Ultrasound, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences , No. 1 East Banshan Road, Gongshu District, Hangzhou, 310022, People's Republic of China
| | - Liping Wang
- Department of Interventional Ultrasound, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences , No. 1 East Banshan Road, Gongshu District, Hangzhou, 310022, People's Republic of China
| | - Dong Xu
- Department of Interventional Ultrasound, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences , No. 1 East Banshan Road, Gongshu District, Hangzhou, 310022, People's Republic of China.
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13
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Transcatheter arterial chemoembolization followed by surgical resection for hepatocellular carcinoma: a focus on its controversies and screening of patients most likely to benefit. Chin Med J (Engl) 2021; 134:2275-2286. [PMID: 34593696 PMCID: PMC8509936 DOI: 10.1097/cm9.0000000000001767] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Surgical resection (SR) is recommended as a radical procedure in the treatment of hepatocellular carcinoma (HCC). However, postoperative recurrence negatively affects the long-term efficacy of SR, and preoperative adjuvant therapy has therefore become a research hotspot. Some clinicians adopt transcatheter arterial chemoembolization (TACE) as a preoperative adjuvant therapy in patients undergoing SR to increase the resection rate, reduce tumor recurrence, and improve the prognosis. However, the findings of the most relevant studies remain controversial. Some studies have confirmed that preoperative TACE cannot improve the long-term survival rate of patients with HCC and might even negatively affect the resection rate. Which factors influence the efficacy of preoperative TACE combined with SR is a topic worthy of investigation. In this review, existing clinical studies were analyzed with a particular focus on several topics: screening of the subgroups of patients most likely to benefit from preoperative TACE, exploration of the optimal treatment regimen of preoperative TACE, and determination of the extent of tumor necrosis as the deciding prognostic factor.
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14
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Memeo R, Conticchio M, Deshayes E, Nadalin S, Herrero A, Guiu B, Panaro F. Optimization of the future remnant liver: review of the current strategies in Europe. Hepatobiliary Surg Nutr 2021; 10:350-363. [PMID: 34159162 DOI: 10.21037/hbsn-20-394] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Liver resection still represent the treatment of choice for liver malignancies, but in some cases inadequate future remnant liver (FRL) can lead to post hepatectomy liver failure (PHLF) that still represents the most common cause of death after hepatectomy. Several strategies in recent era have been developed in order to generate a compensatory hypertrophy of the FRL, reducing the risk of post hepatectomy liver failure. Portal vein embolization, portal vein ligation, and ALLPS are the most popular techniques historically adopted up to now. The liver venous deprivation and the radio-embolization are the most recent promising techniques. Despite even more precise tools to calculate the relationship among volume and function, such as scintigraphy with 99mTc-mebrofenin (HBS), no consensus is still available to define which of the above mentioned augmentation strategy is more adequate in terms of kind of surgery, complexity of the pathology and quality of liver parenchyma. The aim of this article is to analyse these different strategies to achieve sufficient FRL.
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Affiliation(s)
- Riccardo Memeo
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, "F. Miulli" General Hospital, Acquaviva delle Fonti, Bari, Italy
| | | | - Emmanuel Deshayes
- Department of Nuclear Medicine, Institute du Cancer de Montpellier (ICM), Montpellier, France.,INSERM U1194, Montpellier Cancer Research Institute, Montpellier University, Montpellier, France
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Germany
| | - Astrid Herrero
- Department of Surgery, Division of HBP Surgery and Liver Transplantation, St-Eloi University Hospital, Montpellier, France
| | - Boris Guiu
- INSERM U1194, Montpellier Cancer Research Institute, Montpellier University, Montpellier, France.,Department of Radiology, St-Eloi University Hospital, Montpellier, France
| | - Fabrizio Panaro
- Department of Surgery, Division of HBP Surgery and Liver Transplantation, St-Eloi University Hospital, Montpellier, France
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15
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Fang T, Xiao J, Zhang Y, Hu H, Zhu Y, Cheng Y. Combined with interventional therapy, immunotherapy can create a new outlook for tumor treatment. Quant Imaging Med Surg 2021; 11:2837-2860. [PMID: 34079746 PMCID: PMC8107298 DOI: 10.21037/qims-20-173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/01/2021] [Indexed: 02/06/2023]
Abstract
Recent progress in immunotherapy provides hope of a complete cure to cancer patients. However, recent studies have reported that only a limited number of cancer patients with a specific immune status, known as "cold tumor", can benefit from a single immune agent. Although the combination of immune agents with different mechanisms can partially increase the low response rate and improve efficacy, it can also result in more side effects. Therefore, discovering therapies that can improve tumors' response rate to immunotherapy without increasing toxicity for patients is urgently needed. Tumor interventional therapy is promising. It mainly includes transcatheter arterial chemoembolization, ablation, radioactive particle internal irradiation, and photodynamic interventional therapy based on a luminal stent. Interventional therapy can directly kill tumor cells by targeted drug delivery in situ, thus reducing drug dosage and systemic toxicity like cytokine release syndrome. More importantly, interventional therapy can regulate the immune system through numerous mechanisms, making it a suitable choice for immunotherapy to combine with. In this review, we provide a brief description of immunotherapies (and their side effects) on tumors of different immune types and preliminarily elaborate on interventional therapy mechanisms to improve immune efficacy. We also discuss the progress and challenges of the combination of interventional therapy and immunotherapy.
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Affiliation(s)
- Tonglei Fang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Junyuan Xiao
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yiran Zhang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Haiyan Hu
- Department of Oncology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yueqi Zhu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yingsheng Cheng
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
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16
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Beppu T, Yamamura K, Okabe H, Imai K, Hayashi H. Oncological benefits of portal vein embolization for patients with hepatocellular carcinoma. Ann Gastroenterol Surg 2021; 5:287-295. [PMID: 34095718 PMCID: PMC8164464 DOI: 10.1002/ags3.12414] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 10/29/2020] [Accepted: 11/18/2020] [Indexed: 12/28/2022] Open
Abstract
Portal vein embolization (PVE) for hepatocellular carcinoma (HCC) was first introduced in 1986 and has been continuously developed throughout the years. Basically, PVE has been applied to expand the indication of liver resection for HCC patients of insufficient future liver remnant. Importantly, PVE can result in tumor progression in both embolized and non-embolized livers; however, long-term survival after liver resection following PVE is at least not inferior compared with liver resection alone despite the smaller future liver remnant volume. Five-year disease-free survival and 5-year overall survival were 17% to 49% and 12% to 53% in non-PVE patients, and 21% to 78% and 44% to 72% in PVE patients, respectively. At present, it has proven that PVE has multiple oncological advantages for both surgical and nonsurgical treatments. PVE can also enhance the anticancer effects of transarterial chemoembolization and can avoid intraportal tumor cell dissemination. Additional interventional transarterial chemoembolization and hepatic vein embolization as well as surgical two-stage hepatectomy and associated liver partition and portal vein ligation for staged hepatectomy can enhance the oncological benefit of PVE monotherapy. Taken together, PVE is an important treatment which we recommend for listing in the guidelines for HCC treatment strategies.
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Affiliation(s)
- Toru Beppu
- Department of SurgeryYamaga City Medical CenterKumamotoJapan
- Department of Gastroenterological SurgeryGraduate School of Life SciencesKumamoto UniversityKumamotoJapan
| | - Kensuke Yamamura
- Department of SurgeryYamaga City Medical CenterKumamotoJapan
- Department of Gastroenterological SurgeryGraduate School of Life SciencesKumamoto UniversityKumamotoJapan
| | - Hirohisa Okabe
- Department of Gastroenterological SurgeryGraduate School of Life SciencesKumamoto UniversityKumamotoJapan
| | - Katsunori Imai
- Department of Gastroenterological SurgeryGraduate School of Life SciencesKumamoto UniversityKumamotoJapan
| | - Hiromitsu Hayashi
- Department of Gastroenterological SurgeryGraduate School of Life SciencesKumamoto UniversityKumamotoJapan
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17
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Guiu B, Herrero A, Panaro F. Liver venous deprivation: a bright future for liver metastases-but what about hepatocellular carcinoma? Hepatobiliary Surg Nutr 2021; 10:270-272. [PMID: 33898575 DOI: 10.21037/hbsn-21-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Boris Guiu
- Department of Radiology, St-Eloi University Hospital, Montpellier, France
| | - Astrid Herrero
- Department of HBP Surgery & Transplantation, St-Eloi University Hospital, Montpellier, France
| | - Fabrizio Panaro
- Department of HBP Surgery & Transplantation, St-Eloi University Hospital, Montpellier, France
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18
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Induction of liver hypertrophy for extended liver surgery and partial liver transplantation: State of the art of parenchyma augmentation-assisted liver surgery. Langenbecks Arch Surg 2021; 406:2201-2215. [PMID: 33740114 PMCID: PMC8578101 DOI: 10.1007/s00423-021-02148-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/03/2021] [Indexed: 12/17/2022]
Abstract
Background Liver surgery and transplantation currently represent the only curative treatment options for primary and secondary hepatic malignancies. Despite the ability of the liver to regenerate after tissue loss, 25–30% future liver remnant is considered the minimum requirement to prevent serious risk for post-hepatectomy liver failure. Purpose The aim of this review is to depict the various interventions for liver parenchyma augmentation–assisting surgery enabling extended liver resections. The article summarizes one- and two-stage procedures with a focus on hypertrophy- and corresponding resection rates. Conclusions To induce liver parenchymal augmentation prior to hepatectomy, most techniques rely on portal vein occlusion, but more recently inclusion of parenchymal splitting, hepatic vein occlusion, and partial liver transplantation has extended the technical armamentarium. Safely accomplishing major and ultimately total hepatectomy by these techniques requires integration into a meaningful oncological concept. The advent of highly effective chemotherapeutic regimen in the neo-adjuvant, interstage, and adjuvant setting has underlined an aggressive surgical approach in the given setting to convert formerly “palliative” disease into a curative and sometimes in a “chronic” disease.
