This document summarizes a presentation on controversies in hepatobiliary pancreatic surgery. It discusses 4 topics: 1) Whether resectable hilar cholangiocarcinoma should be resected or treated with orthotopic liver transplantation, 2) How to treat node-positive intrahepatic cholangiocarcinoma, 3) Options for unresectable intrahepatic cholangiocarcinoma, and 4) Managing large hepatocellular carcinoma in early cirrhosis. For each topic, one or more case examples are described and various treatment approaches are outlined and discussed. Supporting data from studies on outcomes with different strategies are also presented.

1. AUBHO CONFERNECE
8/2015
P R E S E N T E D B Y :
T H O M A S A L O I A , M D
A S S O C P R O F O F S U R G I C A L O N C O L O G Y
M D A N D E R S O N C A N C E R C E N T E R
Controversies in HPB
Surgery

2. Topics
1. Resectable hilar cholangiocarcinoma: Resection or OLT
2. Node-positive intrahepatic cholangiocarcinoma
3. Unresectable intrahepatic cholangiocarcinoma
4. Large HCC in early cirrhosis

3. Resectable Hilar Cholangiocarcinoma
 55 y/o F presented to an OSH with epigastric fullness and abnormal LFTs.
 Workup included an MRI which demonstrated a small perihilar mass.
 No vascular involvement.
 ERCP identified a stricture with brushings suspicious for adenocarcinoma.
 EUS revealed a 1.2 cm hypoechoic mass with no lymphadenopathy.
Mass
Mass

4. Treatment Options?
A. Chemoradiotherapy followed by OLT
B. Resection
C. Chemotherapy

5. Resectable Hilar Cholangiocarcinoma
 Patient seen by Transplant Team
 Told that survivals better after transplant
 Started on chemoradiation per the Mayo protocol.
 Taken to OR for transplantation, however, procedure aborted secondary to
portal lymph node involvement.
 Developed jaundice and repeat ERCP was performed
 2 metal stents were placed extending deep into right and left liver.
 Referred to MD Anderson for a second opinion.

6. Resectable Hilar Cholangiocarcinoma
 Multiphasic liver CT:
 Now What?

7. Resectable Hilar Cholangiocarcinoma
 Multiphasic liver CT:
 Referred to medical oncology for Gemcitabine and Cisplatin
 Re-evaluate in 3 – 6 months.

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

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

10. Hilar Cholangiocarcinoma
 Should resectable CCA be referred to OLT?
 Patients with clearly resectable de novo HC should be treated with resection.
 Patients with B-C type IV HC might be best treated with transplantation if they
are excellent transplant candidates.

11. Topics
1. Resectable hilar cholangiocarcinoma: Resection or OLT
2. Node-positive intrahepatic cholangiocarcinoma
3. Unresectable intrahepatic cholangiocarcinoma
4. Large HCC in early cirrhosis

12. Node-positive Intrahepatic Cholangiocarcinoma
 57 y/o F presented to the ED with epigastric pain
 CT scan:

13. Node-positive Intrahepatic Cholangiocarcinoma
 Biopsy: adenocarcinoma positive for CK7 and CK 20
 CT suggested regional adenopathy
 EGD and colonoscopy – normal
 PET scan: large intensely hypermetabolic mass in the left liver.
 10 cycles of Gemcitabine and Cisplatin – stable disease.

14. Treatment Options?
A. Radiotherapy
B. Resection
C. Continued chemotherapy

15. Node-positive Intrahepatic Cholangiocarcinoma
 Biopsy: adenocarcinoma positive for CK7 and CK 20
 CT suggested regional adenopathy
 EGD and colonoscopy – normal
 PET scan: large intensely hypermetabolic mass in the left liver.
 10 cycles of Gemcitabine and Cisplatin – stable disease.
 Extended left hepatectomy + caudate and lymphadenectomy.
 Moderately differentiated cholangiocarcinoma with negative margins. 1 lymph
node positive. T2a N1

17. Portal Node Dissection

18. Cholangiocarcinoma
 Adenocarcinoma
 Rich lymphatic plexus
 =Early metastatic disease

19. Cholangiocarcinoma Lymphatic Drainage

20. Node-positive Intrahepatic Cholangiocarcinoma
 Complete surgical resection provides the best option for long-term survival ⁽¹⁾.
 Factors with prognostic significance after ICC resection are the presence of
vascular invasion, multiple tumors, and LNM ⁽²⁾.
 Some authors suggest that an LND should be performed in all patients with ICC
in order to appropriately stage individuals and guide perioperative
management.
 LN+ also constitutes an indication for neoadjuvant therapy.
 NCCN guidelines:
 Recommend considering a lymphadenectomy in resectable disease for accurate staging.
 Lymph node metastases beyond the porta hepatis (M1) contraindicates resection.
1 Herman J M and Pawlik T M, Hepatocellular Carcinoma, Gallbladder Cancer, and Cholangiocarcinoma, in Radiation Oncology: An Evidence-Based Approach, J.J. Lu and
L.W. Brady, Editors. 2008. p. 221–243.
2 Cho S Y, Park S J, Kim S H, Han S S, Kim Y K, Lee K W, Lee S A, Hong E K, Lee W J, and Woo S M. Survival analysis of intrahepatic cholangiocarcinoma after resection. Annals of
Surgical Oncology 2010; 17:1823–1830.

