Superselective Radioembolization of Hepatocellular Carcinoma: 5-Year Results of a Prospective Study

Twenty patients with unresectable hepatocellular carcinoma (HCC) were followed up to 5 years after transarterial radiotherapy with 90Y-resin particles. Diagnostic radioembolizations of 99mTc-macroaggregates facilitated scintigraphic assessment of activity distribution, dose evaluation and final procedural verification. The overall survival rates were 56, 38 and 14% (after 1, 2 and 3 years, resp.). Patients with unifocal HCC and a single feeding artery (n = 7) even presented 83, 67 and 40% (2 alive after 2.75 and 4 years). With multiple arteries (n = 7), the longest survival was 26 months. Patients with multifocal HCC survived up to 33 months after selective radioembolization. Quality of life was improved in all. Survival was positively correlated with absorbed dose but residual/recurrent tumour occurred even after ≥300 Gy. Post-treatment symptoms were minimal (35 applications), pulmonary shunt rates were correctly predicted and pulmonary complications avoided.

Survival after resection of perihilar cholangiocarcinoma-development and external validation of a prognostic nomogram

BACKGROUND

The objective of this study was to derive and validate a prognostic nomogram to predict disease-specific survival (DSS) after a curative intent resection of perihilar cholangiocarcinoma (PHC).

PATIENTS AND METHODS

A nomogram was developed from 173 patients treated at Memorial Sloan Kettering Cancer Center (MSKCC), New York, USA. The nomogram was externally validated in 133 patients treated at the Academic Medical Center (AMC), Amsterdam, The Netherlands. Prognostic accuracy was assessed with concordance estimates and calibration, and compared with the American Joint Committee on Cancer (AJCC) staging system. The nomogram will be available as web-based calculator at mskcc.org/nomograms.

RESULTS

For all 306 patients, the median overall survival (OS) was 40 months and the median DSS 41 months. Median follow-up for patients alive at last follow-up was 48 months. Lymph node involvement, resection margin status, and tumor differentiation were independent prognostic factors in the derivation cohort (MSKCC). A nomogram with these prognostic factors had a concordance index of 0.73 compared with 0.66 for the AJCC staging system. In the validation cohort (AMC), the concordance index was 0.72, compared with 0.60 for the AJCC staging system. Calibration was good in the derivation cohort; in the validation cohort patients had a better median DSS than predicted by the model.

CONCLUSIONS

The proposed nomogram to predict DSS after curative intent resection of PHC had a better prognostic accuracy than the AJCC staging system. Calibration was suboptimal because DSS differed between the two institutions. The nomogram can inform patients and physicians, guide shared decision making for adjuvant therapy, and stratify patients in future randomized, controlled trials.

Blumgart anastomosis for pancreaticojejunostomy minimizes severe complications after pancreatic head resection (Br J Surg 2009; 96: 741-750)

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (www.bjs.co.uk). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length.

Regional chemotherapy for unresectable primary liver cancer: results of a phase II clinical trial and assessment of DCE-MRI as a biomarker of survival

BACKGROUND

This study reports the results of hepatic arterial infusion (HAI) with floxuridine (FUDR) and dexamethasone (dex) in patients with unresectable intrahepatic cholangiocarcinoma (ICC) or hepatocellular carcinoma (HCC) and investigates dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) assessment of tumor vascularity as a biomarker of outcome.

PATIENTS AND METHODS

Thirty-four unresectable patients (26 ICC and eight HCC) were treated with HAI FUDR/dex. Radiologic dynamic and pharmacokinetic parameters related to tumor perfusion were analyzed and correlated with response and survival.

RESULTS

Partial responses were seen in 16 patients (47.1%); time to progression and response duration were 7.4 and 11.9 months, respectively. Median follow-up and median survival were 35 and 29.5 months, respectively; 2-year survival was 67%. DCE-MRI data showed that patients with pretreatment integrated area under the concentration curve of gadolinium contrast over 180 s (AUC 180) >34.2 mM.s had a longer median survival than those with AUC 180 <34 mM.s (35.1 versus 19.1 months, P = 0.002). Decreased volume transfer exchange between the vascular space and extracellular extravascular space (-DeltaK(trans)) and the corresponding rate constant (-Deltak(ep)) on the first post-treatment scan both predicted survival.

CONCLUSIONS

In patients with unresectable primary liver cancer, HAI therapy can be effective and safe. Pretreatment and early post-treatment changes in tumor perfusion characteristics may predict treatment outcome.

Adequate lymph node assessment for extrahepatic bile duct cancer: Do the data support the current AJCC recommendations?

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Background: AJCC staging manual 6th edition states that histologic examination of at least 3 lymph nodes (LN) is required for adequate N stage determination for extrahepatic bile duct cancer (EHBDCA). We hypothesize that this recommendation is insufficient and will lead to underestimation of N stage of EHBDCA. Methods: 257 patients (144 hilar [HCCA] and 113 distal [DCA] cholangiocarcinoma) who underwent curative intent resection for EHBDCA at our institution (1993 -2007) were analyzed. Final disease staging, including lymph node status and total number of nodes examined, was obtained from the pathology report. Differences in disease specific survival (DSS), according to nodal status, were compared using log rank test. R1 resections (n=51) were excluded from this analysis. Results: There were 89 patients (34.6%) with LN metastasis. On multivariate analysis, LN metastasis was an independent prognostic factor of poor survival (median DSS N0 vs N1: 53.3 months vs 19.3 months, p<0.0001, HR= 2.2 [95%CI: 1.5 - 3.2]). Median total LN count (TLNC) was 6 (range: 0 - 42). There was a significant difference in TLNC between HCCA and DCA (median = 3 [range: 0 - 16] vs 12 [range: 1 - 42], p<0.001, respectively). Among patients who underwent R0 resection for EHBDCA, “N0” based on TLNC < 11 was associated with worse DSS than “N0” based on TLNC > 11. When analyzed separately, “N0” based on TLNC < 7 for HCCA and < 11 for DCA revealed poorer DSS than “N0” based on greater TLNC ( Table ). Conclusions: The recommendation for LN assessment of EHBDCA by AJCC 6th Edition (“at least 3”) could lead the underestimation of N stage. HCCA and DCA should have separate recommendations for adequate LN assessment.