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19
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Konishi T, Takamoto T, Hashimoto T, Makuuchi M. Is portal vein embolization safe and effective for patients with impaired liver function? J Surg Oncol 2021; 123:1742-1749. [PMID: 33657243 DOI: 10.1002/jso.26447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 02/16/2021] [Accepted: 02/19/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Portal vein embolization (PVE) is a safe and effective procedure used to increase the safety of extensive hepatectomy for selected patients. However, it is unknown whether PVE is safe for patients with impaired liver functional reserve. METHODS Patients who underwent PVE from April 2007 to September 2016 in our hospital were retrospectively assessed. According to indocyanine green retention rate at 15 min (ICG-R15), we divided patients into Group A (≤10%), Group B (10%-20%), and Group C (>20%). We described and compared the treatment course and the outcome among the three groups. RESULTS A total of 106 patients were assessed and divided into groups A (n = 46), B (n = 49), and C (n = 11). The morbidity and mortality after PVE showed no significant differences among the three groups (A:B:C = 37%:53%:64%, p = .16; A:B:C = 0%:0%:0%, p = 1.00, respectively). The morbidity and mortality after successive hepatectomy also showed no significant differences among the three groups (A:B:C = 55%:71%:78%, p = .19; A:B:C = 0%:2%:0%, p = 1.00, respectively). CONCLUSION A patient with impaired liver functional reserve (ICG-R15 > 20%) can be a candidate for PVE and successive hepatectomy, as safely as a patient with normal and slightly impaired liver functional reserve (ICG-R15 ≤ 20%).
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Affiliation(s)
- Takaaki Konishi
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeshi Takamoto
- Division of Hepato-Biliary-Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Takuya Hashimoto
- Division of Hepato-Biliary-Pancreatic and Transplantation Surgery, Japanese Red Cross Medical Center, Tokyo, Japan
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20
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Bekki Y, Marti J, Toshima T, Lewis S, Kamath A, Argiriadi P, Simpson W, Facciuto L, Patel RS, Gunasekaran G, Kim E, Schiano TD, Facciuto ME. A comparative study of portal vein embolization versus radiation lobectomy with Yttrium-90 micropheres in preparation for liver resection for initially unresectable hepatocellular carcinoma. Surgery 2021; 169:1044-1051. [PMID: 33648768 DOI: 10.1016/j.surg.2020.12.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Portal vein embolization before liver resection is considered the therapy of choice for patients with inadequate future liver remnants. The concept of radioembolization with Yttrium-90 to achieve the same goal has limited data. METHODS We retrospectively compared patients who underwent portal vein embolization and Yttrium-90 lobectomy before resection of hepatocellular carcinoma in patients with chronic liver disease. RESULTS Seventy-three patients underwent portal vein embolization and 22 patients underwent Yttrium-90. Forty-seven percent of patients before portal vein embolization required additional procedures for tumor control, and 27% of patients after Yttrium-90 required additional procedure to mainly induce further hypertrophy. Both therapies achieved the goal of future liver remnants >40%, but the degree of hypertrophy was significantly higher in Yttrium-90 patients (63% for Yttrium-90, 36% for portal vein embolization, P < .01). Tumor response was significantly better with Yttrium-90, achieving complete response in 50% of patients. Resectability rate was higher after portal vein embolization (85% for portal vein embolization, 64% for Yttrium-90, P = .03). Tumor progression was the most common reason precluding surgery. Complete tumor control was the reason not to pursue surgery in 18% of patients after Yttrium-90. CONCLUSION Both preoperative portal vein embolization and Yttrium-90, increases liver resectability rates by inducing hypertrophy of future liver remnants in patients with hepatocellular carcinoma and chronic liver disease. Yttrium-90 lobectomy achieved better tumor control and provided more time to assess therapy response, optimizing the indication for surgery.
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Affiliation(s)
- Yuki Bekki
- Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Josep Marti
- Department of Surgery, Centre Médico-Chirurgical de Tronquières, Aurillac, France
| | - Takeo Toshima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Sara Lewis
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Amita Kamath
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Pamela Argiriadi
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - William Simpson
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lucas Facciuto
- Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rahul S Patel
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ganesh Gunasekaran
- Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Edward Kim
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Thomas D Schiano
- Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Marcelo E Facciuto
- Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
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21
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Shehta A, Lee JM, Suh KS, Kim HC, Hong SK, Cho JH, Yi NJ, Lee KW. Bridging and downstaging role of trans-arterial radio-embolization for expected small remnant volume before liver resection for hepatocellular carcinoma. Ann Hepatobiliary Pancreat Surg 2020; 24:421-430. [PMID: 33234744 PMCID: PMC7691198 DOI: 10.14701/ahbps.2020.24.4.421] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/13/2020] [Accepted: 07/13/2020] [Indexed: 02/06/2023] Open
Abstract
Backgrounds/Aims To evaluate our initial experience of bridging role of trans-arterial radio-embolization (TARE) before major hepatectomy for hepatocellular carcinoma (HCC) in risky patients with small expected remnant liver volume (ERLV). Methods We reviewed the data of patients with HCC who underwent major hepatectomy after TARE during the period between March and December 2017. Patients included had uni-lobar large HCC (>5 cm) requiring major hepatectomy with small ERLV. Results Five patients were included in our study. All patients were Child Pugh class A. A single session of TARE was applied in all patients. None developed any adverse events related to irradiation. The mean tumor size at baseline was 8.4 cm and 6.1 cm after TARE (p=0.077). The mean % of tumor shrinkage was 24.5%. ERLV improved from 354.6 ml at baseline to 500.8 ml after TARE (p=0.012). ERLV percentage improved from 27.2% at baseline to 38.1% after TARE (p=0.004). The mean % of ERLV was 39.5%. The mean interval time between TARE and resection was 99.6 days. Four patients (80%) underwent right hemi-hepatectomy and one patient (20%) underwent extended right hemi-hepatectomy. The mean operation time was 151 minutes, and mean blood loss was 56 ml. The mean hospital stay was 13.8 days, and one patient (20%) developed postoperative morbidity. After a mean follow-up of 15 months, all patients were alive with no recurrence. Conclusions Yttrium-90 TARE can play a bridging role before major hepatectomy for borderline resectable HCC in risky patients with small ERLV.
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Affiliation(s)
- Ahmed Shehta
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Liver Transplantation Unit, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - Jeong-Moo Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyo-Cheol Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae-Hyung Cho
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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22
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Abstract
Patients with hepatocellular carcinoma (HCC) have many treatment options. For patients with surgical indication, consideration of future liver remnant and the surgical complexity of the procedure is essential. A new 3-level complexity classification categorizing 11 liver resection procedures predicts surgical complexity and postoperative morbidity better than reported classifications. Preoperative portal vein embolization can mitigate the risk of hepatic insufficiency. For small HCCs, both liver resection and ablation are effective. New medical treatment options are promising and perioperative use of these drugs may further improve outcomes for patients undergoing liver resection and lead to changes in current treatment guidelines.
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Affiliation(s)
- Yoshikuni Kawaguchi
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX 77030, USA; Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Heather A Lillemoe
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX 77030, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX 77030, USA.
