Traitement Chirurgical HCC Conf Zurich

1 135 vues

Publié le

Majors rules in HCC treatment

Publié dans : Santé & Médecine
0 commentaire
0 j’aime
Statistiques
Remarques
  • Soyez le premier à commenter

  • Soyez le premier à aimer ceci

Aucun téléchargement
Vues
Nombre de vues
1 135
Sur SlideShare
0
Issues des intégrations
0
Intégrations
10
Actions
Partages
0
Téléchargements
27
Commentaires
0
J’aime
0
Intégrations 0
Aucune incorporation

Aucune remarque pour cette diapositive

Traitement Chirurgical HCC Conf Zurich

  1. 1. Liver Resection For HCC Eric Vibert, MD, PhD Centre Hépato-Biliaire, Hop. Paul Brousse
  2. 2. 10 years Recurrence Free Survival 22.4% Février 2011
  3. 3. 2006 HCC < 2 cm 54 pts HBV versus 285 pts HCV Différence à plus de 2 ans 28% 62% 15% 43%
  4. 4. 2000 – 2009 : 127 pts avec CHC sur cirrhose C / Résection R0 Diab. équilibré Diab. non équilibré Treatment of co-factor as diabete is also mandatory to decrease recurrence En préop : BMI et plaquette plus élevés chez les diabétiques RFS à 3 ans : 66% vs 27%
  5. 5. 2013 CHC < 3 cm
  6. 6. 1200 à 1500 Liver Graft / year in France….
  7. 7. Which type of hepatectomy ? AnatomicNon anatomic Unique and inferior to 5 cm
  8. 8. Marge : 1 cm vs 2 cm Suivi moyen : Marge 1 cm (39±17 mois) ; Marge 2 cm (43±15) 2007
  9. 9. Prognosis was in Satellite Nodules
  10. 10. 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% Surgery > Local Destruction if Platelet > 150 000
  11. 11. 2005 Not the same liver, not the same resection…
  12. 12. Recurrence free-survival was similar except in poor differenciated HCC
  13. 13. Kinetics of AFP (Doubling time < 1 month) is more important than level to detect agressive HCC that required margin No correlation between level and kinetic (Dbl time)
  14. 14. Very good accuracy to evaluate tumoral grading for CHC < 5 cm 81 Patients operated for unique CHC unique with preop. Percut. Biopsy 2011
  15. 15. First Message Agressive HCC (Satellite nod, AFP kinetic and poor differentiated HCC) must be treated aggressively with margin AND anatomical resection Is feasible ? The location is higly determinant No choice Choice
  16. 16. Minor hepatectomy
  17. 17. 2006 1997 – 2004 : 157 hepatectomies on cirrhosis Child A : 93% / Minor resection 95% / Mortalité 7% Insuf. Hépatique post-operatoire Complications post-operatoires
  18. 18. 2006 No liver resection on cirrhosis if MELD > 11
  19. 19. 29 patients operated for HCC on Child A cirrhosis Only hepatic venous pressure gradient > 10 mmHg was significant in multivariate analysis for decompensated cirrhosis after hepat. Risk factor in univariate analysis Bilirubin rate Urea rate Rate of platelet ICG Clearence Hepatic venous pressure gradiant, 1996 Ascite at 3 months po
  20. 20. BCLC B BCLC C
  21. 21. 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
  22. 22. Makuuchi et al., Semin Surg Oncol 1993 Ascites None or controlled Not controlled ICGR15 Limited resection Enucleation Not indicated for hepatectomy Trisectorectomy bisectorectomy Left-sided hepatectomy Right-sided sectoriectomy Segmentectomy Limited resection Enucleation Normal 1.1 – 1.5 mg/dL 1.6 – 1.9 mg/dL > 2.0 mg/dL Total bilirubin level Normal 10% - 19% 30% - 39% > 40%20% - 29% Assessment of ICG preoperatively
  23. 23. Hépatectomie mineure Hépatectomie majeure AUC 0,78 [0,66-0,90] Valeur seuil: 12,75 Sensibilité: 74% Spécificité: 71% AUC: 0,66 [0,66-0,87] Sensibilité: 50% Spécificité: 88% p=0,33 2012-2014 : 89 pts operated for HCC on cirrhosis Mort : 2% - Liver Decomp : 34% (Ascite 93%) ICG is the only preoperative data to predict Liver Decomp.
  24. 24. 90 pts including including 17 major hep. : 30% of liver decompensation (20% ascite)