[Table: see text]

No significant financial relationships to disclose.

Gallbladder cancer (GBC): 10-year experience at Memorial Sloan-Kettering Cancer Centre (MSKCC)

BACKGROUND

The incidence of gallbladder cancer (GBC) in the US is 1.2/100,000. This report examines the patterns of presentation, adjuvant treatment and survival of a large cohort of patients with GBC evaluated at MSKCC over a 10-year period.

METHODS

A retrospective analysis of patients referred to MSKCC with a diagnosis of GBC between January 1995 and December 2005 was performed. Patients were identified from the MSKCC cancer registry. Information extracted included, demographics, clinical and pathological stage, surgical management, pathology, adjuvant and palliative therapy, date of relapse, death or last follow-up. Date of diagnosis was defined as date of surgery or biopsy. Survival curves were estimated using the Kaplan-Meier method and compared using the log-rank test.

RESULTS

Four hundred thirty-five GBC cases were identified: 285 (65.5%) females,150 (34.5%) males. Median age 67 years (range 28-100). Pathology: 88% adenocarcinoma, 4% squamous, 3% neuroendocrine, 2% sarcoma. 36.6% presented as AJCC Stage IV. 47% were discovered incidentally at laparoscopic cholecystectomy. One hundred thirty-six of these were re-explored, of whom 100 (73.5%) had residual disease. Of those who underwent curative resections (N = 123), 8 (6.5%) received adjuvant chemotherapy, 8 (6.5%) chemoradiation alone and 8 (6.5%) both chemoradiation and systemic chemotherapy. Median overall survival for the cohort was 10.3 months (95% CI 8.8-11.8) with a median follow up of 26.6 months. The median survival for those presenting with stage Ia-III disease was 12.9 months (95% CI 11.7-15.8 months) and 5.8 months (95% CI 4.5-6.7) for those presenting with stage IV disease. Median survival was 15.7 months (95% CI 12.4-18.4) for those discovered incidentally at laparoscopic cholecystectomy. For those who underwent re-exploration, median survival was 14.6 months (95% CI 12.6-18.3) if residual disease was present, and 72 months (95% CI 34 to infinity) if no evidence of disease. The median survival for those who received adjuvant therapy was 23.4 months (95% CI 15.7-47).

CONCLUSIONS

GBC is commonly diagnosed incidentally (47%). Re-exploration reveals a high incidence of residual disease (74%). Median survival is better for patients who have no evidence of disease on re-exploration (72 months) compared to those with residual disease detected (P < 0.0001). Overall prognosis is poor. Although we did not observe a survival benefit for those who received adjuvant therapy, the study did not have sufficient power to address this question. In addition, the number of patients who received adjuvant therapy was small with marked heterogeneity in clinical and therapeutic details, precluding any definitive conclusions being drawn. Prospective randomized trials of adjuvant therapy are needed in this disease.

Liver atrophy, hypertrophy and regenerative hyperplasia in the rat: the relevance of blood flow

Liver perfusion can be measured sequentially by monitoring the clearance of 85krypton injected into the portal circulation. Preliminary studies in dogs show that the method reflects gas clearance from a homogeneously perfused liver parenchyma and correlates well with measurements of total hepatic blood flow. The method has been adapted to measurement of liver blood flow in normal rats, partially hepatectomized rats and after portacaval transposition with and without partial hepatectomy. There is a marked rise of approximately 250% in the first four hours after partial hepatectomy in the rat. After portacaval trans-position, liver blood flow remains within the normal range and no great rise occurs after partial hepatectomy. In animals subjected to portacaval transposition, there is a reduction in relative liver weight (liver weight/body weight ratio) and when partial hepatectomy is performed three weeks after portacaval transposition, the relative liver weight is regained within three weeks, and does not differ from that of non-hepatectomized controls. DNA synthetic activity, studied during the 72 hours after partial hepatectomy performed three weeks after portacaval transposition, shows an uptake of tritiated thymidine into liver DNA of the same magnitude as and contemporaneous with that of controls. Liver atrophy after portal diversion is not a result of a decrease in absolute liver blood flow. Regenerative hyperplasia appears to be independent of a direct supply of portal blood and occurs in the absence of the post-hepatectomy rise in liver blood flow seen in normal rats.