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23
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Issues to be considered to address the future liver remnant prior to major hepatectomy. Surg Today 2020; 51:472-484. [PMID: 32894345 DOI: 10.1007/s00595-020-02088-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/08/2020] [Indexed: 02/08/2023]
Abstract
An accurate preoperative evaluation of the hepatic function and application of portal vein embolization in selected patients have helped improve the safety of major hepatectomy. In planning major hepatectomy, however, several issues remain to be addressed. The first is which cut-off values for serum total bilirubin level and prothrombin time should be used to define post-hepatectomy liver failure. Other issues include what minimum future liver remnant (FLR) volume is required; whether the total liver volume measured using computed tomography or the standard liver volume calculated based on the body surface area should be used to assess the adequacy of the FLR volume; whether there is a discrepancy between the FLR volume and function during the recovery period after portal vein embolization or hepatectomy; and how best the function of a specific FLR can be assessed. Various studies concerning these issues have been reported with controversial results. We should also be aware that different strategies and management are required for different types of liver damage, such as cirrhosis in hepatocellular carcinoma, cholangitis in biliary tract cancer, and chemotherapy-induced hepatic injury.
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Zhang CW, Dou CW, Zhang XL, Liu XQ, Huang DS, Hu ZM, Liu J. Simultaneous transcatheter arterial chemoembolization and portal vein embolization for patients with large hepatocellular carcinoma before major hepatectomy. World J Gastroenterol 2020; 26:4489-4500. [PMID: 32874060 PMCID: PMC7438194 DOI: 10.3748/wjg.v26.i30.4489] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/10/2020] [Accepted: 07/14/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Sequential transarterial chemoembolization (TACE) and portal vein embolization (PVE) are associated with long time interval that can allow tumor growth and nullify treatments' benefits.
AIM To evaluate the effect of simultaneous TACE and PVE for patients with large hepatocellular carcinoma (HCC) prior to elective major hepatectomy.
METHODS Fifty-one patients with large HCC who underwent PVE combined with or without TACE prior to hepatectomy were included in this study, with 13 patients in the simultaneous TACE + PVE group, 17 patients in the sequential TACE + PVE group, and 21 patients in the PVE-only group. The outcomes of the procedures were compared and analyzed.
RESULTS All patients underwent embolization. The mean interval from embolization to surgery, the kinetic growth rate of the future liver remnant (FLR), the degree of tumor size reduction, and complete tumor necrosis were significantly better in the simultaneous TACE + PVE group than in the other groups. Although the patients in the simultaneous TACE + PVE group had a higher transaminase levels after PVE and TACE, they recovered to comparable levels with the other two groups before surgery. The intraoperative course and the complication and mortality rates were similar among the three groups. The overall survival and disease-free survival were higher in the simultaneous TACE + PVE group than in the other two groups.
CONCLUSION Simultaneous TACE and PVE is a safe and effective approach to increase FLR volume for patients with large HCC before major hepatectomy.
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Affiliation(s)
- Cheng-Wu Zhang
- Department of Hepatopancreatobiliary Surgery and Minimally Invasive Surgery, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310014, Zhejiang Province, China
| | - Chang-Wei Dou
- Department of Hepatopancreatobiliary Surgery and Minimally Invasive Surgery, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310014, Zhejiang Province, China
| | - Xin-Long Zhang
- Department of General Surgery, Aksu Area First Hospital, Aksu 843000, Xinjiang Uygur Autonomous Region, China
| | - Xi-Qiang Liu
- Department of Hepatopancreatobiliary Surgery and Minimally Invasive Surgery, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310014, Zhejiang Province, China
| | - Dong-Shen Huang
- Department of Hepatopancreatobiliary Surgery and Minimally Invasive Surgery, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310014, Zhejiang Province, China
| | - Zhi-Ming Hu
- Department of Hepatopancreatobiliary Surgery and Minimally Invasive Surgery, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310014, Zhejiang Province, China
| | - Jie Liu
- Department of Hepatopancreatobiliary Surgery and Minimally Invasive Surgery, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310014, Zhejiang Province, China
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Allaire M, Goumard C, Lim C, Le Cleach A, Wagner M, Scatton O. New frontiers in liver resection for hepatocellular carcinoma. JHEP Rep 2020; 2:100134. [PMID: 32695968 PMCID: PMC7360891 DOI: 10.1016/j.jhepr.2020.100134] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 04/23/2020] [Accepted: 05/15/2020] [Indexed: 02/08/2023] Open
Abstract
Liver resection is one of the main curative options for early hepatocellular carcinoma (HCC) in patients with cirrhosis and is the treatment of choice in non-cirrhotic patients. However, careful patient selection is required to balance the risk of postoperative liver failure and the potential benefit on long-term outcomes. In the last decades, improved surgical techniques and perioperative management, as well as better patient selection, have enabled the indications for liver resection to be expanded. In this review, we aim to describe the main indications for liver resection in the management of HCC, its role compared to percutaneous ablation and liver transplantation in the therapeutic algorithm, as well as the recent advances in liver surgery that could be used to improve the prognosis of patients with HCC.
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Key Words
- ALPPS, associating liver partition and portal vein ligation for staged hepatectomy
- BCLC, Barcelona Clinic liver cancer
- CSPH, clinically significant portal hypertension
- DFS, disease-free survival
- GSA, galactosyl serum albumin
- HCC
- HCC, hepatocellular carcinoma
- HVGP, hepatic venous pression gradient
- ICG, indocyanine green
- ICG-R15, hepatic clearance of ICG 15 minutes after its intravenous administration
- IL-6, interleukin 6
- LR, liver resection
- LSM, liver stiffness measurement
- Laparoscopy
- Liver resection
- MELD, model for end-stage liver disease
- NAFLD, non-alcoholic fatty liver disease
- OS, overall survival
- PVL, portal vein ligation
- PVTT, tumour-related portal vein thrombosis
- RFA, radiofrequency ablation
- SSM, spleen stiffness measurement
- Surgery
- TACE, transarterial chemoembolisation
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Affiliation(s)
- Manon Allaire
- Sorbonne Université, Service d'Hépatologie, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, AP-HP, Paris, France
- Inserm U1149, Centre de Recherche sur l'Inflammation, France Faculté de Médecine Xavier Bichat, Université Paris Diderot, Paris, France
| | - Claire Goumard
- Sorbonne Université, CRSA, Service de chirurgie digestive, hépato-biliaire et transplantation hépatique, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, AP-HP, Paris, France
| | - Chetana Lim
- Sorbonne Université, CRSA, Service de chirurgie digestive, hépato-biliaire et transplantation hépatique, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, AP-HP, Paris, France
| | - Aline Le Cleach
- Sorbonne Université, Service d'Hépatologie, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, AP-HP, Paris, France
| | - Mathilde Wagner
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale (LIB), Service de Radiologie, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, AP-HP, Paris, France
| | - Olivier Scatton
- Sorbonne Université, CRSA, Service de chirurgie digestive, hépato-biliaire et transplantation hépatique, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, AP-HP, Paris, France
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Balci D, Sakamoto Y, Li J, Di Benedetto F, Kirimker EO, Petrowsky H. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure for cholangiocarcinoma. Int J Surg 2020; 82S:97-102. [PMID: 32645441 DOI: 10.1016/j.ijsu.2020.06.045] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 06/26/2020] [Indexed: 12/15/2022]
Abstract
Perihilar cholangiocarcinoma (PHCC) has been a great challenge for surgeons, requiring advanced skills and expertise and was often associated with high morbidity and mortality. Resectability rates are up to 75% even in experienced centers. In patients with PHCC, radical liver and bile duct resection aiming R0 surgical margins offers the best long-term survival. Therefore, extensive resections with low FLR are commonly needed and PVE is offered to induce remnant liver hypertrophy for a long period. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) is considered a promising approach inducing rapid remnant hypertrophy to prevent dropouts due to complications or tumor progression and increase resectability. Although poor results were reported initially, refinements in technique and risk adjustment of patient selection improved outcomes. The procedure is still under debate for the indication of PHCC. This article reviews the current literature on ALPPS in treatment of perihilar and intrahepatic cholangiocarcinoma.
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Affiliation(s)
- Deniz Balci
- Department of Surgery and Liver Transplantation Unit, Ankara University School of Medicine, Ankara, Turkey.
| | - Yoshihiro Sakamoto
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Japan.
| | - Jun Li
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy.
| | - Elvan Onur Kirimker
- Department of Surgery and Liver Transplantation Unit, Ankara University School of Medicine, Ankara, Turkey.
| | - Henrik Petrowsky
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland.
