Bilobar Disease Research Articles

Comparison of Hepatic Arterial Infusion Pump Chemotherapy vs Resection for Patients With Multifocal Intrahepatic Cholangiocarcinoma

Intrahepatic cholangiocarcinoma (iCCA) is often multifocal (ie, satellites or intrahepatic metastases) at presentation. To compare the overall survival (OS) of patients with multifocal iCCA after hepatic arterial infusion pump (HAIP) floxuridine chemotherapy vs resection. In this cohort study, patients with histologically confirmed, multifocal iCCA were eligible. The HAIP group consisted of consecutive patients from a single center who underwent HAIP floxuridine chemotherapy for unresectable multifocal iCCA between January 1, 2001, and December 31, 2018. The resection group consisted of consecutive patients from 12 centers who underwent a curative-intent resection for multifocal iCCA between January 1, 1990, and December 31, 2017. Resectable metastatic disease to regional lymph nodes and previous systemic therapy were permitted. Patients with distant metastatic disease (ie, stage IV), those who underwent resection before starting HAIP floxuridine chemotherapy, and those who received a liver transplant were excluded. Data were analyzed on September 1, 2021. Overall survival in the 2 treatment groups was compared using the Kaplan-Meier method and log-rank test. A total of 319 patients with multifocal iCCA were included: 141 in the HAIP group (median [IQR] age, 62 [53-70] years; 79 [56.0%] women) and 178 in the resection group (median [IQR] age, 60 [50-69] years; 91 [51.1%] men). The HAIP group was characterized by a higher percentage of bilobar disease (88.0% [n = 124] vs 34.3% [n = 61]), larger tumors (median, 8.4 cm vs 7.0 cm), and a higher proportion of patients with 4 or more lesions (66.7% [94] vs 24.2% [43]). Postoperative mortality after 30 days was 0.8% (95% CI, 0.0%-2.1%) in the HAIP group vs 6.2% (95% CI, 2.3%-9.7%) in the resection group (P = .01). The median OS for HAIP was 20.3 months vs 18.9 months for resection (P = .32). Five-year OS in patients with 2 or 3 lesions was 23.7% (95% CI, 12.3%-45.7%) in the HAIP group vs 25.7% (95% CI, 17.9%-37.0%) in the resection group. Five-year OS in patients with 4 or more lesions was 5.0% (95% CI, 1.7%-14.3%) in the HAIP group vs 6.8% (95% CI, 1.8%-25.3%) in the resection group. After adjustment for tumor diameter, number of tumors, and lymph node metastases, the hazard ratio of HAIP vs resection was 0.75 (95% CI, 0.55-1.03; P = .07). This cohort study found that patients with multifocal iCCA had similar OS after HAIP floxuridine chemotherapy vs resection. Resection of multifocal intrahepatic cholangiocarcinoma needs to be considered carefully given the complication rate of major liver resection; HAIP floxuridine chemotherapy may be an effective alternative option.

Hepatectomy Versus Sorafenib in Advanced Nonmetastatic Hepatocellular Carcinoma: A Real-life Multicentric Weighted Comparison.

The aim of the study was to compare SURG vs SOR regarding the OS and progression-free survival (PFS) in a real-world clinical scenario. The treatment for advanced nonmetastatic HCC belonging to the Barcelona Clinic Liver Cancer stage C (BCLC C) is still controversial. BCLC C patients without extrahepatic spread and tumoral invasion of the main portal trunk were considered. Surgical patients were obtained from the HE.RC.O.LE.S. Register, whereas sorafenib patients were obtained from the ITA.LI.CA register The inverse probability weighting (IPW) method was adopted to balance the confounders between the 2 groups. Between 2008 and 2019, 478 patients were enrolled: 303 in SURG and 175 in SOR group. Eastern Cooperative Oncological Group Performance Status (ECOG-PS), presence of cirrhosis, steatosis, Child-Pugh grade, hepatitis B virus and hepatitis C virus, alcohol intake, collateral veins, bilobar disease, localization of the tumor thrombus, number of nodules, alpha-fetoprotein, age, and Charlson Comorbidity index were weighted by IPW to create two balanced pseudo-populations: SURG = 374 and SOR = 263. After IPW, 1-3-5 years OS was 83.6%, 68.1%, 55.9% for SURG, and 42.3%, 17.8%, 12.8% for SOR (P < 0.001). Similar trends were observed after subgrouping patients by ECOG-PS = 0 and ECOG-PS >0, and by the intrahepatic location of portal vein invasion. At Cox regression, sorafenib treatment (hazard ratio 4.436; 95% confidence interval 3.19-6.15; P < 0.001) and Charlson Index (hazard ratio 1.162; 95% confidence interval 1.06-1.27; P = 0.010) were the only independent predictors of mortality. PFS at 1-3-5 years were 65.9%, 40.3%, 24.3% for SURG and 21.6%, 3.5%, 2.9% for SOR (P = 0.007). In BCLC C patients without extrahepatic spread but with intrahepatic portal invasion, liver resection, if feasible, was followed by better OS and PFS compared with sorafenib.