Effect of percutaneous biliary drainage (PBD) for malignant biliary obstruction (MBO) on quality of life (QoL)

9029

Background: PBD is routinely performed to relieve MBO. The clinical effects of drainage have been well documented, but little has been reported about how PBD effects a patient's QoL. Methods: Between October, 2004 and December, 2006, eligible patients (>18 years old, English speaking, clinical diagnosis of MBO) scheduled to undergo PBD at a comprehensive cancer center were invited to participate in a prospective study evaluating QoL using the Functional Assessment of Cancer Therapy Hepatobiliary (FACT-Hep) instrument, comprised of 5 subscales (physical, emotional, functional and social well being, and disease-specific concerns). FACT is the total score of the first four items; FACT-Hep is the total score of all 5 subscales. Patients completed the instrument at baseline, one week and four weeks following PBD. Instruments were scored following FACT guidelines; changes in QoL between these time points were analyzed using a mixed effect model with time as a categorical variable. Results: One hundred twenty five patients consented to participate in this study. Sixteen were not evaluable and were withdrawn from the study. One hundred nine (60 male / 49 female) patients completed the baseline instrument (100%), 57% at one week and 39% at four weeks. Thirty four patients (31%) completed all time points. The most common diagnoses included cholangiocarcinoma (30%), pancreatic cancer (29%), and metastatic colorectal cancer (17%). Mortality was 10% (N=11) at 4 weeks and 28% (N=30) 8 weeks following PBD, with one patient dying from a procedure related complication. The mean FACT scores are indicated in the table below. A declining score is associated with a decline in QoL. Conclusions: PBD for MBO does not improve overall QoL following PBD. Patients have significant disease related mortality within eight weeks of the procedure.

[Table: see text]

No significant financial relationships to disclose.

Outcomes after resection of synchronous or metachronous hepatic and pulmonary colorectal metastases

4059

Background: Surgical resection of isolated hepatic or pulmonary colorectal metastases prolongs survival in selected patients. However, the benefits of resection and appropriate selection criteria in patients who develop both hepatic and pulmonary metastases are ill-defined. Methods: Data were prospectively collected from 131 patients with colorectal cancer who underwent resection of both hepatic and pulmonary metastases over a 20-year period. Median follow-up was 6.6 years from the time of resection of the primary tumor. Patient, treatment, and outcome variables were analyzed using log-rank, Cox regression, and Kaplan-Meier methods. Results: The site of first metastasis was the liver in 65% of patients, lung in 11%, and both simultaneously in 24%. Multiple hepatic metastases were present in 51% of patients and multiple pulmonary metastases were found in 48%. Hepatic lobectomy or trisegmentectomy was required in 61% of patients while most lung metastases (80%) were treated with wedge excisions. Median survival from resection of the primary disease, first site of metastasis, and second site of metastasis was 6.9, 5.0, and 3.3 years, respectively. After resection of disease at the second site of metastasis, the 1, 3, 5, and 10 year disease-specific survival rates were 91, 55, 31 and 19%, respectively. An analysis of prognostic factors revealed that survival was significantly longer when the disease-free interval between the development of the first and second sites of metastases exceeded one year, in patients with a single liver metastasis, and in patients younger than 55 years. Conclusions: Surgical resection of both hepatic and pulmonary colorectal metastases is associated with prolonged survival in selected patients. Patients with a longer disease free interval between metastases and those with single liver lesions had the best outcomes.

[Table: see text]

No significant financial relationships to disclose.

Predictors of a true complete response in colorectal liver metastases that disappear radiographically following chemotherapy

4058

Background: During chemotherapy for colorectal liver metastases (LM), some lesions disappear by CT scan. This may represent a true complete response (CR) with eradication of tumor or a reduced sensitivity of imaging due to chemotherapy induced hepatic steatosis. This study aimed to determine the significance of radiologic disappearance of LM treated with chemotherapy and factors predictive of a true CR. Methods: Between 2000 and 2003, 435 patients evaluated by a hepatobiliary surgeon were treated with neoadjuvant chemotherapy for LM. Inclusion criteria were fewer than 12 LM initially, disappearance of one or more LM by CT scan and a clinical follow-up of at least 1 year after disappearance. A pathologic CR (pCR) was defined as the absence of a LM in the resected specimen, a durable clinical CR (cCR) was defined as a LM that did not reappear during follow-up imaging. A LM was defined as found if it was detected by other imaging (MRI), at resection, or if it recurred during follow-up. LM that were found were compared to pCR and durable cCR to determine factors predictive of a true CR. Results: During chemotherapy, 39 (9%) patients had a total of 117 LM disappear by follow-up CT scan. The outcome is shown in the Table . Treatment with hepatic arterial infusion (HAI) chemotherapy (n=22) was associated with a significantly higher rate of pCR or durable cCR (42% vs. 14%, p<0.001). LM were also significantly more likely to represent a pCR or durable cCR when the surrounding liver did not demonstrate steatosis (p<0.001), when the patient’s BMI was <30 kg/m2 (p=0.002), and when a preoperative MRI was performed (p=0.01). Conclusions: Among disappearing LM, a pCR occurs in 37% and a durable cCR in 26%, yielding a true CR rate of 63%. The disappearing LM in patients treated with HAI chemotherapy were more likely to a represent true CR when compared to systemic chemotherapy alone. Hepatic steatosis and obesity impaired the ability to detect lesions by CT scan and MRI improved the preoperative detection rate of disappearing LM.

[Table: see text]

No significant financial relationships to disclose.

Rates and patterns of recurrence for percutaneous radiofrequency ablation and open wedge resection for solitary colorectal liver metastasis

INTRODUCTION

The purpose of this study was to compare rates and patterns of disease progression following percutaneous, image-guided radiofrequency ablation (RFA) and nonanatomic wedge resection for solitary colorectal liver metastases.

METHODS

We identified 30 patients who underwent nonanatomic wedge resection for solitary liver metastases and 22 patients who underwent percutaneous RFA because of prior major hepatectomy (50%), major medical comorbidities (41%), or relative unresectability (9%). Serial imaging studies were retrospectively reviewed for evidence of local tumor progression.