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27
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Chan KS, Low JK, Shelat VG. Associated liver partition and portal vein ligation for staged hepatectomy: a review. Transl Gastroenterol Hepatol 2020; 5:37. [PMID: 32632388 PMCID: PMC7063517 DOI: 10.21037/tgh.2019.12.01] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 11/30/2019] [Indexed: 02/05/2023] Open
Abstract
Outcomes of liver resection have improved with advances in surgical techniques, improvements in critical care and expansion of resectability criteria. However, morbidity and mortality following liver resection continue to plague surgeons. Post-hepatectomy liver failure (PHLF) due to inadequate future liver remnant (FLR) is an important cause of morbidity and mortality following liver resection. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel two-staged procedure described in 2012, which aims to induce rapid hypertrophy of the FLR unlike conventional two-stage hepatectomy, which require a longer time for FLR hypertrophy. Careful patient selection and modifications in surgical technique has improved morbidity and mortality rates in ALPPS. Colorectal liver metastases (CRLM) confers the best outcomes post-ALPPS. Patients <60 years old and low-grade fibrosis with underlying hepatocellular carcinoma (HCC) are also eligible for ALPPS. Evidence for other types of cancers is less promising. Current studies, though limited, demonstrate that ALPPS has comparable oncological outcomes with conventional two-stage hepatectomy. Modifications such as partial-ALPPS and mini-ALPPS have shown improved morbidity and mortality compared to classic ALPPS. ALPPS may be superior to conventional two-stage hepatectomy in carefully selected groups of patients and has a promising outlook in liver surgery.
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Affiliation(s)
- Kai Siang Chan
- Department of Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Vishal G. Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
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28
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Lee DH, Kim D, Park YH, Yoon J, Kim JS. Long-term surgical outcomes in patients with hepatocellular carcinoma undergoing laparoscopic vs. open liver resection: A retrospective and propensity score-matched study. Asian J Surg 2020; 44:206-212. [PMID: 32532684 DOI: 10.1016/j.asjsur.2020.05.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/11/2020] [Accepted: 05/14/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND/OBJECTIVES There is limited availability of well-designed comparative studies using propensity score matching with a sufficient sample size to compare laparoscopic liver resection (LLR) vs. open liver resection (OLR) for hepatocellular carcinoma (HCC). We aimed to compare the feasibility and safety of LLR and OLR in patients with HCC. METHODS We enrolled 168 patients who underwent elective LLR (n = 58) or OLR (n = 110) for HCC in two tertiary medical centers between November 2009 and December 2018. Patients who underwent LLR were propensity score-matched to patients who underwent OLR in a 1:1 ratio. Perioperative and postoperative outcomes and disease-free and overall survival rates were prospectively evaluated. RESULTS Among the 116 patients analyzed, 58 each belonged to the LLR and OLR groups. We performed 85 segmentectomies or sectionectomies, 19 left-lateral-sectionectomies, 9 left-hemihepatectomies, and 3 right-hemihepatectomies. There was no significant difference in age, sex, Child-Pugh class, original liver disease, preoperative alpha-fetoprotein, tumor size, tumor location, overall morbidity, and operative time. There was a significant difference in the length of postoperative hospital stay between the two groups (LLR vs OLR; 8 vs 10 days, p = 0.003). The 1-, 3-, and 5-year overall survival rates in the LLR and OLR groups were 96.6%, 92.8%, and 73.3% and 93.1%, 88.8%, and 76.1%, respectively (p = 0.642). The 1-, 3-, and 5-year disease-free survival rates in the LLR and OLR groups were 84.4%, 64.0%, and 60.2% and 93.1%, 67.4%, and 63.9%, respectively (p = 0.391). CONCLUSION LLR for HCC can be performed safely with acceptable short-term and long-term outcomes compared with OLR.
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Affiliation(s)
- Doo-Ho Lee
- Department of Surgery, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea
| | - Doojin Kim
- Department of Surgery, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea
| | - Yeon Ho Park
- Department of Surgery, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea.
| | - Jinmyeong Yoon
- Department of Surgery, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea
| | - Joo Seop Kim
- Department of Surgery, Kangdong Sungsim Hospital, Hallym University School of Medicine, Seoul, South Korea
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29
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Kim D, Cornman-Homonoff J, Madoff DC. Preparing for liver surgery with "Alphabet Soup": PVE, ALPPS, TAE-PVE, LVD and RL. Hepatobiliary Surg Nutr 2020; 9:136-151. [PMID: 32355673 PMCID: PMC7188547 DOI: 10.21037/hbsn.2019.09.10] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 09/10/2019] [Indexed: 02/06/2023]
Abstract
Future liver remnant (FLR) size and function is a critical limiting factor for treatment eligibility and postoperative prognosis when considering surgical hepatectomy. Pre-operative portal vein embolization (PVE) has been proven effective in modulating FLR and now widely accepted as a standard of care. However, PVE is not always effective due to potentially inadequate augmentation of the FLR as well as tumor progression while awaiting liver growth. These concerns have prompted exploration of alternative techniques: associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), transarterial embolization-portal vein embolization (TAE-PVE), liver venous deprivation (LVD), and radiation lobectomy (RL). The article aims to review the principles and applications of PVE and these newer hepatic regenerative techniques.
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Affiliation(s)
- DaeHee Kim
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joshua Cornman-Homonoff
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA
| | - David C. Madoff
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA
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30
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Kokudo N, Takemura N, Ito K, Mihara F. The history of liver surgery: Achievements over the past 50 years. Ann Gastroenterol Surg 2020; 4:109-117. [PMID: 32258975 PMCID: PMC7105847 DOI: 10.1002/ags3.12322] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 12/26/2019] [Indexed: 12/12/2022] Open
Abstract
We reviewed the progress made in the field of liver surgery over the past 50 years. The widespread use and improved outcomes of the hepatectomy were, primarily, due to pioneer surgeons who were responsible for technological advances and rapid improvements in the safety of the procedure in the last century. These advances included the hepatic functional evaluation used to determine the safety limit of liver resections, the introduction of intraoperative ultrasonography, and the development of innovative techniques such as portal vein embolization to increase the remnant liver volume. Cadaveric liver transplantation has been attempted since 1963. However, the clinical outcomes only began improving and becoming acceptable in the 1970s-1980s due to refinements in technology and the development of new immunosuppressants. Partial liver transplantation from living donors, which was first attempted in 1988, required further technological innovation and sophisticated perioperative management plans. Moreover, these developments allowed for further overall improvements to take place in the field of liver surgery. Since the turn of the century, advances in computation and imaging technology have made it possible for safer and more elaborate surgeries to be performed. In Japan, preoperative 3-dimensional simulation technology has been covered by health insurance since 2012 and is now widely used. An urgent need for real-time navigation tools will develop in the future. Indocyanine green (ICG) fluorescence imaging was first used in 2007 and has led to the creation of a new surgical concept known as fluorescence navigation surgery. Laparoscopic surgery and robotic surgery have solved the issue of large incisions, which used to be a major drawback of open liver surgery; however, further improvements are required in order to achieve the level of safety and accuracy observed during open liver resection when performing all minimally invasive procedures. In the near future, liver surgery will become more precise and less invasive due to substantial progress including the development of navigation surgery, cancer imaging, and minimally invasive surgery. This overview of the history of liver surgery over the past 50 years may provide useful insights for further innovation in the next 50 years.
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Affiliation(s)
- Norihiro Kokudo
- Department of SurgeryNational Center for Global Health and MedicineTokyoJapan
| | - Nobuyuki Takemura
- Department of SurgeryNational Center for Global Health and MedicineTokyoJapan
| | - Kyoji Ito
- Department of SurgeryNational Center for Global Health and MedicineTokyoJapan
| | - Fuminori Mihara
- Department of SurgeryNational Center for Global Health and MedicineTokyoJapan
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31
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Palmer DH, Malagari K, Kulik LM. Role of locoregional therapies in the wake of systemic therapy. J Hepatol 2020; 72:277-287. [PMID: 31954492 DOI: 10.1016/j.jhep.2019.09.023] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 09/16/2019] [Accepted: 09/25/2019] [Indexed: 02/07/2023]
Abstract
Multiple systemic agents have recently been approved in the first- and second-line setting for hepatocellular carcinoma (HCC), increasing the therapeutic options for patients and treating physicians. The randomised controlled trials that led to these approvals were predominantly conducted in a population comprised of patients with advanced HCC. However, these trials also included a subset of patients who had progressed after locoregional therapies (LRTs), mostly transarterial chemoembolisation. With a greater number of systemic agents available, the role of LRTs has become a topic of debate, specifically regarding when to transition to systemic therapy in unresectable HCC and the potential opportunities for combining locoregional and systemic therapies. Trials of immuno-oncology agents (notably T cell checkpoint inhibitors) are ongoing in the advanced disease setting and these agents also present opportunities for combination therapies, both with other systemic agents and with LRTs in earlier stage disease. This article will review strategies to guide patient selection for LRT as well as the development of locoregional-systemic combinations based on scientific rationale and the challenges of clinical trial design in this setting.
