Surgical management of hepatic malignancy

Recurrent Hepatocellular Carcinoma in the Right Adrenal Gland 11 Years After Liver Transplantation for Hepatocellular Carcinoma: a Case Report and Literature Review

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver, and extrahepatic metastases are typically found during disease progression. The incidence of adrenal metastasis (AM) from HCC in autopsy series ranges from 4.6 to 12.5%, and it is the second most common site of metastasis after the lungs. To date, there have been few reports of patients who underwent adrenalectomy for isolated AM from HCC after liver transplantation (LT). A woman aged 55 years was referred to our clinic for the evaluation of a right adrenal mass that was detected by abdominal ultrasonography at another center. She had undergone liver transplantation secondary to HCC and acute liver failure due to cryptogenic liver cirrhosis 138 months previously. She had been followed up for 5 years following LT after which she declined to continue with further follow-up. After radiologic and biochemical evaluation, she underwent adrenalectomy and the histopathologic examination revealed a 10 × 8 × 7-cm adrenal mass, which was considered to be an isolated AM from HCC. To our knowledge, this is the first case of isolated AM from HCC in the literature that was diagnosed 138 months after liver transplantation. Isolated AM from HCC after LT is rare and might be detected a long time after LT. Curative surgical resection of isolated metachronous AM from HCC in the absence of disseminated disease might provide for an acceptable disease-free period after adrenalectomy.

Symptomatic Perihepatic Fluid Collections After Hepatic Resection in the Modern Era

BACKGROUND

Improvements in liver surgery have led to decreased mortality rates. Symptomatic perihepatic collections (SPHCs) requiring percutaneous drainage remain a significant source of morbidity.

STUDY DESIGN

A single institution's prospectively maintained hepatic resection database was reviewed to identify patients who underwent hepatectomy between January 2004 and February 2012.

RESULTS

Data from 2173 hepatectomies performed in 2040 patients were reviewed. Overall, 200 (9%) patients developed an SPHC, the majority non-bilious (75.5%) and infected (54%). Major hepatic resections, larger than median blood loss (≥360 ml), use of surgical drains, and simultaneous performance of a colorectal procedure were associated with an SPHC on multivariate analysis. Non-bilious, non-infected (NBNI) collections were associated with lower white blood cell (WBC) counts, absence of a bilio-enteric anastomosis, use of hepatic arterial infusion pump (HAIP), and presence of metastatic disease, and resolved more frequently with a single interventional radiology (IR) procedure (85 vs. 46.5%, p < 0.001) more quickly (15 vs. 30 days, p = 0.001).

CONCLUSIONS

SPHCs developed in 9% of patients in a modern series of hepatic resections, and in one third were non-bilious and non-infected. In the era of modern interventional radiology, the need for re-operation for SPHC is exceedingly rare. A significant proportion of minimally symptomatic SPHC patients may not require drainage, and strategies to avoid unnecessary drainage are warranted.

Detection and classification of different liver lesions: comparison of Gd-EOB-DTPA-enhanced MRI versus multiphasic spiral CT in a clinical single centre investigation

OBJECTIVE

To compare the diagnostic efficacy of Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI) vs. multidetector computed tomography (MDCT) for the detection and classification of focal liver lesions, differentiated also for lesion entity and size; a separate analysis of pre- and postcontrast images as well as T2-weighted MRI sequences of focal and exclusively solid lesions was integrated.

METHODS

Twenty-nine patients with 130 focal liver lesions underwent MDCT (64-detector-row; contrast medium iopromide; native, arterial, portalvenous, venous phase) and MRI (1.5-T; dynamic and tissue-specific phase 20 min after application of Gd-EOB-DTPA). Hepatic lesions were verified against a standard of reference (SOR). CT and MR images were independently analysed by four blinded radiologists on an ordinal 6-point-scale, determining lesion classification and diagnostic confidence.

RESULTS

Among 130 lesions, 68 were classified as malignant and 62 as benign by SOR. The detection of malignant and benign lesions differed significantly between combined and postcontrast MRI vs. MDCT; overall detection rate was 91.5% for combined MRI and 80.4% for combined MDCT (p<0.05). Considering all four readers together, combined MDCT achieved sensitivity of 66.2%, specificity of 79.0%, and diagnostic accuracy of 72.3%; combined MRI reached superior diagnostic efficacy: sensitivity 86.8%, specificity 94.4%, accuracy 90.4% (p<0.05). Differentiated for lesion size, in particular lesions <20mm revealed diagnostic benefit by MRI. Postcontrast MRI also achieved higher overall sensitivity, specificity, and accuracy compared to postcontrast MDCT for focal and exclusively solid liver lesions (p<0.05).