RESULTS

Patients in the RFA group were more likely to have undergone prior liver resection, to have a disease-free interval greater than 1 year, and to have had an abnormal carcinoembryonic antigen (CEA) level before treatment. Two-year local tumor progression-free survival (PFS) was 88% in the Wedge group and 41% in the RFA group. Two patients in the RFA group underwent re-ablation, and two patients underwent resection to improve the 2-year local tumor disease-free survival to 55%. Approximately 30% of patients in each group presented with distant metastasis as a component of their first recurrence. Median overall survival from the time of resection was 80 months in the Wedge group vs 31 months in the RFA group. However, overall survival from the time of treatment of the colorectal primary was not significantly different between the two groups.

CONCLUSIONS

Local tumor progression is common after percutaneous RFA. Surgical resection remains the gold standard treatment for patients who are candidates for resection. For patients who are poor candidates for resection, RFA may help to manage local disease, but close follow-up and retreatment are necessary to achieve optimal results.

Segment-oriented approach to liver resection

Segment-oriented liver resection is a distinct surgical approach and represents the virtuosity of hepatic surgery. It is unique in the finesse of its execution and in its oncologic efficacy and safety. The varied combinations of segmentectomy allow greater flexibility and opportunity for liver surgeons to extirpate the equally diverse nature and location of intrahepatic pathologic conditions. The technique promotes tumor clearance while con-serving uninvolved parenchyma.

The role of staging laparoscopy in hepatobiliary malignancy: prospective analysis of 401 cases

BACKGROUND

Patients with potentially resectable hepatobiliary malignancy are frequently found to have unresectable tumors at laparotomy. We prospectively evaluated staging laparoscopy in patients with resectable disease on preoperative imaging.

METHODS

Staging laparoscopy was performed on 410 patients with potentially resectable hepatobiliary malignancy. The preoperative likelihood of resectability was recorded. Data on preoperative imaging, operative findings, and hospital course were analyzed.

RESULTS

Laparoscopic inspection was complete in 291 (73%) patients. In total, 153 patients (38%) had unresectable disease, 84 of whom were identified laparoscopically, increasing resectability from 62% to 78%. On multivariate analysis, a complete examination, preoperative likelihood of resection, and primary diagnosis were significant predictors of identifying unresectable disease at laparoscopy. The highest yield was for biliary cancers, and the lowest was for metastatic colorectal cancer. In patients with unresectable disease identified at laparoscopy, the mean hospital stay was 3 days, and postoperative morbidity was 9%, compared with 8 days and 27%, respectively, in patients found to have unresectable disease at laparotomy.

CONCLUSIONS

Laparoscopy spared one in five patients a laparotomy while reducing hospital stay and morbidity. Targeting laparoscopy to patients at high risk for unresectable disease requires consideration of disease-specific factors; however, the surgeons' preoperative impression of resectability is also important.

Staging laparoscopy for potentially resectable noncolorectal, nonneuroendocrine liver metastases

BACKGROUND

Carefully selected patients with noncolorectal, nonneuroendocrine (NCNN) liver metastases may benefit from hepatic resection. The incidence of occult unresectable disease and the possible benefits of staging laparoscopy in these patients are not known.

METHODS

From December 1997 to July 2000, staging laparoscopy was performed in 30 consecutive patients with NCNN metastases before planned open exploration and resection. Demographics, extent of preoperative imaging, operative and postoperative findings, and factors associated with laparoscopic identification of unresectable disease were analyzed.

RESULTS

Twenty-four patients (80%) had a complete laparoscopic examination, and 23 had laparoscopic ultrasonography. All patients underwent preoperative computed tomography or magnetic resonance imaging, and 21 (70%) patients had 2 or more preoperative radiological studies. Overall, nine patients had unresectable disease, six of whom were identified by laparoscopy. Of the remaining 24 patients believed to have resectable disease at laparoscopy, 21 went on to a potentially curative procedure. Laparoscopy did not identify irresectability because of vascular involvement in three patients. Laparoscopy added a median of 30 minutes of operative time to those patients going on to laparotomy.

CONCLUSIONS

Laparoscopy identified the majority of patients with occult unresectable disease, improved resectability, and should be routine in patients being considered for potentially curative hepatic resection.

Bronchobiliary fistula complicating oriental cholangiohepatitis

Bronchio biliary fistula in adults is a rare event defined by the passage of bile into the bronchus and the sputum (biloptysis).Typically these lesions occur in the congenital form, as a result of thoracoabdominal trauma, or in rare instances as a result of iatrogenic injury or long-standing biliary tract disease and obstruction. In this paper, we report a novel case of a fatal bronchobiliary fistula that developed in a 67-year-old Chinese male with Oriental cholangiohepatitis. To our knowledge, this is the first case report of a bronchobiliary fistula complicating the clinical management of a patient with this disease.

Peritoneal washings are not predictive of occult peritoneal disease in patients with hilar cholangiocarcinoma

BACKGROUND

Evaluation of peritoneal cytology provides valuable staging information in patients with gastric and pancreatic adenocarcinoma, but its usefulness in patients with extrahepatic cholangiocarcinoma is unclear. The aim of this study was to evaluate the predictive value of peritoneal cytology in patients with potentially resectable hilar cholangiocarcinoma. This study evaluated a possible association between positive peritoneal cytology and percutaneous transhepatic biliary drainage, which is commonly used in these patients and may result in peritoneal biliary leakage and peritoneal seeding.

