Surgery vs ablation in HCC

1. Surgeryfor earlyHCC
EricVibert, MD, PhD
Centre Hépato Biliaire,
Hop. Paul Brousse (AP/HP) -Villejuif

2. 218 patients avec CHC < 2 cm
Suivi médian : 31 mois
26%
Nécrose radiologique complète : 98%
2008
20%

3. 22.4%
Février 2011
4977 patients
(1998 –2003)
50 % HVC
30% HVB
20% Other

5. Prognosiswasin Satellite Nodules

6. 2013
16 / 132 pts (12%)
Satellites Nod.
1990 –2009 : New York + Milan
-NY : Child A / No Portal Hypertension
-Milan : Child A : ICG < 20%
132 pts / Mortalité Pst op 0.7%

7. Marge : 1 cm vs 2 cm
Suivi moyen : Marge 1 cm (39±17 mois) ; Marge 2 cm (43±15)
2007

8. For RF needlethatdestroy a sphereof 3 cm diameter
Diamètretumoral
Nb de «ponction»
1 cm
1
1,75cm
6
3 cm
14
2002

9. No exploration of the liversurface
ICG camera
IOUS

10. 2013
CHC < 3 cm

11. 1200 à 1500 Greffons / an en France….

12. Waiting list : 3 months to 1 year
Inscription
Transplantation
Palliative
Drop-out = 12%
No Drop-out

13. WhenIplanatreatmenttoMisterDurand,IthinktoMisterDupond… Whowillbemorebeneficiatedoflivertransplantationrelativelytoresection?
Riskand Interestof oncologichepatectomy?

15. MELD >11
Sensitivity = 82%
Specificity = 89%
0
20
40
60
80
100
0
20
40
60
80
100
Sensitivity
100 –Specificity
MELD >9
Sensitivity = 87%
Specificity = 63%
0
20
40
60
80
100
0
20
40
60
80
100
Sensitivity
100 –Specificity
Post operative liver failure

1997 -2004 : 157 cirrhotic liver resections
Post operative complications
2006
Child A : 93% / Minor resection : 95% / Mortality 7%

16. The Risk…

17. Variables
MELD score <9 (n=74)
MELD score between 9 and 10 (n=56)
MELD score > 11 (n=24)
Postoperative liver failure
0 (0%)
2 (3.6%)
9 (37.5%)
Postoperative complications
6 (8.1%)
20 (35.7%)
20 (83.3%)
Refractory ascites
5 (6.8%)
15 (26.8%)
20 (83.3%)
Jaundice
2 (2.7%)
10 (17.9%)
19 (79.2%)
Alteration of coagulation factors
3 (4.1%)
12 (21.4%)
19 (79.2%)
Renal impairment
0 (0%)
4 (7.1%)
6 (25%)
Hospital stay (days)
8 (5-38)
9 (6-33)
25 (6-166)
1-year survival
100%
94%
74%

No liver resection in cirrhotic patientwith a MELD Score superior to 12
2006

18. British Journal of Surgery 1997, 84, 1255 - 1259
Survivors (n = 113) Non-survivors (n = 14) P *
All ICG retention at 15 min (%) 11 (3 - 50) 18 (4 - 29) 0.008
Aminopyrine breath test (%) 4-4 (1.3 - 9.6) 4.3 (2.8 – 8.3) 0.69
Amino acid clearance test (1 m-2 min-1) 0.21(1.7 to 4.3) 0.15 (-0.2 to 0.9) 0.35
Albumin (g l-1) 42 (31 - 53) 41 (29 - 46) 0.40
Total bilirubin (μmol l-1) 9 (3 - 70) 14 (7 - 32) 0.05
Aspartate aminotransferase (units l-1) 59 (17 - 365) 97 (39 - 340) 0.02
Alanine aminotransferase (units l-1) 53 (9 - 480) 53 (21 - 322) 0.90
0
15
35
[IGC] mg %
Survivors
Distribution of indocyanine green (ICG) retention at
? in for survivors and patients who died in hospital
Non-survivors
5
25
40
10
20
45
30
 127 hepatectomies dont 91 Majeures
 Child A (n=121) / Child B (n=6)
 Mortalité Hospitalière : 14/127 (11%)
 Valeur seuil d’ICG à 15 minutes
15% pour les Hep. Maj
23% pour les Hep. Min.

19. 2008
1994-2004 : 455 pts opérés pour CHC / Suivi moy.: 46 mois 384 pts avec fibroscopie pré-opératoire
Child A / Sans HTP
56%
71%
Child A / Avec HTP
Définition de l’HTP : VO et/ou
plq < 100 000/ml + Splénomégalie

20. 2003
PVE isan «effort test» for the pathologicalliver…

21. The interest…
To treata problemand to plan the futur

22. Into the parenchyma
Into the HCC
If recurrence
Salvage LT
Preemptive LT
Bridge LT
Early Recurrence
Late Recurrence
CI à la TH ?
Test of time…
Scatton et al. Liver Transpl.
Fuks et al. Hepatology
Swiss
Watch

23. Taux de transplantation secondaire en cas de récidive : 28%
2011

24. 1 -Peu différencié
2 -Inv. Vasc. micro
3 -Nodules satellites
4-Cirrhose (F4)
5 -Diamètre > 3 cm
Récidive dans Milan
65% de TH Salvage

25. Log rank p= 0.038
100%
56%
78%
41%
100%
81%
Living donor : 11
Cadaveric donor : 22
Salvage Transplantation for HCC on cirrhotic liver
Overall Survival (Paul Brousse Experience)

26. MILAN IN (Specimen)
MILAN Out (Specimen)
Mai 2011

27. 5 Gènes : TAF9, RAMP3, HN1, KRT19, RAN

30. N= 35 malades

32. BCLC B
BCLC C

33. The location of HCC…
LiverSPby SIGHT

34. In conclusion…
It waspossible to cure a patient withearlyHCCby liverresectionthatcontaina safetymarginif the patient hadenoughliverfonctionalreserveto support surgery…
Wedidnot plan the futurof the patientSby destruction of the presentbut by itscarefulanalysis…
Thanksfor yourattention
eric.vibert.pbr@gmail. com
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