Hepatocellular Carcinoma: Targeted Therapy and Multidisciplinary P24

13 Laparoscopic Liver Surgery for the Management of Hepatocellular Carcinoma 215 in itself often obviates major hemorrhage. Lastly, use of endovascular staplers are used when the remaining vascular pedicle of the tumor is identified when greater than 90% of the tumor is resected. Liberal application of staplers in a cirrhotic liver often results in deformed staplers and incomplete staple formation, hence should be averted till essential. A margin of 1 cm is considered satisfactory. However, depending on the loca-tion of the lesion (e.g., when tumor abuts major vessels), a smaller margin may be acceptable as long as the tumor does not extend to the resection margins. If the lesion is not deemed resectable or additional lesions are found, radiofrequency abla-tion of the lesion is commonly performed. The RFA probe is placed in the center of the tumor and treated as per the device protocol. Results The skepticism surrounding the advent of laparoscopic liver surgery for hepatoma had to do mainly with the fear of complications and oncological integrity. The safety on both these counts has now been demonstrated in large series. In the preliminary data from a multicenter study from Europe [18], of the 9 cirrhotic patients (Child’s A = 5; B = 4) undergoing laparoscopic liver resec-tion for hepatoma, 5 developed transient liver failure and ascites. Perioperative complications, such as bleeding, need for blood transfusion, need for portal triad clamping, and conversion to open resection, were higher in the hepatoma group as compared to patients with liver metastasis undergoing laparoscopic resection. A tumor-free margin of at least 1 cm was obtained in 70% of patients. No port site metastasis was detected and the disease-free survival was 44% at a mean follow-up of 14 months. Although this study demonstrated the feasibility of laparoscopic liver resection, it did not convince most physicians about a future role in HCC therapy. The first prospective study [19] with a reasonable follow-up included 27 Child’s A cirrhotic patients with solitary peripheral lesions up to 5 cm. The resections included 17 anatomic and 10 non-anatomic resections; the rate of conversion to open resection was 26%. Most of the conversions were required for lesions in seg-ment 6 of the liver. Postoperative complications were noted in 33%, and 15 patients had a surgical margin less than 1 cm. During a mean follow-up of 2 years 8 patients (30%) developed recurrence (includes 3 with local recurrence) and the overall and disease-free 3-year survival rates were 93 and 64%, respectively. A recent study from Italy [20] retrospectively compared laparoscopic and open liver resection for hepatoma in cirrhotic patients. Although the mean operating time was longer in the laparoscopic group, this group required significantly less blood transfusion and use of a Pringle maneuver and had reduced hospital stay and postop-erative complications compared to the open resection group. The resection margin was greater than 1 cm in 92% of the laparoscopic group. The mortality rate and 2-year survival were similar in both groups. 216 K.V. Ravindra and J.F. Buell The largest single center report of laparoscopic liver resections for HCC is a ret-rospective study from Taiwan [21]. This included 116 cirrhotic patients of whom 18 were Child’s status B/C. Major resections (>2 segments) were performed in 19 patients. Ahand port device was used for lesions insegments 7and 8. Conversion to open resection was necessary in 5.2% of patients and the need for blood trans-fusion was low (6.9%). An extremely low complication rate of 6% was reported. A 5-year survival rate of 60% was reported with a complete absence of port site recurrences. An updated European multicenter study (Dagher, personal communication) included 163 resections (cirrhotic: 120; fibrosis: 11, and normal: 32). A pure laparo-scopic approach was used in 95% of cases but required a lower abdominal incision for specimen retrieval. Major resections were done in 10%. The rate of conversion to open resection and the need for blood transfusion were 9.2 and 9.8%, respec-tively. There were 2 postoperative deaths and the morbidity was detailed as liver specific in 11.6% and nonspecific in 10.4%. The mean surgical margin was 14.2 ± 10.6 mm and exceeded 5 mm in 83.4%. At a mean follow-up of 30.4 months, tumor recurrence in the liver was noted in 39.2% (local in 17% and distant 83%). A summary of the majority of reports in the literature is contained in Table 13.2. The above results strongly support the feasibility and safety of the laparoscopic technique in the surgical treatment of hepatoma of the liver in cirrhotics. Summary Laparoscopic resection of liver for hepatoma is a safe option. In centers with the necessary expertise results are equivalent to open surgery. The advantages of small incisions minimizing the incidence of ascites and adhesions are likely to increase the use of this option in the cirrhotic population (Child’s A/B). This is crucially important in those likely to need liver transplantation in the future. References 1. Mazzaferro V, Regalia E, Doci R, et al (1996) Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med 334:693–699 2. Yao FY, Ferrell L, Bass NM, et al (2001) Liver transplantation for hepatocellular carci-noma: expansion of the tumor size limits does not adversely impact survival. Hepatology 33: 1394–1403 3. Livraghi T, Goldberg SN, Lazzaroni S, Meloni F, Solbiati L, Gazelle GS, et al (1999) Small