STUDY DESIGN

From October 1997 through June 2000 26 patients with hilar cholangiocarcinoma underwent staging laparoscopy immediately before planned open exploration and resection. Peritoneal washings were obtained during laparoscopic examination before any biopsies were taken. Cytologic analysis was performed using the Papanicolau technique.

RESULTS

There were 18 men and 8 women, with a median age of 69 years (range 42 to 81 years). The most common presenting symptom was jaundice (n = 19). Previous biliary drainage was performed in 23 patients: 9 percutaneous and 14 endoscopic. Metastatic disease was suspected preoperatively in six patients, three to the liver, two to the peritoneum, and one to regional lymph nodes, all of which were confirmed at laparoscopy. Laparoscopy identified five additional patients with metastatic disease. Peritoneal cytology was positive for malignant cells in two patients, both of whom had gross peritoneal metastases. Nine other patients had metastatic disease to distant sites within the abdomen, but none had positive cytology. Overall, six patients had metastatic disease to the peritoneal cavity, only one of whom had undergone earlier percutaneous biliary drainage.

CONCLUSIONS

Peritoneal cytology was not predictive of occult metastatic disease. Laparoscopic staging identified some patients with unresectable hilar cholangiocarcinoma, but analysis of peritoneal cytology provided no additional information. There was no association between percutaneous transhepatic biliary drainage and peritoneal tumor seeding.

The role of adjuvant therapy after liver resection for colorectal cancer metastases

Intrahepatic recurrence is common after major resection for colorectal cancer (CRC) metastases to the liver. In this review, the available data on different adjuvant therapies from systemic chemotherapy to regional approaches by direct perfusion of chemotherapeutic agents via the hepatic artery and portal vein will be discussed. Intraperitoneal administration of chemotherapy is another form of regional therapy. Novel approaches with immunotherapy and trials of neoadjuvant therapy in association with resection of CRC hepatic metastases have also been reported. The purpose of this review is to outline these various strategies and their role in combination with resection of CRC liver metastases. Although improved hepatic disease-free survival has been demonstrated with some strategies, overall survival is minimally affected and recurrence of metastatic disease at distant sites is still a major problem. Therefore, future directions should incorporate the use of new systemic agents effective against CRC metastases. Identification of subgroups through clinical features, molecular markers, proteins, or specific tumor properties may also help to individualize treatment.

Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma

OBJECTIVE

To analyze resectability and survival in patients with hilar cholangiocarcinoma according to a proposed preoperative staging scheme that fully integrates local, tumor-related factors.

SUMMARY BACKGROUND DATA

In patients with hilar cholangiocarcinoma, long-term survival depends critically on complete tumor resection. The current staging systems ignore factors related to local tumor extent, preclude accurate preoperative disease assessment, and correlate poorly with resectability and survival.

METHODS

Demographics, results of imaging studies, surgical findings, pathology, and survival were analyzed prospectively in consecutive patients. Using data from imaging studies, all patients were placed into one of three stages based on the extent of ductal involvement by tumor, the presence or absence of portal vein compromise, and the presence or absence of hepatic lobar atrophy.

RESULTS

From March 1991 through December 2000, 225 patients were evaluated, 77% of whom were seen and treated within the last 6 years. Sixty-five patients had unresectable disease; 160 patients underwent exploration with curative intent. Eighty patients underwent resection: 62 (78%) had a concomitant hepatic resection and 62 (78%) had an R0 resection (negative histologic margins). Negative histologic margins, concomitant partial hepatectomy, and well-differentiated tumor histology were associated with improved outcome after all resections. However, in patients who underwent an R0 resection, concomitant partial hepatectomy was the only independent predictor of long-term survival. Of the 9 actual 5-year survivors (of 30 at risk), all had a concomitant hepatic resection and none had tumor-involved margins; 3 of these 9 patients remained free of disease at a median follow-up of 88 months. The rates of complications and death after resection were 64% and 10%, respectively. In the 219 patients whose disease could be staged, the proposed system predicted resectability and the likelihood of an R0 resection and correlated with metastatic disease and survival.

CONCLUSION

By taking full account of local tumor extent, the proposed staging system for hilar cholangiocarcinoma accurately predicts resectability, the likelihood of metastatic disease, and survival. Complete resection remains the only therapy that offers the possibility of long-term survival, and hepatic resection is a critical component of the surgical approach.

Results of hepatic resection for sarcoma metastatic to liver

OBJECTIVE

To evaluate the outcome of patients with liver metastases from sarcoma who underwent hepatic resection at a single institution and were followed up prospectively.

SUMMARY BACKGROUND DATA

The value of hepatic resection for metastatic sarcoma is unknown.

METHODS

There were 331 patients with liver metastases from sarcoma who were admitted to Memorial Hospital from 1982 to 2000, and 56 of them underwent resection of all gross hepatic disease. Patient, tumor, and treatment variables were analyzed to assess outcome.

RESULTS

Of the 56 patients who underwent complete resection, 34 (61%) had gastrointestinal stromal tumors or gastrointestinal leiomyosarcomas. Half of the patients required an hepatic lobectomy or extended lobectomy. There were no perioperative deaths in the completely resected group, although 3 of the 75 patients who underwent exploration (4%) died. The postoperative 1-, 3-, and 5-year actuarial survival rates were 88%, 50%, and 30%, respectively, with a median of 39 months. In contrast, the 5-year survival rate of patients who did not undergo complete resection was 4%. On multivariate analysis, a time interval from the primary tumor to the development of liver metastasis greater than 2 years was a significant predictor of survival after hepatectomy.

