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ABSTRACT: Selection of the optimal surgical and interventional therapies for advanced colorectal cancer liver metastases (CRLM) requires multidisciplinary discussion of treatment strategies early in the trajectory of the individual patient's care. This paper reports on expert consensus on locoregional and interventional therapies for the treatment of advanced CRLM. Resection remains the reference treatment for patients with bilateral CRLM and synchronous presentation of primary and metastatic cancer. Patients with oligonodular bilateral CRLM may be candidates for one-stage multiple segmentectomies; two-stage resection with or without portal vein embolization may allow complete resection in patients with more advanced disease. After downsizing with preoperative systemic and/or regional therapy, curative-intent hepatectomy requires resection of all initial and currently known sites of disease; debulking procedures are not recommended. Many patients with synchronous primary disease and CRLM can safely undergo simultaneous resection of all disease. Staged resections should be considered for patients in whom the volume of the future liver remnant is anticipated to be marginal or inadequate, who have significant medical comorbid condition(s), or in whom extensive resections are required for the primary cancer and/or CRLM. Priority for liver-first or primary-first resection should depend on primary tumour-related symptoms or concern for the progression of marginally resectable CRLM during treatment of the primary disease. Chemotherapy delivered by hepatic arterial infusion represents a valid option in patients with liver-only disease, although it is best delivered in experienced centres. Ablation strategies are not recommended as first-line treatments for resectable CRLM alone or in combination with resection because of high local failure rates and limitations related to tumour size, multiplicity and intrahepatic location.
HPB 02/2013; 15(2):119-30. · 1.60 Impact Factor
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ABSTRACT: BACKGROUND: Surgical approach is an accepted approach for metastatic neuroendocrine tumors (NET), but the safety and effectiveness of synchronous liver metastases resection with primary and/or locally recurrent NET is unclear. METHODS: From 1992 to 2009, a total of 36 patients underwent synchronous resection of primary NET or local recurrence and liver metastases. Patients and tumor characteristics, surgical procedures, and postoperative and long-term outcome were reviewed. RESULTS: Primary lesions were solitary in 28 patients (80 %), with a median size of 25 mm. Liver metastases were multiple in 32 cases (89 %), with a bilobar distribution in 29 patients (81 %) and a median size of 62 mm. Resections included gastroduodenal (n = 5), ileocolonic (n = 18), pancreatic resection (n = 13), and major hepatectomy (n = 15). Resections were R0, R1, and R2 in 13, 11, and 12 cases, respectively, and tumors were classified as G1 in 20 (56 %) and G2 in 15 (42 %). There was 1 postoperative death after a Whipple/right trisectionectomy, and postoperative complication occurred in 16 patients (44 %). With a median follow-up of 56 months, 31 patients (89 %) experienced recurrence, which was confined to the liver in 90 %. Reduction of disease to liver only allowed subsequent liver-directed therapy, such as arterial embolization or percutaneous ablation, in 25 patients (71 %). Five-year symptom-free survival and overall survival were 60 %, and 69 %, respectively. CONCLUSIONS: In highly selected patients, an initial surgical approach combining simultaneous resection of liver metastases and primary/recurrent tumors can be performed with low mortality. Most patients develop liver-confined recurrence, which is usually amenable to ablative therapies that offer ongoing disease and symptom control.
Annals of Surgical Oncology 07/2012; · 4.17 Impact Factor
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Efsevia Vakiani,
Manickam Janakiraman,
Ronglai Shen,
Rileen Sinha,
Zhaoshi Zeng,
Jinru Shia,
Andrea Cercek,
Nancy Kemeny, Michael D'Angelica,
Agnes Viale,
Adriana Heguy,
Philip Paty,
Timothy A Chan,
Leonard B Saltz,
Martin Weiser,
David B Solit
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ABSTRACT: To compare the mutational and copy number profiles of primary and metastatic colorectal carcinomas (CRCs) using both unpaired and paired samples derived from primary and metastatic disease sites.