Laparoscopic Compared with Open Liver Resection in the Management of Colorectal Liver Metastases

Introduction: Laparoscopic liver resection (LLR) is increasingly adopted in the management of colorectal liver metastases (CRLM). This study compares perioperative and oncologic outcomes in LLR and open resection (OLR) for CRLM. Methods: Consecutive patients undergoing hepatectomy between 2009-2019 for CRLM at a single tertiary referral centre were prospectively studied. Univariable and multivariable logistic and Cox proportional hazards regression analysis was performed to determine the independent impact of operative approach on perioperative and oncologic outcome. Results: 273 patients were studied. LLR patients were more likely to be ASA-3 (58.0% vs 34.5%, P=0.016), older (65.4±9.4 vs 61.4±10.9 years, P=0.016) and have a greater Charlson comorbidity index (4.6±1.5 vs 4.0±1.4, P=0.008). LLR patients had less bilobar disease (18.0% vs 44.4%, P=0.001), were less likely to undergo major hepatectomy (6.0% vs 36.8%, P<0.001) or portal vein embolization (0.0% vs 10.8%, P=0.015), with increased non-anatomical resection (76.1% vs 66.0%, P=0.016). R0 resection rates were similar (86.0% vs 91.0%, P=0.310). Length of stay (median 7-days in both groups, P=0.313), readmission (4.0% vs 8.6%,P=0.275), and 30-day mortality (0.0% vs 1.8%, P=0.340) were equivalent. On multivariable analysis, major liver resection (OR2.70 [95%CI 1.46- 5.01], P=0.002), but not LLR (P=0.221), independently predicted major postoperative morbidity. Overall survival was similar between groups on univariable (median 47.0 vs 44.0 months, P=0.384) and multivariable analysis (P=0.152). Conclusion: LLR is feasible and safe with outcomes that are at least equivalent to open surgery. LLR may facilitate surgical resection for CRLM among patients with significant baseline comorbidity and anaesthetic risk.

Surgical Outcomes after Synchronous versus Metachronous Hepatectomy in Patients with Metastatic Pancreatic Neuroendocrine Tumors

Introduction: 40-80% of patients with pancreatic neuroendocrine tumors (pNETs) have liver metastases at diagnosis, and debulking surgery can improve survival. Limited data are available on the safety of pancreatectomy with synchronous hepatectomy (SH) for metastatic pNETs. Methods: Patients who underwent hepatectomy for metastatic pNETs at Mayo Clinic from 2000 to 2020 were retrospectively reviewed. Differences between groups were assesssed using chi-square and Mann-Whitney tests. Results: 185 patients underwent hepatectomy for metastatic pNETs: 131 SH and 54 metachronous hepatectomy (MH). SH patients were more likely to have >10 metastases (52.7% vs. 33.3%, p=0.025) and bilobar disease (81.7% vs. 66.7%, p=0.043). Major pancreatectomy (pancreaticoduodenectomy/total pancreatectomy) was performed in 7.6% of SH and 32.6% of MH patients (p<0.001) and major hepatectomy (>/=3 Couinaud segments) in 33.6% of SH and 38.9% of MH patients (p=0.605). >90% debulking was achieved in 93.1% of SH and 94.4% of MH (p=0.999). SH patients had longer operative times (median 289 minutes vs. 222, p<0.001) and greater blood loss (32.8% >1000 ml vs. 13.0%, p=0.010). Transfusion was required in 43.5% after SH and 29.6% after MH (p=0.112). Major complications (Clavien-Dindo >/=3) occurred in 29.8% after SH and 24.1% after MH (p=0.546). Median length of stay was 7 days after SH and 5 days after MH (p<0.001). 90-day mortality was 1.5% after SH and 1.9% after MH (p>0.999). Conclusion: Pancreatectomy with SH can be safely performed in selected patients with metastatic pNETs at high-volume institutions and should be considered in patients presenting with pNETs and synchronous liver metastases.

Quantitative Imaging Biomarkers of the Whole Liver Tumor Burden Improve Survival Prediction in Metastatic Pancreatic Cancer.