CONCLUSIONS

Complete resection of liver metastases from sarcoma in selected patients is associated with prolonged survival. Hepatectomy should be considered when complete gross resection is possible, especially when the time to the development of liver metastasis exceeds 2 years.

Intrahepatic cholangiocarcinoma: resectability, recurrence pattern, and outcomes

Intrahepatic cholangiocarcinoma (IHC) is a rare primary hepatic tumor of bile duct origin for which resection is the most effective treatment. But resectability, outcomes after resection, and recurrence patterns have not been well described. Patients with IHC were identified from a prospective database. Demographic data, tumor characteristics, and outcomes were analyzed. From March 1992 to September 2000, 53 patients with hepatic tumors underwent exploration and were found to have pure IHC on pathologic analysis. Patients with mixed hepatocellular and cholangiocarcinoma tumors were excluded. At exploration, 20 patients were unresectable for an overall resectability rate of 62% (33 of 53). Median survival for patients submitted to resection was 37.4 months versus 11.6 months for patients undergoing biopsy only (p = 0.006; median followup for surviving patients, 15.6 months). Actuarial 3-year survival was 55% versus 21%, respectively. Factors predictive of poor survival after resection included vascular invasion (p = 0.0007), histologically positive margin (p = 0.009), or multiple tumors (p = 0.003). After resection, 20 of 33 patients (61%) recurred at a median of 12.4 months. Sites of recurrence included the liver (14), retroperitoneal or hilar nodes (4), lung (4), and bone (2). The median disease-free survival was 19.4 months, with a 3-year disease-free survival rate of 22%. Factors predictive of recurrence were multiple tumors (p = 0.0002), tumor size (p = 0.001), and vascular invasion (p = 0.01). About two-thirds of patients who appeared resectable on preoperative imaging were amenable to curative resection at the time of operation. Although complete resection improved survival, recurrence was common. The majority of recurrences were local or regional, which may help guide future adjuvant therapy strategies.

Management of 155 patients with benign liver tumours

BACKGROUND

Benign hepatic tumours continue to represent a diagnostic and therapeutic challenge. This study evaluates the indications and results of resection compared with observation in patients with benign hepatic tumours.

METHODS

Patients with a primary diagnosis of benign liver tumour were identified from a prospective database and evaluated retrospectively.

RESULTS

From January 1992 to June 1999, 155 patients with benign hepatic tumours were evaluated. The diagnoses included haemangioma (n = 97), focal nodular hyperplasia (FNH) (n = 42), hepatic adenoma (n = 12) and cystadenoma (n = 4). Sixty-eight patients (44 per cent) underwent resection because of symptoms (n = 36), inability to exclude a malignancy (n = 31) or enlargement on serial imaging (n = 11). The operative morbidity and mortality rates were 21 per cent and zero respectively. Thirty patients had a preoperative percutaneous needle biopsy, 19 of which were either incorrect or indeterminate. Overall, 39 of 42 patients with symptoms attributed to the tumour were asymptomatic after resection and 18 of 21 patients with symptoms considered unrelated to the tumour were asymptomatic after a period of observation and/or treatment of unrelated conditions (median follow-up 16 months).

CONCLUSION

When indicated, resection of benign liver tumours can be performed safely. Symptomatic patients with a small FNH or haemangioma can be observed because their symptoms are unlikely to be related to the liver tumour. Percutaneous needle biopsy rarely changes management.

What is the yield of intraoperative ultrasonography during partial hepatectomy for malignant disease?

BACKGROUND

Previous studies have shown that intraoperative ultrasonography (IOUS) during hepatic resection for malignancy changes the operative plan or identifies occult unresectable disease in a large proportion of patients. This study was undertaken to reassess the yield of IOUS in light of recent improvements in preoperative staging.

STUDY DESIGN

Patients with potentially resectable primary or metastatic hepatic malignancies subjected to exploration, bimanual palpation of the liver, and IOUS were evaluated prospectively. Intraoperative findings were recorded, and preoperative imaging studies were reanalyzed by radiologists blinded to the intraoperative findings. The extent of disease based on preoperative imaging was compared with the intraoperative findings.

RESULTS

From October 1997 until November 1998, 111 patients were evaluated. At exploration, a total of 77 new findings or findings different than suggested on the imaging studies were identified in 61 patients (55%), the most common of which was additional hepatic tumors (n = 37). Thirty-five of 77 (45%) new findings were identified by IOUS alone and 10 (13%) by palpation alone; the remainder were identified by both palpation and IOUS. Forty-seven of 61 patients (77%) underwent a complete resection despite new intraoperative findings, with a modification (n = 28) or no change (n = 19) in the planned operation. Twenty-one patients (19%) had new findings identified only on IOUS. Thirteen of these patients underwent resection with no change in the operative plan, six underwent a modified resection and two were considered to have unresectable disease based solely on the findings of IOUS.

CONCLUSIONS

In patients with hepatic malignancies submitted to a potentially curative resection, new intraoperative findings or findings different than suggested on preoperative imaging studies are common. But resection with no change in the operative plan or a modified resection is still possible in the majority of patients despite such findings. The findings on IOUS alone rarely lead to a change in the operative plan.

A clinical scoring system predicts the yield of diagnostic laparoscopy in patients with potentially resectable hepatic colorectal metastases

BACKGROUND

Laparoscopy may identify occult metastatic disease and prevent unnecessary laparotomy in some patients with potentially resectable colorectal liver metastases but is unnecessary in the majority of individuals who undergo resection. The objectives of the current study were to assess the impact of laparoscopy after extensive preoperative imaging and to determine whether a preoperative clinical risk score can identify those patients most likely to benefit from the procedure.