We performed a multiplatform genomic analysis of 736 fresh frozen CRC tumors from 613 patients. The cohort included 84 patients in whom tumor tissue from both primary and metastatic sites was available and 31 patients with pairs of metastases. Tumors were analyzed for mutations in the KRAS, NRAS, BRAF, PIK3CA, and TP53 genes, with discordant results between paired samples further investigated by analyzing formalin-fixed, paraffin-embedded tissue and/or by 454 sequencing. Copy number aberrations in primary tumors and matched metastases were analyzed by comparative genomic hybridization (CGH).
TP53 mutations were more frequent in metastatic versus primary tumors (53.1% v 30.3%, respectively; P < .001), whereas BRAF mutations were significantly less frequent (1.9% v 7.7%, respectively; P = .01). The mutational status of the matched pairs was highly concordant (> 90% concordance for all five genes). Clonality analysis of array CGH data suggested that multiple CRC primary tumors or treatment-associated effects were likely etiologies for mutational and/or copy number profile differences between primary tumors and metastases.
For determining RAS, BRAF, and PIK3CA mutational status, genotyping of the primary CRC is sufficient for most patients. Biopsy of a metastatic site should be considered in patients with a history of multiple primary carcinomas and in the case of TP53 for patients who have undergone interval treatment with radiation or cytotoxic chemotherapies.
Journal of Clinical Oncology 06/2012; 30(24):2956-62. · 18.37 Impact Factor
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ABSTRACT: Adrenocortical carcinoma (ACC) liver metastases (LM) represent a therapeutic challenge, and it is unclear whether resection is justified. This study assesses long-term outcome and prognostic factors after liver resection for metastatic ACC.
Patients who underwent resection of ACC LM were identified from institutional databases. Recurrence, survival, and tumor characteristics, including β-catenin and TP53 status based on immunohistochemistry and sequencing, were reviewed. The prognostic value of variables was assessed with log-rank test for univariate analysis and Cox proportional hazard models for multivariate analysis.
From 1978 to 2009, 28 patients (20 females; median age, 45 years), including 11 with synchronous metastasis and 3 with extrahepatic metastasis, underwent resection for ACC LM (major hepatectomy in 61%). Postoperative mortality was nil and morbidity 55%. On pathological examination, tumors were multiple in 68%, with a median size of 43 mm, and resections were R0, 1, and 2 in 59%, 33%, and 7%, respectively. All 28 patients developed recurrent disease, which was treated surgically in 11, including repeat hepatectomy in 4. Of the 15 patients with adequate tissue for analysis, β-catenin immunostaining was positive in 7, with 4 corresponding CTNNB1 mutations associated with decreased survival; p53 staining was positive in 5 (4 with corresponding TP53 mutations). The median disease-free and overall survival after hepatectomy was 7 and 31.5 months, respectively, with a 5-year survival of 39%. In multivariate analysis, nonfunctional tumor and surgical treatment of recurrence were independent predictors of good outcome.
In selected patients with ACC LM, resection is associated with long-term survival and is, therefore, justified but rarely curative.
Annals of Surgical Oncology 04/2012; 19(8):2643-51. · 4.17 Impact Factor
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Sébastien Gaujoux,
Javiera Torres,
Sara Olson,
Corrine Winston,
Mithat Gonen,
Murray F Brennan,
David S Klimstra, Michael D'Angelica,
Ronald Dematteo,
Yuman Fong,
Michael House,
William Jarnagin,
Robert C Kurtz,
Peter J Allen
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ABSTRACT: Epidemiologic studies have reported a positive correlation between body mass index (BMI) and pancreatic cancer risk, but clinical relevance of obesity and/or body fat distribution on tumor characteristics and cancer-related outcome remain controversial. We sought to assess the influence of obesity and body fat distribution on pathologic characteristics and survival after pancreaticoduodenectomy for pancreatic adenocarcinoma.
Demographic and biometric data were collected on 328 patients undergoing pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. In a subset of patients, pancreatic fatty infiltration and fibrosis were assessed pathologically, and visceral fat area (VFA) was evaluated. Influence of BMI and body fat distribution on tumor characteristics and survival were evaluated.