Simple SummaryFinding prognostic biomarkers and associated models with high accuracy in patients with pancreatic cancer remains a challenge. The aim of this study was to analyze whether the combination of quantitative imaging biomarkers based on geometric and radiomics analysis of whole liver tumor burden and established clinical parameters improves the prediction of survival in patients with metastatic pancreatic cancer. In this retrospective study a total of 75 patients with pancreatic cancer and liver metastases were analyzed. Segmentations of whole liver tumor burden from baseline contrast-enhanced CT images were used to derive different quantitative imaging biomarkers. For comparison, we chose two clinical prognostic models from the literature. We found that a combined clinical and imaging-based model has a significantly higher predictive performance to discriminate survival than the underlying clinical models alone (p < 0.003).Finding prognostic biomarkers with high accuracy in patients with pancreatic cancer (PC) remains a challenging problem. To improve the prediction of survival and to investigate the relevance of quantitative imaging biomarkers (QIB) we combined QIB with established clinical parameters. In this retrospective study a total of 75 patients with metastatic PC and liver metastases were analyzed. Segmentations of whole liver tumor burden (WLTB) from baseline contrast-enhanced CT images were used to derive QIBs. The benefits of QIBs in multivariable Cox models were analyzed in comparison with two clinical prognostic models from the literature. To discriminate survival, the two clinical models had concordance indices of 0.61 and 0.62 in a statistical setting. Combined clinical and imaging-based models achieved concordance indices of 0.74 and 0.70 with WLTB volume, tumor burden score (TBS), and bilobar disease being the three WLTB parameters that were kept by backward elimination. These combined clinical and imaging-based models have significantly higher predictive performance in discriminating survival than the underlying clinical models alone (p < 0.003). Radiomics and geometric WLTB analysis of patients with metastatic PC with liver metastases enhances the modeling of survival compared with models based on clinical parameters alone.

Selective Internal Radiation Combined with Chemotherapy Maintains the Quality of Life in Intrahepatic Cholangiocarcinomas

Background: In the Yttrium-90 Microspheres in Cholangiocarcinoma (MISPHEC) single-arm phase 2 trial, concomitant chemotherapy and selective internal radiotherapy (SIRT) showed antitumor activity as a first-line treatment of unresectable intrahepatic cholangiocarcinomas (ICCs). In this sub-analysis, we aimed to evaluate one of the secondary endpoints, the health-related quality of life (QoL), evaluated with an EORTC QLQ-C30 instrument at the baseline and during treatment. Methods: The MISPHEC trial included treatment-naïve patients with an unresectable ICC between November 2013 and June 2016. Patients received concomitant first-line chemotherapy with cisplatin and gemcitabine for 8 cycles; SIRT was administered during cycle 1 (for patients with unilobar disease) or cycles 1 and 3 (for patients with bilobar disease) using glass Yttrium-90 microspheres. We evaluated the QoL—measured by the QLQ-C30 questionnaire—at the baseline, every 8 weeks during chemotherapy and follow-up, between 12 and 15 weeks after embolization and every 12 weeks after a liver resection if applicable. Results: A total of 41 patients were included, of which 34 completed questionnaires at the baseline. No clinically significant changes in the global health score or the sub-scales of the QLQ-C30 were observed during follow-up. The physical, social and role function mean score worsened during treatment and fatigue, nausea and pain scores increased although the differences were not clinically significant. In patients undergoing subsequent surgery, the QoL was not impaired. Conclusions: A combination of SIRT and chemotherapy with gemcitabine and cisplatin as the first-line treatment of unresectable ICCs was found to maintain the QoL.

Surgical Resection of Colorectal Liver Metastases: Attitudes and Practice Patterns in the Deep South

BackgroundMetastatic disease is the leading cause of mortality in colorectal cancer. Resection of colorectal liver metastases, when possible, is associated with improved long-term survival and the possibility of cure. However, nationwide studies suggest that liver resection is under-utilized in the treatment of colorectal liver metastases. This study was undertaken to understand attitudes and practice patterns among medical oncologists in the Deep South. MethodsA survey of medical oncologists in the states of Alabama, Mississippi, and the Florida panhandle was performed. Respondents were queried regarding perceptions of resectability and attitudes towards surgical referral. ResultsWe received 63 responses (32% response rate). Fifty percent of respondents reported no liver surgeons in their practice area. Commonly perceived contraindications to liver resection included extrahepatic metastatic disease (72%), presence of > 4 metastases (72%), bilobar metastases (61%), and metastases > 5 cm (46%). Bilobar metastatic disease was perceived as a contraindication more frequently by non-academic medical oncologists (70% vs. 33%, p = 0.03). ConclusionsWide variations exist in perceptions of resectability and referral patterns for colorectal liver metastases among surveyed medical oncologists. There is a need for wider dissemination of resectability criteria and more liver surgeon involvement in the management of patients with colorectal liver metastases.