  25. 25. > 16 kpA: Ascite and/or POLF
  26. 26. No evident difference between Laparoscopy and Laparotomy 70% 40%
  27. 27. Foie Non Tumoral Foie Tumoral Si Récidive Salvage Rehépatectomie ? De Principe Bridge Récidive Précoce Récidive Tardive CI à la TH ? Le test of time… Scatton et al. Liver Transpl. Fuks et al. Hepatology
  28. 28. N= 35 malades
  29. 29. Second Message Minor hepatectomy is feasible if MELD < 12 and FibroScan < 17-20 kPa (or ICG-15’ < 13%) Laparoscopy facilitates subsequent liver transplantation and must be used if oncological rules are respected
  30. 30. Major hepatectomy < 20% of standard liver volume or 0.5% body weight on non cirrhotic liver Liver Surgical Planner (Available on iTunes) Truant et al. JACS 2008Ribeiro, Vauthey et al. BJS 2007
  31. 31. 2003 PVE is an « effort test » for the pathological liver…
  32. 32. 2000-2010 : N= 231 pts (US) / 3 Centres Plaquette Préop < 150.000 / mLCourbe ROC / Maj. Compl. 134 Maj. Hep / 3% PVE JACS, Avril 2011
  33. 33. Be careful… Hepatofugal flow… No effect of portal vein embolization and risk of portal thrombosis
  34. 34. TACE PVE Major Hep. Rational of this strategy 1 PVE increases arterial flow and increases HCC vascularization 2 Intra tumoral arterioportal shunt decrease PVE efficacy 3 Blockage of intra-operative portal metastases 2003
  35. 35. 2011
  36. 36. 2009 PVE only or upfront hepatectomy…
  37. 37. 2006 Circulating Cells Ant App. decrease Massive Hemorrhage (> 2 l) : 28% vs 7% But no impact of recurrence…
  38. 38. 2000 – 2011 : 62 pts – 84% diabete 32 (52%) Majors hepatectomies TACE/PVE (n=8) et PVE (n=1) 38 (61%) abnormal liver parenchyma - F1/F2 ou Stéatohépatite (n=20) - F3/F4 (n=18) 15% des CHC réséqués en 2010 18% postop. mortality
  39. 39. Non transplantable patient (Med 70 years) and CHC > 10 cm (75%) Liver biopsy is mandatory to evaluated precisely parenchyma Protection of the liver parenchyma…. Clamping seems deleterious
  40. 40. Third Message No major hepatectomy in abnormal parenchyma without preoperative PVE, especially before Right Hepatectomy TACE before PVE in HCC < 5 cm improved survival
  41. 41. Surgery is Usefull or not ? Macroscopic Vascular Invasion
  42. 42. BCLC B BCLC C
  43. 43. Early tumor : ≤5 cm AND ≤3 nod AND no vascular invasion Intermediate tumor : ≤5 cm AND >3 nod OR with vascular invasion >5 cm AND ≤3 nod AND no vascular invasion Locally advanced tumor : ≤5 cm AND >3 nod AND with vascular invasion >5 cm AND >3 nod AND/OR vascular invasion ECOG Performance Status1- Général status of pts: Score de Child-Pugh2- Function reserve: 3 – Tumoral status: 4 - Envahissement extra-hépatique : Vasculaire et/ou métastatique 3856 ps – 79% HVB 38% resection, LT or ablation 25% TACE as 1st treatment
  44. 44. HKLC I HKLC IIa HKLC IIb HKLC Va (TH) HKLC IIIa HKLC IIIb HKLC IVa HKLC Vb
  45. 45. 2046 patients including 297 pts BCLC C / Mort. 2.7% 25% 50% 2013
  46. 46. Chir (n=70) vs Nexavar (n=44) in BCLC C in 4 Centers in France (Bondy, Creteil, Grenoble, Paul Brousse) N=17 N=16 p=0.17 Propensity score to compare 2 populations Constantin et al. Submitted to EASL Globally no difference….
  47. 47. But perhaps a role of adjuvant treatment p=0.011 N=34 N=44 25.2 m9.4 m Constantin et al. Submitted to EASL To explore…. Which treatment…
  48. 48. Conclusions and Perspectives • Oncological HCC resection imposed margin – Prognostic value of margin according to diameter and genetic of HCC ? • The location of HCC defined the type of surgery – Staging of HCC must included also location • Underlying liver parenchyma is the key – Elastometry will replaced all and notably liver biopsy ? • Surgical treatment of HCC BLCL C is feasible – Adjuvant and perhaps neoadjuvant must be explored

×