hepatocellular carcinoma: treatment with radio-frequency ablation versus ethanol injection. Radiology 210:655–661 4. Zhou XD, Tang ZY (1998) Cryotherapy for primary liver cancer. Semin Surg Oncol 14: 171–174 5. Shiina S, Tagawa K, Niwa Y, et al (1993) Percutaneous ethanol injection therapy for hepatocellular carcinoma: results in 146 patients. AJR Am J Roentgenol 160(5):1023–1028 6. Matsukawa T, Yamashita Y, Arakawa A, et al (1997) Percutaneous microwave coagulation therapy in liver tumors. A 3-year experience. Acta Radiol 38:410–415 13 Laparoscopic Liver Surgery for the Management of Hepatocellular Carcinoma 217 7. Pacella CM, Bizzarri G, Guglielmi R, et al (2001) Laser thermal ablation in the treatment of small hepatocellular carcinoma: results in 74 patients. Radiology 221:712–720 8. Llovet JM, Bruix J (2003) Systematic review of randomized trials for unresectable hepatocel-lular carcinoma: Chemoembolization improves survival. Hepatology 37:429–442 9. Salem R, Lewandowski RJ, Atassi B, et al (2005) Treatment of unresectable hepatocellular carcinoma with use of 90Y microspheres (TheraSphere): safety, tumor response, and survival. J Vasc Interv Radiol 16:1627–1639 10. Lau H, Man K, Fan ST, Yu WC, Lo CM, Wong J (1997) Evaluation of preoperative hep-atic function in patients with hepatocellular carcinoma undergoing hepatectomy. Br J Surg 84:1255–1259 11. Bryant R, Laurent A, Tayar C, et al (2008) Liver resection for hepatocellular carcinoma. Surg Oncol Clin N Am 17:607–633, ix 12. Lau WY (1997) The history of liver surgery. J R Coll Surg Edinb 42:303–309 13. Buell JF, Thomas MT, Rudich S, et al (2008) Experience with more than 500 minimally invasive hepatic procedures. Ann Surg 248:475–486 14. KoffronAJ,AuffenbergG,KungR,AbecassisM(2007)Evaluationof300minimallyinvasive liver resections at a single institution: less is more. Ann Surg 246:385–392 15. Nguyen KT, Gamblin TC, Geller DA (2008) Laparoscopic liver resection for cancer. Future Oncol 4:661–670 16. Vauthey JN, Chaoui A, Do KA, et al (2000) Standardized measurement of the future liver remnant prior to extended liver resection: methodology and clinical associations. Surgery 127:512–519 17. Makuuchi M, Sano K (2004) The surgical approach to HCC: our progress and results in Japan. Liver Transpl 10(2 Suppl 1):S46–S52 18. GigotJF,GlineurD,SantiagoAzagraJ,etal(2002)Laparoscopicliverresectionformalignant liver tumors: preliminary results of a multicenter European study. Ann Surg 236:90–97 19. Cherqui D, Laurent A, Tayar C, et al (2006) Laparoscopic liver resection for peripheral hepa-tocellular carcinoma in patients with chronic liver disease: midterm results and perspectives. Ann Surg 243:499–506 20. Belli G, Fantini C, D’Agostino A, et al (2007) Laparoscopic versus open liver resection for hepatocellular carcinoma in patients with histologically proven cirrhosis: short- and middle-term results. Surg Endosc 21:2004–2011 21. Chen HY, Juan CC, Ker CG (2008) Laparoscopic liver surgery for patients with hepatocellular carcinoma. Ann Surg Oncol 15:800–806 22. Poon RT (2007) Current role of laparoscopic surgery for liver malignancies. Surg Technol Int 16:73–81 23. Buell JF, Koffron AJ, Thomas MJ, et al (2005) Laparoscopic liver resection. J Am Coll Surg 200:472–480 24. Santambrogio R, Aldrighetti L, Barabino M, et al (2009) Laparoscopic liver resections for hepatocellular carcinoma. Is it a feasible option for patients with liver cirrhosis? Langenbecks Arch Surg 394:255–264 Chapter 14 Liver Transplant for Hepatocellular Carcinoma Thomas A. Aloia, A. Osama Gaber, and R. Mark Ghobrial Keywords Liver cancer · Liver transplantation · Immunosuppression · Outcomes · Prognostic factors History of Liver Transplant for HCC From the start of liver transplantation, treatment of hepatocellular carcinoma (HCC) has played a central role. Following the unsuccessful transplant of a child with biliary atresia in 1963, the second and third attempts at liver transplantation at the University of Colorado were in adults with advanced HCC. At autopsy, both recipients were found to have micrometastatic disease [1]. As liver transplantation proceeded in an experimental environment, the high mortality procedure was fre-quently reserved for patients with advanced malignancy. In 1967, a 19-month-old child with primary liver cancer became the first liver transplant recipient to achieve prolonged survival, but recurred within 4 months and died of disseminated cancer at 400 days [2]. As the procedure and immunosuppression were refined, patient and allograft survivals improved to the point that oncologic recurrence and survival rates could be determined [3, 4]. This initial experience clearly showed that, in the immunosuppressed state fol-lowing liver transplantation, patients with advanced stage HCC had extraordinarily high recurrence rates [5]. As more experience was gained and allograft outcomes continued to improve, the non-oncologic indications for liver transplantation were expanded and, appropriately, oncologic indications were constricted [6]. In 1989, a moratorium on liver transplantation for HCC was put in place. Following this, enthusiasm waned and few guidelines directed the listing and transplantation of patients with HCC until the publication of the “Milan criteria” R.M. Ghobrial ( ) Department of Surgery, Weill-Cornell Medical College, The Methodist Hospital, Houston, TX, USA K.M. McMasters, J.-N. Vauthey (eds.), Hepatocellular Carcinoma, 219 DOI 10.1007/978-1-60327-522-4_14, C Springer Science+Business Media, LLC 2011 ... - tailieumienphi.vn