Metastatic disease to the liver: Locoregional therapy strategies and outcomes

Secondary cancers of the liver are more than twenty times more common than primary tumors and are incurable in most cases. While surgical resection and systemic chemotherapy are often the first-line therapy for metastatic liver disease, a majority of patients present with bilobar disease not amenable to curative local resection. Furthermore, by the time metastasis to the liver has developed, many tumors demonstrate a degree of resistance to systemic chemotherapy. Fortunately, catheter-directed and percutaneous locoregional approaches have evolved as major treatment modalities for unresectable metastatic disease. These novel techniques can be used for diverse applications ranging from curative intent for small localized tumors, downstaging of large tumors for resection, or locoregional control and palliation of advanced disease. Their use has been associated with increased tumor response, increased disease-free and overall survival, and decreased morbidity and mortality in a broad range of metastatic disease. This review explores recent advances in liver-directed therapies for metastatic liver disease from primary colorectal, neuroendocrine, breast, and lung cancer, as well as uveal melanoma, cholangiocarcinoma, and sarcoma. Therapies discussed include bland transarterial embolization, chemoembolization, radioembolization, and ablative therapies, with a focus on current treatment approaches, outcomes of locoregional therapy, and future directions in each type of metastatic disease.

Nationwide oncological networks for resection of colorectal liver metastases in the Netherlands: Differences and postoperative outcomes

IntroductionWidespread differences in patient demographics and disease burden between hospitals for resection of colorectal liver metastases (CRLM) have been described. In the Netherlands, networks consisting of at least one tertiary referral centre and several regional hospitals have been established to optimize treatment and outcomes. The aim of this study was to assess variation in case-mix, and outcomes between these networks. MethodsThis was a population-based study including all patients who underwent CRLM resection in the Netherlands between 2014 and 2019. Variation in case-mix and outcomes between seven networks covering the whole country was evaluated. Differences in case-mix, expected 30-day major morbidity (Clavien-Dindo ≥3a) and 30-day mortality between networks were assessed. ResultsIn total 5383 patients were included. Thirty-day major morbidity was 5.7% and 30-day mortality was 1.5%. Significant differences between networks were observed for Charlson Comorbidity Index, ASA 3+, previous liver resection, liver disease, preoperative MRI, preoperative chemotherapy, ≥3 CRLM, diameter of largest CRLM ≥55 mm, major resection, combined resection and ablation, rectal primary tumour, bilobar and extrahepatic disease. Uncorrected 30-day major morbidity ranged between 3.3% and 13.1% for hospitals, 30-day mortality ranged between 0.0% and 4.5%. Uncorrected 30-day major morbidity ranged between 4.4% and 6.0% for networks, 30-day mortality ranged between 0.0% and 2.5%. No negative outliers were observed after case-mix correction. ConclusionVariation in case-mix and outcomes are considerably smaller on a network level as compared to a hospital level. Therefore, auditing is more meaningful at a network level and collaboration of hospitals within networks should be pursued.

Short-Term Outcomes of Secondary Liver Surgery for Initially Unresectable Colorectal Liver Metastases Following Modern Induction Systemic Therapy in the Dutch CAIRO5 Trial.

To present short-term outcomes of liver surgery in patients with initially unresectable colorectal liver metastases (CRLM) downsized by chemotherapy plus targeted agents. The increase of complex hepatic resections of CRLM, technical innovations pushing boundaries of respectability, and use of intensified induction systemic regimens warrant for safety data in a homogeneous multicenter prospective cohort. Patients with initially unresectable CRLM, who underwent complete resection after induction systemic regimens with doublet or triplet chemotherapy, both plus targeted therapy, were selected from the ongoing phase III CAIRO5 study (NCT02162563). Short-term outcomes and risk factors for severe postoperative morbidity (Clavien Dindo grade ≥ 3) were analyzed using logistic regression analysis. A total of 173 patients underwent resection of CRLM after induction systemic therapy. The median number of metastases was 9 and 161 (93%) patients had bilobar disease. Thirty-six (20.8%) 2-stage resections and 88 (51%) major resections (>3 liver segments) were performed. Severe postoperative morbidity and 90-day mortality was 15.6% and 2.9%, respectively. After multivariable analysis, blood transfusion (odds ratio [OR] 2.9 [95% confidence interval (CI) 1.1-6.4], P = 0.03), major resection (OR 2.9 [95% CI 1.1-7.5], P = 0.03), and triplet chemotherapy (OR 2.6 [95% CI 1.1-7.5], P = 0.03) were independently correlated with severe postoperative complications. No association was found between number of cycles of systemic therapy and severe complications (r = -0.038, P = 0.31). In patients with initially unresectable CRLM undergoing modern induction systemic therapy and extensive liver surgery, severe postoperative morbidity and 90-day mortality were 15.6% and 2.7%, respectively. Triplet chemotherapy, blood transfusion, and major resections were associated with severe postoperative morbidity.