A significant positive correlation between BMI and VFA was observed, with a wide range of VFA value within each BMI class. According to BMI or VFA distribution, there were no significant differences in patient characteristics, intraoperative or perioperative outcome, or pathologic characteristics, with the exception of significantly higher blood loss in patients with an increased body weight or VFA. Unadjusted overall and disease-free survival between BMI class and VFA quartile were not significantly different.
In this study, obesity and body fat distribution were not correlated with specific tumor characteristics or cancer-related outcome.
Annals of Surgical Oncology 03/2012; 19(9):2908-16. · 4.17 Impact Factor
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ABSTRACT: Cystic pancreatic endocrine neoplasms (CPENs) are uncommon tumors with uncertain disease biology and ill-defined diagnostic features.
A prospectively maintained pancreatic cyst registry was queried, and 31 cases of CPEN that were resected between 1995 and 2010 were identified. Patient and lesion characteristics were detailed and compared with resected non-PEN cystic lesions. Recurrence and survival outcome were compared with 31 noncystic PENs matched for functional status, differentiation, size, World Health Organization classification, grade, and presence of metastases.
During the study period, CPENs accounted for 7% of resected pancreatic cysts (31/469) and 12% of resected PENs (31/255). CPENs were primarily sporadic (94%), solitary (87%), nonfunctioning (100%), and incidentally discovered (68%). The median diameter was 2.1 cm (range, 0.9-6.2 cm), and preoperative imaging identified septations in 29%, a solid component in 26%, and cyst wall enhancement or a characteristic hypervascular rim in 45% of cases. Preoperative imaging and/or cytology suggested the diagnosis of CPEN in 61%. Compared with resected nonendocrine cystic lesions, CPEN were less frequently symptomatic, less likely to contain septations, and smaller. Compared with matched noncystic PENs, CPENs had comparable demographic, radiologic, and pathologic features and statistically similar long-term outcome (5-year disease-free survival: CPEN: 100% vs PEN: 86%, P = .947).
In this study, CPENs were primarily asymptomatic small lesions that could be characterized in the majority of cases by cyst wall enhancement on preoperative imaging and/or cytologic assessment. No significant difference in recurrence or survival outcome was identified between cystic and noncystic PENs.
Surgery 11/2011; 151(4):518-25. · 3.10 Impact Factor
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ABSTRACT: To determine the local recurrence rate and factors associated with recurrence after intraoperative ablation of colorectal cancer liver metastases.
A retrospective analysis of a prospectively maintained database was performed for patients who underwent ablation of a hepatic colorectal cancer metastasis in the operating room from April 1996 to March 2010. Kaplan-Meier survival curves and Cox models were used to determine recurrence rates and assess significance.
Ablation was performed in 10% (n = 158 patients) of all cases during the study period. Seventy-eight percent were performed in conjunction with a liver resection. Of the 315 tumors ablated, most tumors were ≤ 1 cm in maximum diameter (53%). Radiofrequency ablation was used to treat most of the tumors (70%). Thirty-six tumors (11%) had local recurrence as part of their recurrence pattern. Disease recurred in the liver or systemically after 212 tumors (67%) were ablated. On univariate analysis, tumor size greater than 1 cm was associated with a significantly increased risk of local recurrence (hazard ratio 2.3, 95% confidence interval 1.2-4.5, P = 0.013). The 2 year ablation zone recurrence-free survival was 92% for tumors ≤ 1 cm compared to 81% for tumors >1 cm. On multivariate analysis, tumor size of >1 cm, lack of postoperative chemotherapy, and use of cryotherapy were significantly associated with a higher local recurrence rate.
Intraoperative ablation appears to be highly effective treatment for hepatic colorectal tumors ≤ 1 cm.
Annals of Surgical Oncology 08/2011; 19(3):834-41. · 4.17 Impact Factor
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ABSTRACT: To evaluate the role of intraoperative ablation as an adjunct to resection in patients with recurrent colorectal liver metastases (rCLM).