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Affiliation(s)
- Daniel H Palmer
- Liverpool CR UK/NIHR Experimental Cancer Medicine Centre, University of Liverpool, Liverpool, UK.
| | - Katerina Malagari
- 2(nd) Department of Radiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Laura M Kulik
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, USA
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32
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Advances in resection and transplantation for hepatocellular carcinoma. J Hepatol 2020; 72:262-276. [PMID: 31954491 DOI: 10.1016/j.jhep.2019.11.017] [Citation(s) in RCA: 126] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/25/2019] [Accepted: 11/26/2019] [Indexed: 02/08/2023]
Abstract
It would be impossible to summarise all of the significant developments in the surgical management of hepatocellular carcinoma (HCC), even just over the past year, in a manuscript of this scope. Thus, we have selected topics for discussion that are the subject of current controversy and have attempted to present balanced points of view. Hepatic resection and transplantation are both mature modalities, and for the most part technical advances and improvements in candidate selection are incremental. The ability to readily cure hepatitis C stands out as the most impactful development in the field over recent years, especially in Western countries where hepatitis C has long been the chief aetiology underlying HCC and a predictor of poor outcomes after surgery, but its full implications remain to be clarified. The rising incidence of non-alcoholic steatohepatitis-related HCC and what it means with regard to surgical HCC management is an area of great current interest. With advancing technology, non-surgical locoregional treatments are gaining increasing application as potentially curative therapies. In addition, the advances in molecular and genomic assessment of HCC hold promise for personalising treatment and prognostication. The possible role of immunotherapy as an adjuvant to resection is being aggressively investigated. While liver surgery maintains an important role, the care of patients with HCC is more and more a team effort and needs to take place in the context of a well-integrated interdisciplinary programme to achieve the best outcomes for patients.
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Terasawa M, Allard MA, Golse N, Sa Cunha A, Cherqui D, Adam R, Saiura A, Vibert E. Sequential transcatheter arterial chemoembolization and portal vein embolization versus portal vein embolization alone before major hepatectomy for patients with large hepatocellular carcinoma: An intent-to-treat analysis. Surgery 2019; 167:425-431. [PMID: 31780050 DOI: 10.1016/j.surg.2019.09.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 09/06/2019] [Accepted: 09/23/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Little is known about the value of sequential transcatheter arterial chemoembolization and portal vein embolization compared with portal vein embolization alone before major hepatectomy for large hepatocellular carcinoma. We aimed to compare early and long-term outcomes of these two strategies. METHODS We included all consecutive patients with large hepatocellular carcinoma (≥50 mm) scheduled for sequential transcatheter arterial chemoembolization and portal vein embolization or portal vein embolization alone before major hepatectomy from January 2005 to December 2015. Comparisons were made on an intent-to-treat basis. RESULTS A total of 55 patients were included as follows: sequential transcatheter arterial chemoembolization and portal vein embolization (n = 27) and portal vein embolization alone (n = 28). Baseline patient and tumor characteristics were similar in the 2 groups. Downstaging after transcatheter arterial chemoembolization changed the initial strategy in 4 patients who finally underwent liver transplant (n = 1) and limited hepatectomy (n = 3). Overall survival and progression-free survival were better in the transcatheter arterial chemoembolization group compared with the portal vein embolization alone group (3-year overall survival of 60% vs 20%; P = .01 and 3-year progression-free survival of 35% vs 0%; P < .001). The proportion of patients who finally underwent hepatectomy after transcatheter arterial chemoembolization plus portal vein embolization was 91% vs 68% after portal vein embolization alone (P = .08). Hypertrophy of the future remnant liver after portal vein embolization was greater after transcatheter arterial chemoembolization (43% vs 31%, P = 0.03). After resection, the group that received transcatheter arterial chemoembolization and portal vein embolization experienced better progression-free survival compared with portal vein embolization alone (3-year progression-free survival of 28% vs 0%; P = .03). CONCLUSION Our results suggest that transcatheter arterial chemoembolization before portal vein embolization increases the degree of hypertrophy of the future remnant liver after portal vein embolization and yields improved oncologic outcomes in patients with large hepatocellular carcinomas planned for major hepatectomy.
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Affiliation(s)
- Muga Terasawa
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Marc-Antoine Allard
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; Unités Mixtes de Recherche en Santé, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France.
| | - Nicolas Golse
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; Unités Mixtes de Recherche en Santé, Villejuif, France
| | - Antonio Sa Cunha
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Daniel Cherqui
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - René Adam
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France; Unités Mixtes de Recherche en Santé, INSERM, Villejuif, France
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Eric Vibert
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; Unités Mixtes de Recherche en Santé, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
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Lee TC, Morris MC, Patel SH, Shah SA. Expanding the Surgical Pool for Hepatic Resection to Treat Biliary and Primary Liver Tumors. Surg Oncol Clin N Am 2019; 28:763-782. [PMID: 31472918 DOI: 10.1016/j.soc.2019.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Surgical management of primary liver and biliary tract tumors has evolved over the past several decades, resulting in improved outcomes in these malignancies with historically poor prognoses. Expansion of patient selection criteria, progress in neoadjuvant and adjuvant therapies, development of techniques to increase future liver remnant, and the select utilization of liver transplantation have all contributed to increasing the patient pool for surgical intervention. Ongoing and future studies need to focus on improving multimodality treatment regimens and further refining the selection criteria for transplantation in order to optimize utilization of limited organ resources.
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Affiliation(s)
- Tiffany C Lee
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA
| | - Mackenzie C Morris
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA
| | - Sameer H Patel
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA.
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Akateh C, Black SM, Conteh L, Miller ED, Noonan A, Elliott E, Pawlik TM, Tsung A, Cloyd JM. Neoadjuvant and adjuvant treatment strategies for hepatocellular carcinoma. World J Gastroenterol 2019; 25:3704-3721. [PMID: 31391767 PMCID: PMC6676544 DOI: 10.3748/wjg.v25.i28.3704] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/13/2019] [Accepted: 06/22/2019] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common liver malignancy worldwide and a major cause of cancer-related mortality for which liver resection is an important curative-intent treatment option. However, many patients present with advanced disease and with underlying chronic liver disease and/or cirrhosis, limiting the proportion of patients who are surgical candidates. In addition, the development of recurrent or de novo cancers following surgical resection is common. These issues have led investigators to evaluate the benefit of neoadjuvant and adjuvant treatment strategies aimed at improving resectability rates and decreasing recurrence rates. While high-level evidence to guide treatment decision making is lacking, recent advances in locoregional and systemic therapies, including antiviral treatment and immunotherapy, raise the prospect of novel approaches that may improve the outcomes of patients with HCC. In this review, we evaluate the evidence for various neoadjuvant and adjuvant therapies and discuss opportunities for future clinical and translational research.
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Affiliation(s)
- Clifford Akateh
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Sylvester M Black
- Division of Transplant Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Lanla Conteh
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Eric D Miller
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Anne Noonan
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Eric Elliott
- Division of Diagnostic Radiology, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Allan Tsung
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
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Tustumi F, Ernani L, Coelho FF, Bernardo WM, Junior SS, Kruger JAP, Fonseca GM, Jeismann VB, Cecconello I, Herman P. Preoperative strategies to improve resectability for hepatocellular carcinoma: a systematic review and meta-analysis. HPB (Oxford) 2018; 20:1109-1118. [PMID: 30057123 DOI: 10.1016/j.hpb.2018.06.1798] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/14/2018] [Accepted: 06/16/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Preoperative strategies to increase the future liver remnant are useful methods to improve resectability rates for patients with hepatocellular carcinoma (HCC). The aim of this study was to perform a systematic review and meta-analysis of the main strategies used for this purpose. METHODS A systematic review was performed in PubMed, EMBASE, Cochrane and Scielo/LILACS. The procedures included for analysis were portal vein embolization or ligation (PVE/PVL), sequential transarterial embolization and PVE (TACE + PVE), radioembolization (RE) and associated liver partition and portal vein ligation for staged hepatectomy (ALPPS). Perioperative morbidity and mortality, post-hepatectomy liver failure (PHLF), and survival rates were evaluated. RESULTS A total of 46 studies were included in the systematic review (1284 patients). Resection rate was higher in TACE + PVE (90%; N = 315) when compared to PVE/PVL (75%; N = 254; P = <0.001) and similar to ALPPS (84%; N = 43; P = 0.374) and RE (100%; N = 28; P = 0.14). ALPPS was associated with higher PHLF and perioperative mortality rates when compared to PVE/PVL and TACE + PVE. ALPPS and RE showed higher risk of major complications than PVE/PVL and TACE + PVE. CONCLUSION Preoperative strategies to increase liver volume are effective in achieving resectability of HCC. TACE + PVE is as safe as PVL/PVE providing higher OS. ALPPS is associated with a higher risk of PHLF, major complications, and mortality. RE despite the small experience seems to present similar resection rate and OS as TACE + PVE with higher rate of major complications.