CONCLUSION

Combined and postcontrast Gd-EOB-DTPA-enhanced MRI provided significantly higher overall detection rate and diagnostic accuracy, including low inter-observer variability, compared to MDCT in a single centre study.

Patient selection for surgical management of primary and metastatic liver cancers: current perspectives

The surgical management of liver malignancies remains a mainstay in the treatment of such patients, and has benefited from dramatic advancements over the last two decades. Improvements in surgical technique, better understanding of hepatic anatomy, and improvement in anesthesiological supportive care has resulted in a decline in perioperative morbidity and operative mortality. Proper patient selection for surgical and nonsurgical treatment currently employs a multidisciplinary approach in our institution. This review will focus on the surgical treatment options for both primary and secondary liver cancers.

Tumor-associated lymphangiogenesis correlates with prognosis after resection of human hepatocellular carcinoma

BACKGROUND

Experimental results from animal models as well as studies of human cancers indicate a critical role for tumor-associated lymphangiogenesis in tumor progression. However, its significance in hepatocellular carcinoma (HCC) is not well established.

METHODS

We analyzed tissue specimens from healthy liver (n = 36), cirrhotic liver (n = 24), and HCC (n = 60) by immunohistochemistry, using antibody D2-40 specific for lymphendothelia. We subsequently quantified lymphatic microvessel density (LVD). The LVD was correlated with clinicopathological characteristics of the tumors as well as survival and disease-free survival of the patients.

RESULTS

In contrast to healthy as well as cirrhotic liver, lymphangiogenesis was induced in HCC. Lymphatic vessels were detected in the intratumoral septa as well as within the bulk of tumor cells. Tumors with high LVD (24 of 60) had developed significantly more frequently in cirrhotic livers (P = 0.001) and were more frequently restricted to one liver lobe (P = 0.04). Univariate analysis revealed high LVD as a marker for reduced survival and disease-free survival disadvantage (median >60 vs. 21 months, P = 0.018, and 19 vs. 8 months, P = 0.047, respectively). In multivariate analysis, LVD showed a trend toward association with reduced survival (P = 0.059) and represented an independent prognostic factor for disease-free survival (P = 0.017).

CONCLUSIONS

Tumor-associated lymphangiogenesis is involved in neovascularization of hepatocellular carcinoma. Quantitative analysis of LVD demonstrated a significant influence of lymphangiogenesis on survival and established LVD as an independent predictor of disease-free survival. Quantification of LVD may be helpful in identifying patients with a high risk of tumor recurrence.

Selection criteria for liver resection in patients with hepatocellular carcinoma and chronic liver disease

Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide with an annual occurrence of one million new cases. An etiologic association between HBV infection and the development of HCC has been established with a relative risk 200-fold greater than in non-infected individuals. Hepatitis C virus is also proving an important predisposing factor for this malignancy with an incidence rate of 7% at 5 years and 14% at 10 years. The prognosis depends on tumor stage and degree of liver function, which affect the tolerance to invasive treatments. Although surgical resection is generally accepted as the treatment of choice for HCC, new treatment strategies, such as local ablative therapies, transarterial embolization and liver transplantation, have been developed nowadays. With increasing detection of small HCCs from screening programs for cirrhotic patients, it is foreseen that locoregional therapy will play an important role in the near future.

Trends in survival after surgery for cholangiocarcinoma: a 30-year population-based SEER database analysis

The prognosis of patients with cholangiocarcinoma historically has been poor, even after surgical resection. Although data from some single-institution series indicate improvement over historical results, survival after surgical therapy for cholangiocarcinoma has not been investigated in a population-based study. We used the Surveillance, Epidemiology, and End Results database to identify patients who underwent surgery for cholangiocarcinoma from 1973 through 2002. Multivariate modeling of survival after surgery for intrahepatic cholangiocarcinoma showed an improvement in survival only within the last decade studied, resulting in a cumulative 34.4% improvement in survival from 1992 through 2002. In contrast, multivariate modeling of survival after surgery for extrahepatic cholangiocarcinoma revealed a 23.3% increase in adjusted survival per each decade studied, resulting in a cumulative 53.7% improvement from 1973 through 2002. We conclude that survival after surgery for extrahepatic cholangiocarcinoma has dramatically improved since 1973. Patients with intrahepatic cholangiocarcinoma, however, have achieved an improvement in survival largely confined to more recent years. We suggest that these trends are largely caused by developments in imaging technology, improvements in patient selection, and advances in surgical techniques.

Liver resection for metastases from renal cell carcinoma

BACKGROUND

This study was conducted to evaluate the safety and efficacy of liver resection in patients with hepatic metastases from renal cell carcinoma and to identify selection criteria for patients suitable for resection.