All patients undergoing curative-intent reoperative surgery for rCLM from 1992 to 2009 at a tertiary cancer center were included. Overall survival (OS) and recurrence-free survival (RFS) were compared between patients treated with resection alone or in combination with ablation.
A total of 112 reoperative hepatectomies were performed, of which 16 were combined with ablation. The proportion of patients treated with resection and ablation increased from 0% to 41%. Patients undergoing resection and ablation had a greater tumor burden (median, 4 vs. 1, p < 0.0001) and higher baseline clinical risk scores (median, 3 vs. 2, p = 0.065) than patients undergoing resection alone. Patients undergoing resection and ablation had lower intraoperative blood loss than patients undergoing resection alone (344 vs. 877 ml, p = 0.018). Five-year OS from the time of surgery was 48.6%. In multivariable analysis, there was no significant difference in OS or RFS based on the treatment modality.
In patients with rCLM, the use of intraoperative ablation can extend the limits of surgical resection in patients with disease that might otherwise not be amenable to complete resection.
Journal of Gastrointestinal Surgery 07/2011; 15(7):1168-72. · 2.83 Impact Factor
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Lucian Panait,
Peter Learn,
Christopher Dimaio,
David Klimstra,
Kinh Gian Do,
Theresa Schwarz, Michael D'Angelica,
Ronald DeMatteo,
Peter Kingham,
Peter Allen,
Yuman Fong,
William R Jarnagin
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ABSTRACT: Schwannomas are usually benign nerve sheath tumors, which typically arise in the head, neck, spinal cord and extremities. Schwannoma of the biliary tract is an extremely rare finding. Patients generally lack symptoms and seek medical attention when tumor growth causes obstructive jaundice. Preoperative diagnosis is difficult and resection is the treatment of choice.
A 54 year-old female with history of back and right labia minor melanoma for which she underwent complete excision and right inguinal lymph node dissection more than 10 years ago, was evaluated for new onset gastroesophageal reflux symptoms and found to have markedly abnormal liver enzymes. Imagining studies revealed intrahepatic ductal dilatation and a 5.2 cm mass in the porta hepatis that was not consistent with cholangiocarcinoma or hepatocellular carcinoma. Multiple percutaneous biopsies of the mass failed to provide a definitive diagnosis. With a high clinical suspicion of metastatic melanoma and no other evident sites of disease, operative intervention was undertaken for diagnosis and definitive treatment.
Diagnostic laparoscopy was performed initially, but access to the mass was difficult, given its location. Subsequently, the patient underwent laparotomy, with tumor excision, common bile duct resection and hepato-jejunostomy. Pathologic examination and analysis were consistent with cellular schwannoma. Postoperatively, the patient recovered uneventfully, and liver function studies returned to normal.
Schwannomas are uncommon tumors, which very rarely arise from the biliary tract and cause biliary obstruction. Exploration is indicated in order to establish the diagnosis and to render definitive treatment.
Surgical Oncology 06/2011; 20(4):e157-9. · 2.44 Impact Factor
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Constantinos T Sofocleous,
Elena N Petre,
Mithat Gonen,
Karen T Brown,
Stephen B Solomon,
Anne M Covey,
William Alago,
Lynn A Brody,
Raymond H Thornton, Michael D'Angelica,
Yuman Fong,
Nancy E Kemeny
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ABSTRACT: To evaluate the clinical outcomes of percutaneous radiofrequency (RF) ablation of colorectal cancer liver metastases (CLMs) that recur after hepatectomy.
From December 2002 to December 2008, 71 CLMs that developed after hepatectomy were ablated in 56 patients. Medical records and imaging were reviewed to determine technique effectiveness/complete ablation (ie, ablation defect covering the entire tumor on 4-6-week postablation computed tomography [CT]), complications, and local tumor progression (LTP) at the site of ablation. LTP-free and overall survival were calculated by using Kaplan-Meier methodology. A modified clinical risk score (CRS) including nodal status of the primary tumor, time interval between diagnoses of the primary tumor and liver metastases, number of tumors, and size of the largest tumor was assessed for its effect on overall survival and LTP.