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Affiliation(s)
- Francisco Tustumi
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil.
| | - Lucas Ernani
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Fabricio F Coelho
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Wanderley M Bernardo
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Sérgio S Junior
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Jaime A P Kruger
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Gilton M Fonseca
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Vagner B Jeismann
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Ivan Cecconello
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Paulo Herman
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
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Is disease progression a contraindication for the strategy of portal vein embolization followed by hepatectomy for hepatocellular carcinoma? Surgery 2018; 165:696-702. [PMID: 30467039 DOI: 10.1016/j.surg.2018.10.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/06/2018] [Accepted: 10/19/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Portal vein embolization has been used worldwide to induce hypertrophy of the future liver remnant and to reduce the risk of hepatic insufficiency and death after major hepatectomy. However, whether disease progression after portal vein embolization can affect long-term oncologic outcomes in patients with hepatocellular carcinoma is uncertain. METHODS From a total of 107 patients who underwent portal vein embolization and subsequent hepatectomy between 2000 and 2016, 57 patients with hepatocellular carcinoma were enrolled. We evaluated their long-term oncologic outcomes and investigated whether the disease progression between portal vein embolization and subsequent hepatectomy affected survival. RESULTS The 5-year overall survival and disease-free survival after hepatectomy were 74.5% and 31.7%, respectively. Multivariate analyses revealed that tumor number before hepatectomy ≥3 (hazard ratio 3.59, P = .019), des-γ-carboxy prothrombin >200 mAU/mL (hazard ratio 3.36, P = .045), and red blood cell transfusion (hazard ratio 11.03, P = .0008) were independent prognostic factors for overall survival. Male sex (hazard ratio 3.74, P = .029), bilobar tumor distribution (hazard ratio 3.65, P = .004), and red blood cell transfusion (hazard ratio 6.22, P = .0026) were independent prognostic factors for disease-free survival. Disease progressions after portal vein embolization, including increases in tumor size, tumor number, α-fetoprotein, lens culinaris agglutinin-reactive fraction of α-fetoprotein, and des-γ-carboxy prothrombin, were observed in 22.8%, 14.0%, 29.8%, 19.3%, and 47.4% of patients, respectively. Only an increase of tumor number significantly decreased the disease-free survival rate after hepatectomy in a univariate analysis, and none of the variables affected overall survival. CONCLUSION Disease progression after portal vein embolization did not affect long-term survival in patients with hepatocellular carcinoma if the planned subsequent hepatectomy could be completed.
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Zhang ZF, Luo YJ, Lu Q, Dai SX, Sha WH. Conversion therapy and suitable timing for subsequent salvage surgery for initially unresectable hepatocellular carcinoma: What is new? World J Clin Cases 2018; 6:259-273. [PMID: 30211206 PMCID: PMC6134280 DOI: 10.12998/wjcc.v6.i9.259] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 07/18/2018] [Accepted: 08/07/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To review the conversion therapy for initially unresectable hepatocellular carcinoma (HCC) patients and the suitable timing for subsequent salvage surgery.
METHODS A PubMed search was undertaken from 1987 to 2017 to identify articles using the keywords including “unresectable” “hepatocellular carcinoma”, ”hepatectomy”, ”conversion therapy”, “resection”, “salvage surgery” and “downstaging”. Additional studies were investigated through a manual search of the references from the articles. The exclusion criteria were duplicates, case reports, case series, videos, contents unrelated to the topic, comments, and editorial essays. The main and widely used conversion therapies and the suitable timing for subsequent salvage surgery were discussed in detail. Two members of our group independently performed the literature search and data extraction.
RESULTS Liver volume measurements [future liver remnant (FLR)/total liver volume or residual liver volume/bodyweight ratio] and function tests (scoring systems and liver stiffness) were often performed in order to justify whether patients were suitable candidates for surgery. Successful conversion therapy was usually defined as downstaging the tumor, increasing FLR and providing subsequent salvage surgery, without increasing complications, morbidity or mortality. The requirements for performing salvage surgery after transcatheter arterial chemoembolization were the achievement of a partial remission in radiology, the disappearance of the portal vein thrombosis, and the lack of extrahepatic metastasis. Patients with a standardized FLR (sFLR) > 20% were good candidates for surgery after portal vein embolization, while other predictive parameters like growth rate, kinetic growth rate were treated as an effective supplementary. There was probably not enough evidence to provide a standard operation time after associating liver partition and portal vein ligation for staged hepatectomy or yttrium-90 microsphere radioembolization. The indications of any combinations of conversion therapies and the subsequent salvage surgery time still need to be carefully and comprehensively evaluated.
CONCLUSION Conversion therapy is recommended for the treatment of initially unresectable HCC, and the suitable subsequent salvage surgery time should be reappraised and is closely related to its previous therapeutic effect.
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Affiliation(s)
- Ze-Feng Zhang
- Department of Gastroenterology and Hepatology, Guangdong Geriatrics Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
| | - Yu-Jun Luo
- Department of Gastroenterology and Hepatology, Guangdong Geriatrics Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
| | - Quan Lu
- Department of Gastroenterology and Hepatology, Guangdong Geriatrics Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
| | - Shi-Xue Dai
- Department of Gastroenterology and Hepatology, Guangdong Geriatrics Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
| | - Wei-Hong Sha
- Department of Gastroenterology and Hepatology, Guangdong Geriatrics Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
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Golse N, El Bouyousfi A, Marques F, Bancel B, Mohkam K, Ducerf C, Merle P, Sebagh M, Castaing D, Sa Cunha A, Adam R, Cherqui D, Vibert E, Mabrut JY. Large hepatocellular carcinoma: Does fibrosis really impact prognosis after resection? J Visc Surg 2018. [DOI: 10.1016/j.jviscsurg.2017.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Compensatory hypertrophy of the liver after external beam radiotherapy for primary liver cancer. Strahlenther Onkol 2018; 194:1017-1029. [PMID: 30105451 DOI: 10.1007/s00066-018-1342-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 07/14/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE We investigated whether external beam radiotherapy (EBRT) could induce compensatory liver hypertrophy in liver cancers and assessed related clinical factors. METHODS A total of 82 consecutive patients receiving EBRT for hepatocellular carcinoma (n = 77) or cholangiocarcinoma (n = 5) from April 2012 to June 2014 were recruited and divided into two subgroups according to tumor location in the right or left lobe. The left lateral and right lobes were considered as unirradiated volumes accordingly. Total liver volume (TLV), nontumor liver volume (NLV), left and right lobe whole volume (LLWV and RLWV, respectively), volume of liver irradiated < 30 Gy (V< 30 Gy), Child-Pugh (CPS) score, future liver remnant (FLR) ratio, and percentage of FLR hypertrophy from baseline (%FLR) were assessed. RESULTS In the right lobe group, %FLR hypertrophy and LLWV increased significantly at all follow-ups (p < 0.001). %FLR hypertrophy steadily increased until the fourth follow-up. Multivariate analysis showed that the factor associated with maximum %FLR hypertrophy was tumor extent (upper or lower lobe vs. both lobes; p = 0.022). Post-RT treatments including transarterial chemoembolization or hepatic arterial infusion chemotherapy were associated with a CPS increase ≥ 2 (p = 0.002). Analysis of the RT only subgroup also showed a significant increase of %FLR until the fourth follow-up (p < 0.001). In the left lobe group, %FLR hypertrophy and RLWV showed no significant changes during follow-up. CONCLUSION Significant compensatory hypertrophy of the liver was observed, with a steady increase of %FLR hypertrophy until the fourth follow-up (median: 396 days). Locally advanced tumors extending across the upper and lower right lobe were a significant factor for compensating hypertrophy after EBRT.