Prognostic factors of unresectable hepatocellular carcinoma treated with yttrium-90 radioembolization: results from a large cohort over 13 years at a single center.

A previous study of patients with unresectable hepatocellular carcinoma (HCC) was extended to further examine factors associated with overall survival (OS) after selective internal radiation therapy with yttrium-90 resin microspheres (Y90 SIRT). Data from patients of any age diagnosed with unresectable HCC and treated with Y90 SIRT at our institution from 2004 through 2017 were retrospectively analyzed. Among other criteria, patients had to have Eastern Cooperative Oncology Group performance status 0 to 2, not have received Y90 SIRT previously, and not have extrahepatic disease. Primary outcome was OS; secondary outcomes included tumor response and adverse events (AEs). Kaplan-Meier survival analyses and multivariable Cox proportional hazards models were used to evaluate prognostic factors for OS. Of the 226 patients, 59% were White, 77% were male, and the mean age at first SIRT procedure was 65.1±9.4 years. More than half had received previous treatment for HCC. The most common etiology was hepatitis C (n=138/224 available, 62%), followed by alcohol use (n=45, 20%), and nonalcoholic steatohepatitis (n=27, 12%). The mean model for end-stage liver disease score at baseline was 8.8±2.2. Patients were followed-up for a median of 12.2 months (95% CI, 0.0-62.6). Median OS was 16.6 months (95% CI, 13.1 to not reached). Bilobar disease, higher albumin-bilirubin score at baseline, prior treatment with sorafenib, alcohol use etiology, and higher administered dose were associated with shorter survival, whereas subsequent liver transplant [in 26 patients (11.5%)] was associated with longer survival. Of the 186 patients with AEs data, 75 (40.3%) patients reported an event and, of these, 13 (17.3%) patients had grade 4 bilirubin values. In a large, diverse population treated at a single center over 13 years, Y90 SIRT produced a median OS of 16.6 months in patients with unresectable HCC and enabled subsequent transplantation in a subset of patients. Factors affecting the length of survival should be considered when making treatment decisions for unresectable HCC.

Surgical treatment of gastric cancer liver metastases: Systematic review and meta-analysis of long-term outcomes and prognostic factors.

The prognosis of patients with metastatic gastric cancer remains dismal, with palliative treatment as standard of care. However, encouraging results have been reported for surgical resection of liver only metastatic gastric cancer in carefully selected patients. A systematic review of articles published from 2000 onwards was conducted according to PRISMA guidelines. Twenty-nine studies were included in qualitative and quantitative analysis. Meta-analysis of proportions pointed out 29.1 % 5ySR (I 2 = 39 %). The pooled weighted median of MSTs was 31.1 months. T stage > 2, metastasis greatest dimension ≥ 5 cm, the presence of multiple metastases and bilobar disease resulted among the strongest predictors of mortality. Funnel plots, Egger's tests, and P-curve analyses failed to show significant publication bias. Based on strict selection criteria and robust statistical analyses, our results show that, in very carefully selected patients without extrahepatic disease, surgical resection with curative intent may significantly improve overall survival.

The role of R0/R1vasc resection in the treatment of patients affected by marginal resectable colorectal liver metastases: A pairwise propensity score match analysis

Increasingly, patients with multiple colorectal liver metastases (CRLM) are surgically treated. R1par surgery remains one of the negative prognostic factors for overall survival (OS). According to our data on R1 in main intrahepatic vascular contact (MVC), we investigate the oncological outcome of patients with multiple bilobar disease with bilateral MVC (BC), compared to patients with unilateral MVC (UC) and patients with disease and no MVC (NC). This single-institution study included patients who underwent hepatectomy for multiple (≥ 4) bilobar CRLM lesions from 2004-2019. Three-hundred-fifty-five patients meet the inclusion criteria. One-hundred-thirty-two patients with R1par resection were excluded. Three groups were defined: NC, UC, BC. After pairwise propensity score match 145 patients were analyzed. No differences between groups were observed in the preoperative variables. Increased surgical time, hilar clamping, and blood loss were reported in the BC group. Postoperative minor morbidity, liver failure rate, overall and local recurrences were higher in the BC group. BC patients were more likely to be re-resected. Cumulative OS 3-5 years survival in NC, UC, BC were 54%-40%, 49%-35%, 57%-24% (p < 0.91). At multivariate analysis, factors influencing OS, were N status of the primitive lesions, RAS status, and repeated hepatectomy. Patients with BC and lesions ≥ 4 are generally considered unresectable or suitable for staged hepatectomy. This retrospective study shows that these patients can be submitted to the so called enhanced-one-staged hepatectomy with the same oncological results, however surgical complexity, postoperative minor morbidity and postoperative liver failure are increased.