Tumor size ranged between 0.5 and 5.7 cm. Complete ablation was documented in 67 of 71 cases (94%). Complications included liver abscess (n = 1) and pleural effusion (n = 1). Median overall survival time was 31 months. One-, 2- and 3-year overall survival rates were 91%, 66%, and 41%, respectively. CRS was an independent factor for overall survival (74% for CRS of 0-2 vs 42% for CRS of 3-4 at 2 y; P = .03) and for LTP-free survival (66% for CRS of 0-2 vs 22% for CRS of 3-4 at 1 y after a single ablation; P <.01).
CT-guided RF ablation can be used to treat recurrent CLM after hepatectomy. A low CRS is associated with better clinical outcomes.
Journal of vascular and interventional radiology: JVIR 06/2011; 22(6):755-61. · 1.81 Impact Factor
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ABSTRACT: This study evaluates the significance of tumor involvement of the liver in early T-stage tumors and lymph node (LN) metastases on outcome after R0 resection of gallbladder cancer (GBCA).
A prospectively maintained database, supplemented with review of the medical record, was used to identify patients who underwent a complete (R0) resection for GBCA. All patients underwent definitive surgical treatment at the initial operation (1 stage) or after initial noncurative cholecystectomy (incidental tumors, 2 stage), including partial hepatectomy and portal LN dissection, with or without bile duct and/or adjacent organ resection. Clinicopathological variables, including TNM stage, histologic tumor involvement of liver (residual or direct extension in the GB fossa or discontiguous disease), and the total number of regional LNs assessed were analyzed for their association with outcome.
One hundred twenty-two patients were identified and analyzed. The median follow up period was 23 months. Liver and nodal involvement by GBCA were observed in 61 (50%) and 41(34%) patients, respectively. Among patients with T2 tumors (n = 53), 48 (91%) were incidental. Liver involvement was present in 26%, and this factor was associated with decreased recurrence-free (RFS) and disease-specific survival (DSS) compared with patients with T2 tumors without liver involvement (median RFS, 12 months vs. not reached, P = 0.004, median DSS 25 months versus not reached, P = 0.003); T1b tumors (n = 10) were not associated with liver involvement. The median total lymph node count (TLNC) was 3 (range 0-20). For the entire cohort, survival of patients classified as N0 based on TLNC < 6 was significantly worse than that of N0 patients based on TLNC ≥ 6 (median RFS, 22 months versus not reached, P < 0.001, median DSS 41 months versus not reached, P < 0.001). Liver involvement and TLNC remained significant prognostic factors in a multivariate model that included TNM stage.
Resection and histologic evaluation of at least 6 lymph nodes improves risk-stratification after resection of GBCA. Incidental T2 tumors are often associated with residual liver disease and should be reclassified to reflect the adverse outcome. The data suggests a need for standardized minimum requirements for adequate surgical treatment and pathological examination.