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Marti J, Giacca M, Alshebeeb K, Bahl S, Hua C, Horn JC, BouAyache J, Patel R, Facciuto M, Schwartz M, Florman S, Kim E, Gunasekaran G. Analysis of Preoperative Portal Vein Embolization Outcomes in Patients with Hepatocellular Carcinoma: A Single-Center Experience. J Vasc Interv Radiol 2018; 29:920-926. [DOI: 10.1016/j.jvir.2018.01.780] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/22/2018] [Accepted: 01/24/2018] [Indexed: 12/11/2022] Open
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Alvarez FA, Castaing D, Figueroa R, Allard MA, Golse N, Pittau G, Ciacio O, Sa Cunha A, Cherqui D, Azoulay D, Adam R, Vibert E. Natural history of portal vein embolization before liver resection: a 23-year analysis of intention-to-treat results. Surgery 2018; 163:1257-1263. [DOI: 10.1016/j.surg.2017.12.027] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 12/22/2017] [Accepted: 12/22/2017] [Indexed: 12/12/2022]
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Teo JY, Allen JC, Ng DCE, Abdul Latiff JB, Choo SP, Tai DWM, Low ASC, Cheah FK, Chang JPE, Kam JH, Lee VTW, Chung AYF, Chan CY, Chow PKH, Goh BKP. Prospective study to determine early hypertrophy of the contra-lateral liver lobe after unilobar, Yttrium-90, selective internal radiation therapy in patients with hepatocellular carcinoma. Surgery 2018; 163:1008-1013. [PMID: 29306542 DOI: 10.1016/j.surg.2017.10.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/20/2017] [Accepted: 10/11/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Liver resection is a major curative option in patients presenting with hepatocellular carcinoma. An inadequate functional liver remnant is a major limiting factor precluding liver resection. In recent years, hypertrophy of the functional liver remnant after selective internal radiation therapy hypertrophy has been observed, but the degree of hypertrophy in the early postselective internal radiation therapy period has not been well studied. METHODS We conducted a prospective study on patients undergoing unilobar, Yttrium-90 selective internal radiation therapy for hepatocellular carcinoma to evaluate early hypertrophy at 4-6 weeks and 8-12 weeks after selective internal radiation therapy. RESULTS In the study, 24 eligible patients were recruited and had serial volumetric measurements performed. The median age was 66 years (38-75 years). All patients were either Child-Pugh Class A or B, and 6/24 patients had documented, clinically relevant portal hypertension; 15 of the 24 patients were hepatitis B positive. At 4-6 weeks, modest hypertrophy was seen (median 3%; range -12 to 42%) and this increased at 8-12 weeks (median 9%; range -12 to 179%). No preprocedural factors predictive of hypertrophy were identified. CONCLUSION Hypertrophy of the functional liver remnant after selective internal radiation therapy with Yttrium-90 occurred in a subset of patients but was modest and unpredictable in the early stages. Selective internal radiation therapy cannot be recommended as a standard treatment modality to induce early hypertrophy for patients with hepatocellular carcinoma. (Surgery 2017;160:XXX-XXX.).
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Affiliation(s)
- Jin Yao Teo
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - John Carson Allen
- Office of Clinical Sciences, Duke-NUS Graduate Medical School Singapore, Singapore
| | - David Chee Eng Ng
- Department of Nuclear Medicine and PET, Singapore General Hospital, Singapore
| | | | - Su Pin Choo
- Department of Medical Oncology, National Cancer Centre Singapore, Singapore
| | - David Wai-Meng Tai
- Department of Medical Oncology, National Cancer Centre Singapore, Singapore
| | | | - Foong Koon Cheah
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | - Jason Pik Eu Chang
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Juinn Huar Kam
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Victor T W Lee
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Alexander Yaw Fui Chung
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Chung Yip Chan
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Pierce Kah Hoe Chow
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Brian K P Goh
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Singapore General Hospital, Singapore.
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Hung ML, McWilliams JP. Portal vein embolization prior to hepatectomy: Techniques, outcomes and novel therapeutic approaches. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Matthew L. Hung
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Justin P. McWilliams
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Matthew Hawkins C, Towbin AJ, Roebuck DJ, Monroe EJ, Gill AE, Thakor AS, Towbin RB, Cahill AM, Lungren MP. Role of interventional radiology in managing pediatric liver tumors : Part 2: percutaneous interventions. Pediatr Radiol 2018; 48:565-580. [PMID: 29396792 DOI: 10.1007/s00247-018-4072-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 11/22/2017] [Accepted: 01/03/2018] [Indexed: 02/07/2023]
Abstract
Hepatoblastoma and hepatocellular carcinoma (HCC) are the most common pediatric liver malignancies, with hepatoblastoma occurring more commonly in younger children and HCC occurring more commonly in older children and adolescents. Although surgical resection (including transplant when necessary) and systemic chemotherapy have improved overall survival rate for hepatoblastoma to approximately 80% from 30%, a number of children with this tumor type are not eligible for operative treatment. In contradistinction, pediatric HCC continues to carry a dismal prognosis with an overall 5-year survival rate of 30%. The Paediatric Hepatic International Tumour Trial (PHITT) is an international trial aimed at evaluating both existing and emerging oncologic therapies for primary pediatric liver tumors. Interventional radiology offers a number of minimally invasive procedures that aid in diagnosis and therapy of pediatric liver tumors. For diagnosis, the PHITT biopsy guidelines emphasize and recommend percutaneous image-guided tumor biopsy. Additionally, both percutaneous and endovascular procedures provide therapeutic alternatives that have been, to this point, only minimally utilized in the pediatric population. Specifically, percutaneous ablation offers a number of cytotoxic technologies that can potentially eradicate disease or downstage children with unresectable disease. Percutaneous portal vein embolization is an additional minimally invasive procedure that might be useful to induce remnant liver hypertrophy prior to extended liver resection in the setting of a primary liver tumor. PHITT offers an opportunity to collect data from children treated with these emerging therapeutic options across the world. The purpose of this manuscript is to describe the potential role of minimally invasive percutaneous transhepatic procedures, as well as review the existing data largely stemming from the adult HCC experience.
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Affiliation(s)
- C Matthew Hawkins
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-guided Medicine, Emory University School of Medicine, Atlanta, GA, USA.
- Department of Radiology and Imaging Sciences, Division of Pediatric Radiology, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston, 1364 Clifton Road NE, Suite D112, Atlanta, GA, 30322, USA.
| | - Alexander J Towbin
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Derek J Roebuck
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | - Eric J Monroe
- Department of Radiology, Division of Interventional Radiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Anne E Gill
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-guided Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Radiology and Imaging Sciences, Division of Pediatric Radiology, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston, 1364 Clifton Road NE, Suite D112, Atlanta, GA, 30322, USA
| | - Avnesh S Thakor
- Department of Radiology, Lucille Packard Children's Hospital, Stanford University, Stanford, CA, USA
| | - Richard B Towbin
- Department of Radiology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Anne Marie Cahill
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Matthew P Lungren
- Department of Radiology, Lucille Packard Children's Hospital, Stanford University, Stanford, CA, USA
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Nakamura I, Iimuro Y, Hai S, Kondo Y, Hatano E, Fujimoto J. Impaired Value of 99m Tc-GSA Scintigraphy as an Independent Risk Factor for Posthepatectomy Liver Failure in Patients with Hepatocellular Carcinoma. Eur Surg Res 2018; 59:12-22. [PMID: 29332090 DOI: 10.1159/000484044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 10/06/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Posthepatectomy liver failure (PHLF) was recently defined with the corresponding recommendations as follows: grade A, no change in clinical management; grade B, clinical management with noninvasive treatment; and grade C, clinical management with invasive treatment. In this study, we identified the risk factors for grade B and C PHLF in patients with hepatocellular carcinoma (HCC). METHODS Of 339 HCC patients who underwent curative hepatic resection, 218 were included for analysis. The LHL15 index (uptake ratio of the liver to that of the liver and heart at 15 min) was measured by 99m Tc-GSA (99m technetium-labelled galactosyl human serum albumin); remnant LHL15 was calculated as LHL15 × [1 - (resected liver weight - tumor volume)/whole liver volume without tumor]. RESULTS A total of 163 patients were classified as having no PHLF, whereas 17, 37, and 1 patient had PHLF grade A, B, and C, respectively. There were significant differences in indocyanine green R15, serum albumin, prothrombin time, Child-Pugh classification, LHL15 and remnant LHL15 between patients with grades B/C PHLF and patients with grade A or no PHLF. Only remnant LHL15 was identified as an independent risk factor for grades B/C PHLF (p = 0.023), with a cut-off value of 0.755. CONCLUSIONS Remnant LHL15 was an independent risk factor for grades B/C PHLF. Patients with impaired remnant LHL15 value of <0.755 should be carefully monitored for PHLF.
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Lim C, Shinkawa H, Hasegawa K, Bhangui P, Salloum C, Gomez Gavara C, Lahat E, Omichi K, Arita J, Sakamoto Y, Compagnon P, Feray C, Kokudo N, Azoulay D. Salvage liver transplantation or repeat hepatectomy for recurrent hepatocellular carcinoma: An intent-to-treat analysis. Liver Transpl 2017; 23:1553-1563. [PMID: 28945955 DOI: 10.1002/lt.24952] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 08/09/2017] [Accepted: 09/17/2017] [Indexed: 02/07/2023]
Abstract
The salvage liver transplantation (LT) strategy was conceived for initially resectable and transplantable hepatocellular carcinoma (HCC) to obviate upfront transplantation, with salvage LT in the case of recurrence. The longterm outcomes of a second resection for recurrent HCC have improved. The aim of this study was to perform an intention-to-treat analysis of overall survival (OS) comparing these 2 strategies for initially resectable and transplantable recurrent HCC. From 1994 to 2011, 391 patients with HCC who underwent salvage LT (n = 77) or a second resection (n = 314) were analyzed. Of 77 patients in the salvage LT group, 21 presented with resectable and transplantable recurrent HCC and 18 underwent transplantation. Of 314 patients in the second resection group, 81 presented with resectable and transplantable recurrent HCC and 81 underwent a second resection. The 5-year intention-to-treat OS rates, calculated from the time of primary hepatectomy, were comparable between the 2 strategies (72% for salvage transplantation versus 77% for second resection; P = 0.57). In patients who completed the salvage LT or second resection procedure, the 5-year OS rates, calculated from the time of the second surgery, were comparable between the 2 strategies (71% versus 71%; P = 0.99). The 5-year disease-free survival (DFS) rates were 72% following transplantation and 18% following the second resection (P < 0.001). Similar results were observed after propensity score matching. In conclusion, although the 5-year OS rates were similar in the salvage LT and second resection groups, the salvage LT strategy still achieves better DFS. Second resection for recurrent HCC might be considered to be the best alternative option to LT in the current organ shortage. Liver Transplantation 23 1553-1563 2017 AASLD.