METHODS

Between December 1997 and July 1999, 103 consecutive patients with potentially resectable colorectal liver metastases underwent laparoscopy prior to planned laparotomy and partial hepatectomy. Surgical findings, length of hospital stay, and hospital charges were analyzed. Patients were assigned a clinical risk score (CRS) based on five factors related to the primary tumor and the hepatic disease. The likelihood of finding occult unresectable disease and the yield of laparoscopy were analyzed with respect to the CRS.

RESULTS

Seventy-seven patients (75%) underwent resection. Laparoscopy identified 14 of 26 patients with unresectable disease, 10 of whom were spared an unnecessary laparotomy. In patients who underwent biopsy only, the laparoscopic identification of unresectable disease shortened the hospital stay (1.2 +/- 0.6 days vs. 5.8 +/- 2.3 days; p = 0.0001) and reduced the total hospital charges by 55% (P = 0.0001). The CRS predicted the likelihood of occult unresectable disease, which was 12% in those with a score < or = 2 but increased to 42% in those with a score > 2 (P = 0.001). If laparoscopy were used only in high risk patients (CRS > 2), 57 laparoscopies would have been avoided and the net savings doubled.

CONCLUSIONS

With extensive preoperative imaging, the vast majority of patients with potentially resectable hepatic colorectal metastases do not benefit from laparoscopy. However, in the minority of patients with occult unresectable disease, laparoscopy prevents unnecessary laparotomy and reduces hospital stay and the total hospital charges. The CRS, previously shown to predict survival after hepatic resection, identifies those high risk patients most likely to benefit from laparoscopy and may improve resource utilization.

Hepatic adenoma associated with recombinant human growth hormone therapy in a patient with Turner's syndrome

BACKGROUND

Turner's syndrome is a genetic disorder of females with well-described karyotypic abnormalities and phenotypic features. Recombinant human growth hormone (HGH) therapy is one component of a hormonal treatment strategy for these patients and is used to promote sexual maturity and to increase height.

METHODS

Literature review of hepatic complications following the initiation of growth hormone therapy for patients with Turner's syndrome, and case report presentation of a 13-year-old female with Turner's syndrome developing a hepatic adenoma following 3 years of HGH treatment.

RESULTS

The association between Turner's syndrome and HGH treatment-associated hepatic adenoma has not been described previous to this report. In this patient, surgical resection was contraindicated and the patient was successfully treated by hepatic artery embolization. The unique management issues relating to this case, and a possible association between HGH therapy and the development of hepatic adenoma are discussed.

CONCLUSION

This work represents the first documentation of a hepatic adenoma developing in a patient with Turner's syndrome following HGH treatment, and suggests a novel and causal association between HGH treatment and the development of hepatic adenoma in patients with Turner's syndrome.

A clinical scoring system predicts the yield of diagnostic laparoscopy in patients with potentially resectable hepatic colorectal metastases

BACKGROUND

Laparoscopy may identify occult metastatic disease and prevent unnecessary laparotomy in some patients with potentially resectable colorectal liver metastases but is unnecessary in the majority of individuals who undergo resection. The objectives of the current study were to assess the impact of laparoscopy after extensive preoperative imaging and to determine whether a preoperative clinical risk score can identify those patients most likely to benefit from the procedure.

METHODS

Between December 1997 and July 1999, 103 consecutive patients with potentially resectable colorectal liver metastases underwent laparoscopy prior to planned laparotomy and partial hepatectomy. Surgical findings, length of hospital stay, and hospital charges were analyzed. Patients were assigned a clinical risk score (CRS) based on five factors related to the primary tumor and the hepatic disease. The likelihood of finding occult unresectable disease and the yield of laparoscopy were analyzed with respect to the CRS.

RESULTS

Seventy-seven patients (75%) underwent resection. Laparoscopy identified 14 of 26 patients with unresectable disease, 10 of whom were spared an unnecessary laparotomy. In patients who underwent biopsy only, the laparoscopic identification of unresectable disease shortened the hospital stay (1.2 +/- 0.6 days vs. 5.8 +/- 2.3 days; p = 0.0001) and reduced the total hospital charges by 55% (P = 0.0001). The CRS predicted the likelihood of occult unresectable disease, which was 12% in those with a score < or = 2 but increased to 42% in those with a score > 2 (P = 0.001). If laparoscopy were used only in high risk patients (CRS > 2), 57 laparoscopies would have been avoided and the net savings doubled.

CONCLUSIONS

With extensive preoperative imaging, the vast majority of patients with potentially resectable hepatic colorectal metastases do not benefit from laparoscopy. However, in the minority of patients with occult unresectable disease, laparoscopy prevents unnecessary laparotomy and reduces hospital stay and the total hospital charges. The CRS, previously shown to predict survival after hepatic resection, identifies those high risk patients most likely to benefit from laparoscopy and may improve resource utilization.

Recent advances in hepatic resection

Hepatic surgery has emerged over the last three decades and has proven to be a safe and effective treatment for primary and secondary malignancies, as well as for benign diseases of the liver. During the past 10 years, several major advances have been made in 1) surgical technique with the advent of portal pedicle ligation maneuvers and the implementation of mechanical staplers, 2) intraoperative management with the development of low central venous pressure anesthesia, and 3) surgical technology with the innovation of laparoscopy for staging of patients with cancer and performing minimally invasive liver resection. We present a summary of our experience with these advances.