Annals of surgery 05/2011; 254(2):320-5. · 7.90 Impact Factor
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Michael D'Angelica,
John Ammori,
Mithat Gonen,
David S Klimstra,
Philip S Low,
Linda Murphy,
Martin R Weiser,
Philip B Paty,
Yuman Fong,
Ronald P DeMatteo,
Peter Allen,
William R Jarnagin,
Jinru Shia
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ABSTRACT: Folate receptor alpha (FRα), encoded by folate receptor 1 (adult) gene, has emerged as a cancer biomarker and potential therapeutic target. In addition, its expression in tumors may offer prognostic information. The aim of this study was to assess the prognostic value of FRα expression and other common molecular markers in resected liver metastases from colorectal cancer. To maximize potential biological differences, we selected two groups of patients with markedly different outcomes as study subjects. Immunohistochemical analysis of FRα expression and other common markers (thymidylate synthase, p53, p27, BCL2, ki67, MLH1, MSH2 and MGMT) on tissue microarrays was carried out on samples from 160 patients; 56 patients survived at least 10 years following liver resection, and 104 died within 2 years of surgery. These markers were evaluated and compared with standard clinical predictors of outcome including a previously validated clinical risk score. Our results showed that in addition to known clinical risk factors, FRα positivity was significantly associated with the early death group (32% compared with 13%; P=0.03). None of the other common molecular markers were differentially expressed between the two groups. On multivariate analysis, clinical risk score, margin status and FRα expression were independently associated with outcome. Specific multivariate comparisons confirmed that FRα expression was associated with outcome independent of the clinical risk score and margin. These data demonstrate that FRα expression is present in a subset of resected hepatic colorectal cancer metastases, and this marker is independently associated with survival after hepatic resection. The prognostic value of FRα expression and the utility of FRα-targeted therapies in stage-IV colorectal cancer patients deserve further exploration.Keywords: folate receptor 1 (adult); folate-targeted therapy; liver metastasis
Modern Pathology 05/2011; 24(9):1221-1228. · 4.79 Impact Factor
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ABSTRACT: Hepatic metastases are common with colorectal cancer. The primary blood supply to hepatic metastases is the hepatic artery. Regional chemotherapy utilizing the hepatic artery is one treatment option for liver metastases. The advantage of hepatic arterial chemotherapy is that high concentrations of the therapeutic drug are obtained in the liver with minimal systemic toxicity. Recently, systemic chemotherapy regimens have been added to hepatic arterial infusional chemotherapy to treat hepatic metastases. Due to the high response rates in the liver, resection rates are increasing in patients originally thought to have unresectable liver disease. Hepatic arterial chemotherapy has also been used in the adjuvant setting after resection of all liver metastases in order to minimize hepatic recurrences. The role of hepatic arterial infusional therapy in treating hepatic colorectal metastases includes treating patients with both resectable and unresectable metastases in the adjuvant, neoadjuvant, or palliative settings.
Journal of Surgical Oncology 12/2010; 102(8):988-95. · 2.10 Impact Factor
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ABSTRACT: Up to 50% of patients with colorectal cancer will develop metastatic disease in the liver. While surgical extirpation remains the best option for long-term survival, several complementary modalities such as laparoscopy, radiofrequency ablation, and microwave coagulation have gained wide acceptance as primary and adjunct therapies for both resectable and unresectable disease. This review will focus on the application and outcome of these techniques in patients with colorectal liver metastases.
Journal of Surgical Oncology 12/2010; 102(8):968-74. · 2.10 Impact Factor
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ABSTRACT: To assess the effect of increasing body mass index, intra-abdominal fat, and outer abdominal fat on outcome in patients undergoing major hepatectomy.
Cohort study.
Memorial Sloan-Kettering Cancer Center.
We studied patients aged 19 to 86 years undergoing major hepatic resection between June 18, 1996, and November 6, 2001. Complications were extracted from a prospective database at a tertiary cancer center.
A total of 349 patients were grouped according to body mass index for analysis. Preoperative abdominal computed tomographic scans were examined and measurements of perinephric fat (as a surrogate for intra-abdominal fat) and outer abdominal fat taken at uniform anatomical locations.
We compared 30-day mortality and morbidity figures, length of stay, and operating times.
Body mass index had an influence on operative time (P = .02) but no significant effect on mortality, frequency of any complications, frequency of severe complications, or length of stay (P = .80, P = .89, P = .16, and P = .81, respectively). Outer abdominal fat had no significant effect on any of the 5 outcome measures. Perinephric fat measurements had a significant effect on most outcome measures (P = .004 for mortality, P = .003 for frequence of complications, P < .001 for frequence of severe complications, and P = .001 for length of stay).
Outer appearances of obesity do not correlate with poor outcomes for major upper abdominal operations. A simple measurement of perinephric fat, as a surrogate for intra-abdominal fat, on preoperative imaging gives a more useful risk assessment for patients undergoing major upper abdominal operations.
Archives of surgery (Chicago, Ill.: 1960) 11/2010; 145(11):1069-73. · 4.32 Impact Factor
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ABSTRACT: Despite improvements in surgery and chemotherapy, most patients develop recurrence after hepatectomy for metastatic colorectal cancer. Data are lacking on the effect of these patterns on outcome.