METHODS

Between January 1988 and March 2006, 31 patients underwent liver resection for metastases from renal cell carcinoma. Patients were identified from a prospective database and retrospectively reviewed. Patient, tumor, and operative parameters were analyzed for their influence on long-term survival.

RESULTS

The overall 1-, 3- and 5-year survival rates were 82.2%, 54.3%, and 38.9%, respectively. One patient was deceased and 4 developed complications during the postoperative course. In the univariate analysis, site of the primary tumor (P = 0.013), disease-free interval (P = 0.012), and resection margins (P = 0.008) showed significant influence on long-term survival. In the multivariate analysis, only the resection margins were identified as an independent prognostic factor after liver resection.

CONCLUSIONS

Liver resection is effective and safe in the treatment of patients with hepatic metastases from renal cell carcinoma and offers the chance of long-term survival and cure. Achieving a margin-negative resection is the most important criterion in the selection of suitable patients for liver resection. However, the number of patients in the present study was small, and investigations of larger series may provide further prognostic parameters in these patients.

Intermittent hepatic vein balloon occlusion during radiofrequency ablation in the liver

The purpose of the study was to assess the feasibility of intermittent hepatic vein balloon occlusion during percutaneous radiofrequency (RF) ablation. Eight non-anticoagulated patients who had primary (n = 2) and metastatic (n = 6) liver tumors with a mean diameter of 4.2 cm (range 2.4-6.5 cm) were treated, resulting in a mean ablation diameter of 6.3 cm (range 4.3-9.3 cm). Six of 9 (67%) of the balloon-occluded hepatic veins were patent. No clinical sequelae of thrombosis were noted. Mean length of follow-up with CT and/or MRI was 12 months. Local tumor control was achieved in 5 of 8 patients. Intermittent hepatic vein balloon occlusion could potentially be a low-risk adjunctive maneuver for thermal ablation therapy in the treatment of large tumors and tumors adjacent to large vessels.

The treatment of hepatic metastases in colorectal carcinoma

Colorectal carcinoma is the third most common cause of cancer death in the United States, with 135,000 new cases and 55,000 deaths annually. Ultimately, two-thirds (99,000) of all patients with colorectal cancer will develop metastasis to the liver and other organs in their life span, making metastatic colorectal cancer the second leading cause of cancer-related death in North America. The optimal management of these patients has become increasingly complex with the myriad of treatment options that are available. Because the timing of any therapy (surgery, chemotherapy, or others) has become integral to the success of the treatment, a collaborative approach involving multiple specialties is needed for the best patient outcome. Defined clinical and pathologic determinants of outcome have been demonstrated to effect the overall and disease-free survival of patients with metastatic colorectal cancer. Understanding of these determinants remains essential to any treating physician and has lead to significant paradigm shifts in the management of patients with metastatic colorectal cancer.

Multidisciplinary management of ruptured hepatocellular carcinoma

Spontaneous rupture of hepatocellular carcinoma (HCC) is a dramatic presentation of the disease. Most published studies are from Asian centers, and North American experience is limited. This study was undertaken to review the experience of ruptured HCC at a North American multidisciplinary unit. Thirty patients presenting with ruptured HCC at a tertiary care center from 1985 to 2004 were studied retrospectively and analyzed according to the demographics, clinical presentation, tumor characteristics, treatment, and outcome in four treatment groups: emergency resection, delayed resection (resection after angiographic embolization), transcatheter arterial embolization (TAE), and conservative management. Ten, 10, 7, and 3 patients underwent emergency resection, delayed resection, TAE, and conservative treatment, respectively. The mean age of all patients was 57 years, and the mean Child-Turcotte-Pugh score was 7 +/- 2. Cirrhosis was present in 57% of the patients. Seventy percent of tumors were greater than 5 cm in diameter, and 68% of patients had multiple tumors. There was a trend toward higher 30-day mortality in the emergency resection group than in the delayed resection group. One-year survival was significantly better in the delayed resection group. In selected patients, the multidisciplinary approach of angiographic embolization and delayed resection affords better short-term survival than emergency resection.

Bipolar radiofrequency ablation of liver metastases during laparotomy. First clinical experiences with a new multipolar ablation concept

BACKGROUND AND OBJECTIVE

Radiofrequency ablation (RFA) is a promising method for local treatment of liver malignancies. Currently available systems for radiofrequency ablation use monopolar current, which carries the risk of uncontrolled electrical current paths, collateral damages and limited effectiveness. To overcome this problem, we used a newly developed internally cooled bipolar application system in patients with irresectable liver metastases undergoing laparotomy. The aim of this study was to clinically evaluate the safety, feasibility and effectiveness of this new system with a novel multipolar application concept.