Extended hepatic resection: a 6-year retrospective study of risk factors for perioperative mortality

BACKGROUND

Extended hepatic resection (more than four liver segments) is a major operative procedure that is associated with significant risk. The purpose of this study was to assess the impact of perioperative variables on in-hospital mortality after extended hepatectomy.

STUDY DESIGN

Consecutive patients who underwent extended hepatic resection were studied. The prognostic value of 29 perioperative variables was evaluated using in-hospital mortality as the endpoint. For each variable, the odds ratio (95% confidence interval) for in-hospital mortality was calculated. Those variables with a lower confidence limit > 1 were considered important risk factors. The population was stratified into categories of patients having the same number of risk factors, and mortality was estimated for each group. These data were used to develop a risk assessment algorithm.

RESULTS

There were 14 deaths (6%) in 226 patients. Three preoperative variables (cholangitis, creatinine > 1.3 mg/dL, and total bilirubin > 6 mg/dL) and two operative variables (blood loss > 3 L and vena caval resection) appear to be important factors for in-hospital mortality. The mortality associated with the presence of any two of the five factors was 100% (5 of 5), and the mortality associated with the absence of these factors was 3% (6 of 191).

CONCLUSIONS

Perioperative evaluation of patients undergoing extended hepatic resection should include the quantitation of mortality risk factors. The combination of any two factors among preoperative cholangitis, elevated serum creatinine, elevated serum bilirubin, high operative blood loss, and vena cava resection may carry a high mortality risk. These results require prospective validation.

Resection of hilar cholangiocarcinoma--a European and United States experience

Improvements in preoperative imaging, patient selection, and refined operative techniques have allowed a more radical surgical approach to hilar cholangiocarcinoma. A total of 269 patients with histologically proven cholangiocarcinoma were treated during a 20-year period under the direction of one surgeon (LHB) over three separate time periods in different institutions: 131 patients at the Hepatobiliary Unit of Hammersmith Hospital, London, England, from January 1977 to September 1985; 48 patients at Inselspital, University of Bern, Switzerland, between October 1986 and October 1990; and 90 patients at Memorial Sloan-Kettering Cancer Center, New York, between March 1991 and April 1997. An increase in the use of concomitant hepatectomy was noted over these time periods, paralleled by an increase in achieving negative margins and in survival. Hilar cholangiocarcinoma should not be considered an incurable disease, but patients should be aggressively evaluated for possible curative resection before any intervention is performed. Good long-term results can be achieved and cure is possible provided a complete tumor resection with negative margins is obtained.

Gallbladder cancer: comparison of patients presenting initially for definitive operation with those presenting after prior noncurative intervention

OBJECTIVE

To compare patients with gallbladder cancer presenting for therapy with and without prior operation elsewhere to determine if an initial noncurative procedure alters outcome.

SUMMARY BACKGROUND DATA

Nihilism has traditionally surrounded treatment of gallbladder cancer, particularly since the majority of cases are discovered during exploration for presumed gallstone disease when unsuspected cancers cannot be handled definitively and tumor is often violated.

METHODS

Presentation, operative data, complications, and survival were examined for 410 patients presenting between July 1986 and March 2000. In particular, the 248 patients presenting for therapy after prior operation elsewhere were compared with the remainder who presented without prior operation to determine if an initial noncurative procedure alters outcome.

RESULTS

Overall Outcome: 51 patients were inoperable, 92 were subjected to exploration and biopsy only, 135 to noncurative cholecystectomy, 30 to surgical bypass, and 102 to potentially curative resections consisting of portal lymph node dissection and liver parenchymal resections. Operative mortality was 3.9%. T-stage predicted likelihood of distant metastases and resectability. Median survival for resected patients was 26 months and 5-year survival was 38%, and for patients not resected, 5.4 months and 4% (P <.0001). Effect of Prior Operation: 22 patients subjected to potentially curative resection as the first surgical procedure were compared to 80 patients resected after prior exploration elsewhere. Mortality, complication, and long-term survival were the same. By multivariate analysis (Cox regression), resectability and stage were independent predictors (P <.001) of long-term survival, but prior surgical exploration was not.

CONCLUSION

Unresected gallbladder cancer is a rapidly fatal disease. Radical resection can provide long-term survival, even for large tumors with extensive liver invasion. Long-term survival can be achieved for patients presenting after prior noncurative surgical exploration.

Survival after resection of multiple hepatic colorectal metastases

BACKGROUND

Hepatic resection is potentially curative in selected patients with colorectal metastases. It is a widely held practice that multiple colorectal hepatic metastases are not resected, although outcome after removal of four or more metastases is not well defined.

METHODS

Patients with four or more colorectal hepatic metastases who submitted to resection were identified from a prospective database. Number of metastases was determined by serial sectioning of the gross specimen at the time of resection. Demographic data, tumor characteristics, complications, and survival were analyzed.

RESULTS

From August 1985 to September 1998, 155 patients with four or more metastatic tumors (range 4-20) underwent potentially curative resection by extended hepatectomy (39%), lobectomy (42%), or multiple segmental resections (19%). Operative morbidity and mortality were 26% and 1%, respectively. Actuarial 5-year survival was 23% for the entire group (median = 32 months) and there were 12 actual 5-year survivors. On multivariate analysis, only number of hepatic tumors (P = .005) and the presence of a positive margin (P = .003) were independent predictors of poor survival.

CONCLUSIONS

Hepatic resection in patients with four or more colorectal metastases can achieve long-term survival although the results are less favorable as the number of tumors increases. Number of hepatic metastases alone should not be used as a sole contraindication to resection, but it is clear that the majority of patients will not be cured after resection of multiple lesions.