A retrospective review of a prospectively maintained hepatobiliary database was performed. Pattern and timing of recurrence and outcome after recurrence were analyzed. Univariate and multivariate analyses of factors associated with outcome after recurrence were carried out.
From January 1997 through May 2003, a total of 733 patients underwent hepatectomy for colorectal metastases. Of these, 637 patients (87%) were included in the analysis, and in 393 patients (62%), recurrence was documented at the time of last follow-up. Initial recurrence patterns included the following: liver only in 120 patients (31%), lung only in 107 (27%), other single sites in 49 (12%), and multiple sites in 117 (30%). Recurrence occurred within 2 years of hepatectomy in 75% of patients and after 3 years in 11%. Margins at hepatectomy, recurrence pattern, resected recurrence, and disease-free interval from time of colectomy to hepatic metastasis and from time of hepatectomy to recurrence were independently associated with survival as measured from the time of recurrence. Recurrence in the lung, resected recurrence, and time to recurrence after hepatectomy were associated with prolonged survival as measured from the time of hepatectomy and the time of recurrence.
The timing and pattern of recurrence after hepatic resection for metastatic colorectal cancer are important predictors of long-term survival.
Annals of Surgical Oncology 11/2010; 18(4):1096-103. · 4.17 Impact Factor
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ABSTRACT: As the number of effective treatment options has increased, the management of patients with hepatocellular carcinoma has become complex. The most appropriate therapy depends largely on the functional status of the underlying liver. In patients with advanced cirrhosis and tumor extent within the Milan criteria, liver transplantation is clearly the best option, as this therapy treats the cancer along with the underlying hepatic parenchymal disease. As the results of transplantation has become established in patients with limited disease, investigation has increasingly focused on downstaging patients with disease outside of Milan criteria and defining the upper limits of transplantable tumors. In patients with well preserved hepatic function, liver resection is the most appropriate and effective treatment. Hepatic resection is not as constrained by tumor extent and location to the same degree as transplantation and ablative therapies. Some patients who recur after resection may still be eligible for transplantation. Ablative therapies, particularly percutaneous radiofrequency ablation and transarterial chemoembolization have been used primarily to treat patients with low volume irresectable tumors. Whether ablation of small tumors provides long term disease control that is comparable to resection remains unclear.
HPB 06/2010; 12(5):302-10. · 1.60 Impact Factor
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ABSTRACT: To determine the time course of liver hypertrophy after portal vein embolization (PVE).
In a cohort study, computed tomography volumetrics were calculated for livers during a 1-year period after PVE.
Tertiary liver cancer treatment center.
Ten patients who were subjected to PVE and were found subsequently to not be candidates for liver resection.
Right PVE.
Left and right liver volumes.
The left liver continued growing for the entire first year after PVE, while the right liver continued to atrophy. The total volume remained remarkably constant.
Early PVE during administration of a course of neoadjuvant therapy would be beneficial for enhanced growth of the liver before liver resection.
Archives of surgery (Chicago, Ill.: 1960) 04/2010; 145(4):351-4; discussion 354-5. · 4.32 Impact Factor
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ABSTRACT: To develop 2 instruments that predict the probability of perioperative red blood cell transfusion in patients undergoing elective liver resection for primary and secondary tumors.
Hepatic resection is the most effective treatment for several benign and malign conditions, but may be accompanied by substantial blood loss and the need for perioperative transfusions. While blood conservation strategies such as autologous blood donation, acute normovolemic hemodilution, or cell saver systems are available, they are economically efficient only if directed toward patients with a high risk of transfusion.
Using preoperative data from 1204 consecutive patients who underwent liver resection between 1995 and 2000 at Memorial Sloan- Kettering Cancer Center, we modeled the probability of perioperative red blood cell transfusion. We used the resulting model, validated on an independent dataset (n = 555 patients), to develop 2 prediction instruments, a nomogram and a transfusion score, which can be easily implemented into clinical practice.