PATIENTS AND METHODS

Patients with a maximum of five liver metastases having a maximum diameter of 5 cm underwent laparotomy and abdominal exploration to control resectability. In cases of irresectability, RFA with the newly developed bipolar application system was performed. Treatment was carried out under ultrasound guidance. Depending on tumour size, shape and location, up to three applicators were simultaneously inserted in or closely around the tumour, never exceeding a maximum probe distance of 3 cm. In the multipolar ablation concept, the current runs alternating between all possible pairs of consecutively activated electrodes with up to 15 possible electrode combinations. Post-operative follow-up was evaluated by CT or MRI controls 24-48 h after RFA and every 3 months.

RESULTS

In a total of six patients (four male, two female; 61-68 years), ten metastases (1.0-5.5 cm) were treated with a total of 14 RF applications. In four metastases three probes were used, and in another four and two metastases, two and one probes were used, respectively. During a mean ablation time of 18.8 min (10-31), a mean energy of 48.8 kJ (12-116) for each metastases was applied. No procedure-related complications occurred. The patients were released from the hospital between 7 and 12 days post-intervention (median 9 days). The post-interventional control showed complete tumour ablation in all cases.

CONCLUSIONS

Bipolar radiofrequency using the novel multipolar ablation concept permits a safe and effective therapy for the induction of large volumes of coagulation in the local treatment of liver metastases.

In-vivo evaluation of a novel bipolar radiofrequency device for interstitial thermotherapy of liver tumors during normal and interrupted hepatic perfusion

BACKGROUND

Only monopolar systems have thus far been available for radiofrequency ablation of liver tumors, whose application is restricted because of the incalculable energy flow, reduction of electrical tissue conduction, and limited lesion size. The aim of this study was to evaluate a novel internally cooled bipolar radiofrequency application device under in vivo conditions and to compare the effect of this system on lesion size when combined with hepatic arterial microembolization or complete hepatic blood flow occlusion.

MATERIALS AND METHODS

In a porcine liver model, RFA (60 W, 12 min) was performed with either normal (n = 12), partially interrupted (arterial microembolization via a hepatic artery catheter n = 12) or completely interrupted hepatic perfusion (Pringle's maneuver, n = 12). RFA parameters (impedance, power output, temperature, applied energy) were determined continuously during therapy. RFA lesions were macroscopically assessed after liver dissection.

RESULTS

Bipolar RFA induced clinical relevant ellipsoid thermal lesions without complications. Hepatic inflow occlusion led to a 4.3-fold increase in lesion volume after arterial microembolization and a 5.8-fold increase after complete interruption (7.4 cm(3)versus 31.9 cm(3)versus 42.6 cm(3), P < 0.01).

CONCLUSIONS

The novel bipolar RFA device is a safe and effective alternative to monopolar RFA-systems. Interrupting hepatic perfusion significantly increases lesion volumes in bipolar RFA. This beneficial effect can also be achieved in the percutaneous application mode by RFA combined with arterial microembolization via a hepatic artery catheter.

Clinical analysis of the risk factors for recurrence of HCC and its relationship with HBV

AIM: To comprehend the risk factors of recurrence of hepatocellular carcinoma (HCC) and its relationship with the infection patterns of hepatitis B virus (HBV).

METHODS: All materials of 270 cases of postoperative HCC were statistically analyzed by SPSS software. Recurrence and metastasis were classified into early ( ≤2 years) and late phase (>2 years). Risk factors for recurrence and metastasis after surgery in each group were analyzed.

RESULTS: Out of 270 cases of HCC, 162 cases were followed up in which recurrence and metastasis occurred in 136 cases. There were a lot of risk factors related to recurrence and metastasis of HCC; risk factors contributing to early phase recurrence were serum AFP level, vascular invasion, incisal margin and operative transfusion, gross tumor classification and number of intrahepatic node to late phase recurrence. The HBV infective rate of recurrent HCC was 94.1%, in which “HBsAg, HBeAb, HBcAb” positive pattern reached 45.6%. The proportion of HBV infection in solitary large hepatocellular carcinoma (SLHCC) evidently decreased compared to nodular hepatocellular carcinoma (NHCC) (P<0.05).

CONCLUSION: The early and late recurrence and metastasis after hepatectomy of HCC were associated with different risk factors. The early recurrence may be mediated by vascular invasion and remnant lesion, the late recurrence by tumor’s clinical pathology propert, as multicentric carcinogenesis or intrahepatic carcinoma de novo. HBV replication takes a great role in this process. From this study, we found that SLHCC has more satisfactory neoplasm biological behavior than NHCC.