Role of C11-FDG dual-tracer PET-CT scan in metastatic screening of hepatocellular carcinoma-a cost-effectiveness analysis.

We aimed to identify predictive factors for positron emission tomography (PET)-detected hepatocellular carcinoma (HCC) metastasis and a cost-effective approach to preoperative PET-computed tomography (CT) for detecting metastasis. Clinicopathological and survival data of HCC patients having PET-CT with 18F-fludeoxyglucose (FDG) and 11C-acetate (ACT) following contrast-enhanced CT/magnetic resonance imaging (MRI) for preoperative tumor staging were reviewed. Binary logistic regression was performed to identify predictive factors for PET-detected metastasis. A cost-benefit analysis model was built for the incurred costs and the impact of PET-CT findings on treatment strategy was studied. Totally 152 patients were analyzed. Dual-tracer PET-CT detected metastasis in 17 patients (11%). By multivariate analysis, alpha-fetoprotein (AFP) ≥400 ng/mL [relative risk (RR): 4.30, 95% confidence interval (CI): 1.41-13.15, P=0.011] and bilobar disease (RR: 3.94, 95% CI: 1.24-12.52, P=0.014) were independent predictive factors for PET-detected metastasis. PET-CT findings altered the treatment strategy for 12 patients (7.9%); three partial hepatectomies, eight episodes of transarterial chemoembolization (TACE) and one episode of ablation were avoided, with an estimated cost-saving of US $91,000, $150,000 and $10,600 respectively. Had the PET-CT been performed only for patients with AFP ≥400 ng/mL or bilobar disease (n=74), metastasis would have been confirmed in 14 patients (18.9%), and the cost-saving per patient was estimated at US $1,070. Dual-tracer PET-CT is cost-effective and useful for preoperative HCC staging in patients with AFP ≥400 ng/mL or bilobar disease. Its routine use in preoperative workup for all HCC patients is not recommended. Unilobar disease with AFP <400 ng/mL can achieve good negative predictive value for PET-detected metastasis. Screening patients with either factor can avoid unnecessary procedures and is thus cost-effective for preoperative HCC workup.

Safety and efficacy of right portal vein embolization in patients with prior left lateral liver resection.

In patients with bilobar metastatic liver disease, surgical clearance of both liver lobes may be achieved through multiple-stage liver resections. For patients with extensive disease, a major two-staged hepatectomy consisting of resection of liver segments II and III before right-sided portal vein embolization (PVE) and resection of segments V-VIII may be performed, leaving only segments IV ± I as the liver remnant. To describe the outcome following right-sided PVE after prior complete resection of liver segments II and III. In this retrospective study, 15 patients (mean age = 60.4 ± 9.3 years) with liver metastases from colorectal cancer (n = 14) and uveal melanoma (n = 1) who were scheduled to undergo a major two-stage hepatectomy, were included. Total liver volume (TLV) and volume of the future liver remnant (FLR) were measured on pre- and postinterventional computed tomography (CT) scans, and standardized FLR volumes (ratio FLR/TLV) were calculated. Patient data were retrospectively analyzed regarding peri- and postinterventional complications, with special emphasis on liver function tests. The mean standardized post-PVE FLR volume was 26.9% ± 6.4% and no patient developed hepatic insufficiency after the PVE. Based on FLR hypertrophy and liver function tests, all but one patient were considered eligible for the subsequent right-sided hepatectomy. However, due to local tumor progression, only 9/15 patients eventually proceeded to the second stage of surgery. . Right-sided PVE was safe and efficacious in this cohort of patients who had previously undergone a complete resection of liver segments II and III as part of a major staged hepatectomy pathway leaving only segments IV(±I) as the FLR. .