The planned number of liver segments resected, concomitant extrahepatic organ resection, a diagnosis of primary liver malignancy, as well as preoperative hemoglobin and platelets levels predicted the probability of perioperative red blood cell transfusion. The predictions of the model appeared accurate and with good discriminatory abilities, generating an area under the receiver operating characteristic curve of 0.71.
Preoperative factors can be combined into risk profiles to predict the likelihood of transfusion during or after elective liver resection. These predictions, easy to calculate in the frame of a nomogram or of a transfusion score, can be used to identify patients who are at high risk for red cell transfusions and therefore most likely to benefit from blood conservation techniques.
Annals of surgery 12/2009; 250(6):914-21. · 7.90 Impact Factor
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Joseph F Buell,
Daniel Cherqui,
David A Geller,
Nicholas O'Rourke,
David Iannitti,
Ibrahim Dagher,
Alan J Koffron,
Mark Thomas,
Brice Gayet,
Ho Seong Han, [......],
Joseph Espat,
Michael Abecassis,
Myrddin Rees,
Yuman Fong,
Kelly M McMasters,
Christoph Broelsch,
Ron Busuttil,
Jacques Belghiti,
Steven Strasberg,
Ravi S Chari
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ABSTRACT: To summarize the current world position on laparoscopic liver surgery.
Multiple series have reported on the safety and efficacy of laparoscopic liver surgery. Small and medium sized procedures have become commonplace in many centers, while major laparoscopic liver resections have been performed with efficacy and safety equaling open surgery in highly specialized centers. Although the field has begun to expand rapidly, no consensus meeting has been convened to discuss the evolving field of laparoscopic liver surgery.
On November 7 to 8, 2008, 45 experts in hepatobiliary surgery were invited to participate in a consensus conference convened in Louisville, KY, US. In addition, over 300 attendees were present from 5 continents. The conference was divided into sessions, with 2 moderators assigned to each, so as to stimulate discussion and highlight controversies. The format of the meeting varied from formal presentation of experiential data to expert opinion debates. Written and video records of the presentations were produced. Specific areas of discussion included indications for surgery, patient selection, surgical techniques, complications, patient safety, and surgeon training.
The consensus conference used the terms pure laparoscopy, hand-assisted laparoscopy, and the hybrid technique to define laparoscopic liver procedures. Currently acceptable indications for laparoscopic liver resection are patients with solitary lesions, 5 cm or less, located in liver segments 2 to 6. The laparoscopic approach to left lateral sectionectomy should be considered standard practice. Although all types of liver resection can be performed laparoscopically, major liver resections (eg, right or left hepatectomies) should be reserved for experienced surgeons facile with more advanced laparoscopic hepatic resections. Conversion should be performed for difficult resections requiring extended operating times, and for patient safety, and should be considered prudent surgical practice rather than failure. In emergent situations, efforts should be made to control bleeding before converting to a formal open approach. Utilization of a hand assist or hybrid technique may be faster, safer, and more efficacious. Indications for surgery for benign hepatic lesions should not be widened simply because the surgery can be done laparoscopically. Although data presented on colorectal metastases did not reveal an adverse effect of the laparoscopic approach on oncological outcomes in terms of margins or survival, adequacy of margins and ability to detect occult lesions are concerns. The pure laparoscopic technique of left lateral sectionectomy was used for adult to child donation while the hybrid approach has been the only one reported to date in the case of adult to adult right lobe donation. Laparoscopic liver surgery has not been tested by controlled trials for efficacy or safety. A prospective randomized trial appears to be logistically prohibitive; however, an international registry should be initiated to document the role and safety of laparoscopic liver resection.
Laparoscopic liver surgery is a safe and effective approach to the management of surgical liver disease in the hands of trained surgeons with experience in hepatobiliary and laparoscopic surgery. National and international societies, as well as governing boards, should become involved in the goal of establishing training standards and credentialing, to ensure consistent standards and clinical outcomes.
Annals of surgery 11/2009; 250(5):825-30. · 7.90 Impact Factor