21. Topics
1. Resectable hilar cholangiocarcinoma: Resection or OLT
2. Node-positive intrahepatic cholangiocarcinoma
3. Unresectable intrahepatic cholangiocarcinoma
4. Large HCC in early cirrhosis

22. Unresectable IHCC
 54 yo man presents with left liver cholangio, portal
and gastric LAD, and a small right liver metastasis
 Stable on induction systemic therapy, but
mounting toxicities
 Able to radiate but bowel at risk

23. Treatment Options?
 Options?
A. Low dose radiation
B. High dose radiation with bowel perforation risk 20%
C. Experimental protocol chemotherapy

24. Non-target Radiation Risk
Left Liver
Cholangio
overlying
stomach

25. Alloderm Envelope with Clips

26. Alloderm Spacer in Place
Clip Suture

27. MIS Alloderm Placement

28. MIS Alloderm Placement

29. duodenum
colon
3 cm
Envelope
Envelope
tumor

30. “Ablative” IMRT 67.5 Gy /15 fractions

31. Results
 12 patients
 Mean dose of radiation delivered was 76.1 Gy (58.1-100 Gy).
 Mean follow-up after completion of RT was 19.5 months.
 2 patients developed mild radiation-induced GI toxicity (RTOG grade 2). No GI
bleeding, RILD or readmission.
 RT was able to control liver disease in 42.9%. Only 2 patients had isolated in-
field progression of liver disease.
 Overall survival rate was 72% over a 2 year period.
Ismael/Crane/Aloia, in prep, 2015

32. Topics
1. Resectable hilar cholangiocarcinoma: Resection or OLT
2. Node-positive intrahepatic cholangiocarcinoma
3. Unresectable intrahepatic cholangiocarcinoma
4. Large HCC in early cirrhosis

33. Large HCC in Early Cirrhosis
 60 y/o gentleman with chronic hepatitis B was diagnosed with a right liver
mass (biopsy: well differentiated HCC).
 INR 0.9, PLT 344,000, Bilirubin 0.6, Albumin 4.5.
 Presented to MD Anderson for a second opinion.
Volumetry: FLR for extended right
hepatectomy = 28%.

34. Treatment Options?
A. TACE alone
B. Resection
C. OLT
D. Chemotherapy
E. PVE
F. Combination

35. Large HCC in Early Cirrhosis
 60 y/o gentleman with chronic hepatitis B was diagnosed with a right liver
mass (biopsy: well differentiated HCC).
 INR 0.9, PLT 344,000, Bilirubin 0.6, Albumin 4.5.
 Presented to MD Anderson for a second opinion.
Volumetry: FLR for extended right
hepatectomy = 28%.
TACEPVE

36. Large HCC in Early Cirrhosis
 Preoperative imaging:
 FLR 36%
 KGR 2%-age points/week

37. Case Presentation
• 61 yo male
– EtOH Child’s A cirrhosis
– Large central HCC
• ERILS
– Premeds
– No narcotics
– Steroids
– Lidocaine
– Epidural
• Inflow Occlusion
– 4 x 15
– EBL: 225cc
– No transfusions
• C-Gram
• Air Leak Test
– 4 parenchymal bile duct repairs
Aloia, JACS, 2015 & Zimmitti, JACS, 2013

38. Case Presentation
• 61 yo male
– EtOH Child’s A cirrhosis
– Large central HCC
• Post Op: ERILS
– No NG
– No Narcotics
– POD1 Diet and Exercise
– POD2 Foley out
– POD3 Drain Bili=1.4
• Drain removed
– POD4 Epidural out
– POD5 DC
– Lovenox x 23d
– Path: T1, N0, Marg-
Aloia, JACS, 2015

39. Large HCC in Early Cirrhosis
 16 patients underwent TACE followed by PVE with a 2 week hypertrophy of 22%.
 Concluded: procedure contributes to both the broadening of surgical indications
and the safety of performing major hepatectomies in HCC patients with chronic
liver disease.

40. Suggested Algorithm: HCC in Early Cirrhosis
Low
FLR
T<5 cm
TACE
PVE
T>5 cm
?Y90
PVE

41. ???????????
 Thomas A. Aloia, MD
 E: taaloia@mdanderson.org
 T: @mdahpbaloia