Abstract No. 7 Experience with radioembolization for hepatocellular carcinoma complicated by portal vein tumor thrombus

Hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) has a poor prognosis of 3 months without treatment. A study found that where the predicted radiation dose to PVTT was greater than 205 Gy, median overall survival was 18.2 months. Follow-up studies have been lacking. We evaluated our experience treating PVTT with radioembolization using post-radioembolization PET/CT to calculate radiation dose. We reviewed medical charts for all radioembolizations for HCC with PVTT at a large academic institution for the past 3 years. Patient demographics, labs, tumor type/location and imaging were reviewed. Mirada Simplicit90Y software was used for radiation dosimetry calculations. Sixteen patients had HCC with PVTT and were treated with TheraSphere radioembolization. Six patients were excluded from review because of no follow-up, developed PVTT during treatment or died from drug overdose. Eight of 10 patients had radiation doses to PVTT greater than 238 Gy. Two patients had PVTT radiation doses of 148 and 101 Gy and no response was seen in PVTT. One patient had a dose of 187 Gy and partial response was seen in PVTT. Three patients with radiation doses greater than 238 Gy had complete responses in the PVTT and parenchymal disease; two are living over 2.5 years from procedure, and one died from a gastrointestinal bleed at 404 days. Although these three patients had PVTT involving main/lobar portal veins, parenchymal disease was unilobar. Of remaining four patients, two had complete and two had partial responses in PVTT; however, none had complete overall imaging responses because of prior untreated hepatic vein tumor thrombus (HVTT) or bilobar parenchymal disease. Eight patients also had medical therapy. Our limited experience found that HCC with PVTT treated with radioembolization had mean survival of 778 days for those with unilobar parenchymal disease, regardless of extent of PVTT, when the PVTT was treated with a radiation dose greater than 238 Gy. Patients with bilobar parenchymal disease who had their PVTT treated with a radiation dose greater than 238 Gy had a mean survival of 181 days.

Hand-assisted Laparoscopic Surgery for Colorectal Liver Metastasis: Analysis of Short-term and Long-term Results.

There is scant data regarding the outcomes of hand-assisted laparoscopic surgery (HALS) for colorectal liver metastasis (CRLM). The aim of this study is to report our experience and analyze the short-term and long-term results. Retrospective study of patients undergoing HALS for CRLM in 2 university affiliated medical centers. Two hundred and thirty-eight liver procedures were performed on 145 patients including 205 parenchymal sparing resections and 33 anatomic resections. The median number of metastases was 1 (range: 1 to 8), 38 patients (26.2%) had 3 or more metastases, and 41 patients (28.3 had a bi-lobar disease. The tumor size was 20 (2 to 90) mm, and 52 patients (36.6%) had a tumor larger than 30 mm. Nighty-nine patients (67.8%) received neoadjuvant chemotherapy. In 8 patients (5.5%) the laparoscopic liver resection was combined with ablation, and 16 patients (11%) underwent a synchronous resection of colorectal cancer. The median operative time, blood loss during surgery, and postoperative hospital stay were 163 minutes, 300 mL, and 4 days, respectively. The median modified Iwate complexity score was 4 (0 to 10) and the conversion rate to open surgery was 5.5%. The overall and major complication rates were 23.8% and 3.6%, respectively. The mortality rate was 0.7%. R0 resections were achieved in 91% of patients. Median overall survival for all the cohort (intend to treat) was 59 months, and the 8- and 10-year overall survival rates were 47.3% and 24.9%, respectively. This study shows that HALS is a safe and efficacious treatment for selected patients with CRLM.

The Impact of Postoperative Ascites on Survival After Surgery for Hepatocellular Carcinoma: a National Study

BackgroundPostoperative ascites (POA) is the most common complication after liver surgery for hepatocarcinoma (HCC), but its impact on survival is not reported. The aim of the study is to investigate its impact on overall survival (OS) and disease-free survival (DFS), and secondarily to identify the factors that may predict the occurrence. MethodData were collected from 23 centers participating in the Italian Surgical HCC Register (HE.RC.O.LE.S. Group) between 2008 and 2018. POA was defined as ≥500 ml of ascites in the drainage after surgery. Survival analysis was conducted by the Kaplan Meier method. Risk adjustment analysis was conducted by Cox regression to investigate the risk factors for mortality and recurrence. ResultsAmong 2144 patients resected for HCC, 1871(88.5%) patients did not experience POA while 243(11.5%) had the complication. Median OS for NO-POA group was not reached, while it was 50 months (95%CI = 41–71) for those with POA (p < 0.001). POA independently increased the risk of mortality (HR = 1.696, 95%CI = 1.352–2.129, p < 0.001). Relapse risk after surgery was not predicted by the occurrence of POA. Presence of varices (OR = 2.562, 95%CI = 0.921–1.822, p < 0.001) and bilobar disease (OR = 1.940, 95%CI = 0.921–1.822, p: 0.004) were predictors of POA, while laparoscopic surgery was protective (OR = 0.445, 95%CI = 0.295–0.668, p < 0.001). Ninety-day mortality was higher in the POA group (9.1% vs 1.9% in NO-POA group, p < 0.001). ConclusionThe occurrence of POA after surgery for HCC strongly increases the risk of long-term mortality and its occurrence is relatively frequent. More efforts in surgical planning should be made to limit its occurrence.