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Affiliation(s)
- Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation and, Henri Mondor Hospital, AP-HP, Paris-Est University, Créteil, France
| | - Hiroji Shinkawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, New Delhi, India
| | - Chady Salloum
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation and, Henri Mondor Hospital, AP-HP, Paris-Est University, Créteil, France
| | - Concepcion Gomez Gavara
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation and, Henri Mondor Hospital, AP-HP, Paris-Est University, Créteil, France
| | - Eylon Lahat
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation and, Henri Mondor Hospital, AP-HP, Paris-Est University, Créteil, France
| | - Kiyohiko Omichi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Junichi Arita
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yoshihiro Sakamoto
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Philippe Compagnon
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation and, Henri Mondor Hospital, AP-HP, Paris-Est University, Créteil, France
| | - Cyrille Feray
- Department of Hepatology, Henri Mondor Hospital, AP-HP, Paris-Est University, Créteil, France
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Daniel Azoulay
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation and, Henri Mondor Hospital, AP-HP, Paris-Est University, Créteil, France
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Huang SY, Aloia TA. Portal Vein Embolization: State-of-the-Art Technique and Options to Improve Liver Hypertrophy. Visc Med 2017; 33:419-425. [PMID: 29344515 DOI: 10.1159/000480034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Portal vein embolization (PVE) is associated with a high technical and clinical success rate for induction of future liver remnant hypertrophy prior to surgical resection. The degree of hypertrophy is variable and depends on multiple factors, including technical aspects of the procedure and underlying chronic liver disease. For patients with insufficient liver volume following PVE, adjunctive techniques, such as intra-portal administration of stem cells, dietary supplementation, transarterial embolization, and hepatic vein embolization, are available. Our purpose is to review the state-of-the-art technique associated with high-quality PVE and to discuss options to improve hypertrophy of the future liver remnant.
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Affiliation(s)
- Steven Y Huang
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Rajakannu M, Cherqui D, Ciacio O, Golse N, Pittau G, Allard MA, Antonini TM, Coilly A, Sa Cunha A, Castaing D, Samuel D, Guettier C, Adam R, Vibert E. Liver stiffness measurement by transient elastography predicts late posthepatectomy outcomes in patients undergoing resection for hepatocellular carcinoma. Surgery 2017; 162:766-774. [PMID: 28711320 DOI: 10.1016/j.surg.2017.06.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 06/02/2017] [Accepted: 06/06/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Postoperative hepatic decompensation is a serious complication of liver resection in patients undergoing hepatectomy for hepatocellular carcinoma. Liver fibrosis and clinical significant portal hypertension are well-known risk factors for hepatic decompensation. Liver stiffness measurement is a noninvasive method of evaluating hepatic venous pressure gradient and functional hepatic reserve by estimating hepatic fibrosis. Effectiveness of liver stiffness measurement in predicting persistent postoperative hepatic decompensation has not been investigated. METHODS Consecutive patients with resectable hepatocellular carcinoma were recruited prospectively and liver stiffness measurement of nontumoral liver was measured using FibroScan. Hepatic venous pressure gradient was measured intraoperatively by direct puncture of portal vein and inferior vena cava. Hepatic venous pressure gradient ≥10 mm Hg was defined as clinically significant portal hypertension. Primary outcome was persistent hepatic decompensation defined as the presence of at least one of the following: unresolved ascites, jaundice, and/or encephalopathy >3 months after hepatectomy. RESULTS One hundred and six hepatectomies, including 22 right hepatectomy (20.8%), 3 central hepatectomy (2.8%), 12 left hepatectomy (11.3%), 11 bisegmentectomy (10.4%), 30 unisegmentectomy (28.3%), and 28 partial hepatectomy (26.4%) were performed in patients for hepatocellular carcinoma (84 men and 22 women with median age of 67.5 years; median model for end-stage liver disease score of 8). Ninety-day mortality was 4.7%. Nine patients (8.5%) developed postoperative hepatic decompensation. Multivariate logistic regression bootstrapped at 1,000 identified liver stiffness measurement (P = .001) as the only preoperative predictor of postoperative hepatic decompensation. Area under receiver operating characteristic curve for liver stiffness measurement and hepatic venous pressure gradient was 0.81 (95% confidence interval, 0.506-0.907) and 0.71 (95% confidence interval, 0.646-0.917), respectively. Liver stiffness measurement ≥22 kPa had 42.9% sensitivity and 92.6% specificity and hepatic venous pressure gradient ≥10 mm Hg had 28.6% sensitivity and 96.3% specificity. CONCLUSION In selected patients undergoing liver resection for hepatocellular carcinoma, transient elastography is an easy and effective test to predict persistent hepatic decompensation preoperatively.
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Affiliation(s)
- Muthukumarassamy Rajakannu
- Department of chirurgie hépatique et transplantation, Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Inserm, Unité UMR-S 1193, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Daniel Cherqui
- Department of chirurgie hépatique et transplantation, Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Oriana Ciacio
- Department of chirurgie hépatique et transplantation, Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France
| | - Nicolas Golse
- Department of chirurgie hépatique et transplantation, Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France
| | - Gabriella Pittau
- Department of chirurgie hépatique et transplantation, Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France
| | - Marc Antoine Allard
- Department of chirurgie hépatique et transplantation, Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France
| | - Teresa Maria Antonini
- Department of hépatologie, Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France
| | - Audrey Coilly
- Department of hépatologie, Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Inserm, Unité UMR-S 1193, Villejuif, France
| | - Antonio Sa Cunha
- Department of chirurgie hépatique et transplantation, Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Denis Castaing
- Department of chirurgie hépatique et transplantation, Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Inserm, Unité UMR-S 1193, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Didier Samuel
- Department of hépatologie, Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Inserm, Unité UMR-S 1193, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Catherine Guettier
- Department of anatomo-pathologie, Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Inserm, Unité UMR-S 1193, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - René Adam
- Department of chirurgie hépatique et transplantation, Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France; Inserm, Unité UMR-S 776, Villejuif, France
| | - Eric Vibert
- Department of chirurgie hépatique et transplantation, Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, Villejuif, France; Inserm, Unité UMR-S 1193, Villejuif, France; Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France.
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Ironside N, Bell R, Bartlett A, McCall J, Powell J, Pandanaboyana S. Systematic review of perioperative and survival outcomes of liver resections with and without preoperative portal vein embolization for colorectal metastases. HPB (Oxford) 2017; 19:559-566. [PMID: 28438427 DOI: 10.1016/j.hpb.2017.03.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 02/14/2017] [Accepted: 03/01/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this systematic review was to evaluate perioperative and long term outcomes in patients who underwent PVE prior to liver resection for colorectal liver metastases. METHODS A systematic search of PubMed, MEDLINE, Embase and the Cochrane library was performed in accordance with PRISMA guidelines. Studies including patients who underwent liver resection with and without PVE (N-PVE) were included. RESULTS Thirteen studies including 1345 were included of which 539 patients had PVE and 806 had N-PVE. Eight studies reported that from a total of 450 patients who underwent PVE, 136 (30%) did not proceed to liver resection. In 114 (84%) patients this was due to disease progression. The postoperative morbidity was 42% (n = 151) after PVE and 10% (n = 35) developed postoperative liver failure after liver resection. Median overall survival, reported in all studies, was 38.9 months and 45.6 months respectively, following resection with PVE and N-PVE. The median disease free survival, reported in eight studies, was 15.7 (PVE) and 21.4 (N-PVE) months respectively. CONCLUSION Following PVE 70% of patients proceed to liver resection, with a 10% risk of postoperative liver failure. Tumour progression after PVE was the predominant reason for not proceeding to liver resection.
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Affiliation(s)
- Natasha Ironside
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Richard Bell
- Department of Hepatobiliary Surgery, St James Hospital, Leeds, UK
| | - Adam Bartlett
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Hepatobiliary Surgery, Auckland City Hospital, Auckland, New Zealand
| | - John McCall
- Department of Hepatobiliary Surgery, Auckland City Hospital, Auckland, New Zealand
| | - James Powell
- Department of Hepatobiliary Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Sanjay Pandanaboyana
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Hepatobiliary Surgery, Auckland City Hospital, Auckland, New Zealand.
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