Multimodal treatment strategies for colorectal liver metastases.

Colorectal cancer is the third most common cancer worldwide. Half of CRC patients develop liver metastases during the course of the disease, with a 5-year survival rate close to zero in the absence of therapy. Surgical resection remains the only possible curative option, and current guidelines recommend adjuvant chemotherapy, resulting in a 5-year survival rate exceeding 50%. Neoadjuvant systemic therapy is not indicated in cases with simple resection but should be offered to all patients with extensive bilobar disease. Personalised systemic treatment is essential to convert upfront non-resectable lesions to resectable ones. Anatomical resections, non-anatomical resections and two-stage hepatectomies can be performed though open or minimally invasive (laparoscopic or robotic) surgery. The extent of a hepatic resection is limited by the risk of postoperative liver failure due to a too small liver remnant, inflow or outflow obstruction or insufficient biliary drainage. About 75% of patients are diagnosed with non-resectable liver metastases not amenable to a standard upfront resection. In recent years, effective therapeutic approaches have revolutionised liver surgery and new strategies have enabled the conversion of primarily non-resectable metastatic disease for resection. These strategies include oncological and surgical therapies, as well as combinations of the two. From an oncological perspective, colorectal liver metastases&nbsp; may be treated by systemic chemotherapy or immunotherapy, or selective intra-hepatic arterial infusion chemotherapy, depending on the extent of the disease and the mutational status. In surgery, we often apply two-stage strategies using portal vein occlusion, such as portal vein embolisation or ligation, or complex two-stage hepatectomy such as associating liver partition and portal vein ligation for staged hepatectomy. Other additive tools to reach curative resection are tumour ablations (electroporation, microwave or radiofrequency). The role of stereotactic radiation of liver metastases is not yet well defined. Modern radiation techniques, including image guidance, breath hold and gating, were only introduced for a larger patient population in recent years. Therefore, prospective studies with larger patient cohorts are still pending. Over the last decade, liver transplantation has gained increasing attention in selective cases of non-resectable colorectal liver metastases, with promising cohort studies, but definitive recommendations must await the results of ongoing randomised controlled trials. The optimal treatment of patients with colorectal liver metastases requires the timely association of various strategies, and all cases must be discussed at multidisciplinary team conferences. While colorectal liver metastases was a uniformly lethal condition a few decades ago, it has become amenable to curative therapies, with excellent quality of life in many scenarios. This review reports on up-to-date treatment modalities and their combinations in the treatment algorithm of colorectal liver metastases. &nbsp; &nbsp.

Survival and Outcome in Patients Receiving Drug-Eluting Beads Transarterial Chemoembolization for Large Hepatocellular Carcinoma (>5 cm)

This study aimed to study the outcome and survival of patients with large hepatocellular carcinoma (HCC) receiving drug-eluting beads (DEBs) transarterial chemoembolization (TACE). In addition, tumor morphologies were correlated with the response and survival to analyze the association of morphology with the outcome. Patients with large HCC (>5cm) who underwent DEB-TACE for palliation were analyzed retrospectively. Patients were assessed for objective response (OR) and overall survival (OS), which was calculated from the first session of DEB-TACE to the last follow-up/death. OR and OS were calculated for the entire study group and were compared amongthe subgroups consisting of solitary versus multifocal HCC, unilobar versus bilobar disease, well-defined versus ill-defined HCC, and HCC with homogeneous enhancement versus HCC with heterogeneous enhancement. Sixty-seven DEB-TACE procedures were performed in 25 patients (average: 2.7±1.4 sessions per patient). The mean lesion size was 9.9±4.5cm. Of 25 patients, 13 (52%) had multifocal HCC. Unilobar disease was seen in 15patients (60%). The mean duration of follow-up was 24.4 months. OR at 6 and 12 months were 56% and 48%, respectively, with well-defined lesions showing better OR. The median OS was 28 months (95% confidence interval, 12.3-43.6). OS rate at 12 and 24 months was 92% and 57%, respectively. OS was seen to be superior in well-defined HCC and unilobar disease. In this study, DEB-TACE has shown to have a good response in patients having large/multifocal HCC with preserved liver functions. Well-defined HCC and unilobar disease have a better response and survival.