O. Farges

Assessment of the benefits and risks of percutaneous biopsy before surgical resection of hepatocellular carcinoma

BACKGROUND/AIMSnBecause of a potential risk of needle tract seeding, the use of ultrasound (US)-guided biopsy for the diagnosis of hepatocellular carcinoma (HCC) is controversial. This study was aimed at determining the usefulness, accuracy and safety of this technique as well as the incidence of needle tract seeding.nnnMETHODSnFrom 1986 to 1996, 137 patients who underwent resection or transplantation for suspected HCC had US-guided biopsy before surgery. The analysis of the resected liver was compared to the results of biopsy. Patients were assessed with a mean follow up of 38 months.nnnRESULTSnThe diagnosis of HCC was established by biopsy in 122 patients (89%). Thirteen of the 15 patients with negative biopsy were shown to have HCC after surgery. The remaining two patients had non-malignant nodules. Sensitivity and accuracy of US-guided biopsy were 90 and 91%, respectively. Accuracy was significantly influenced by the location of the nodule but not by its size. Needle tract seeding occurred in two patients (1.6%).nnnCONCLUSIONSnIn this series, the incidence of needle tract seeding was less than 2% and no recurrence was observed after local excision. This risk should be balanced with the risk of deciding an aggressive treatment in a patient without malignancy. Patients with negative biopsy should undergo a second biopsy and/or repeated investigations by imaging techniques.

A Single-Center Surgical Experience of 122 Patients With Single and Multiple Hepatocellular Adenomas

BACKGROUND & AIMSnHepatocellular adenoma (HA) is associated with risk of bleeding and malignancy, justifying resection. Patients with multiple forms of HA are difficult to manage. We evaluated the characteristics and outcome of 122 patients with single and multiple HAs after surgery.nnnMETHODSnFrom 1990 to 2004, 122 patients (14 male) underwent surgical resection. Complications (hemorrhage and malignancy) were assessed according to size, number, and histologic subtype (steatotic, telangiectatic, and unclassified), with a mean follow-up period of 70 months.nnnRESULTSnHemorrhagic HA occurred in 21% of cases and malignant HA occurred in 8%. Risk of complications was not related to the number of HAs but was associated with size (>5 cm), especially of telangiectatic and unclassified subtypes. Patients with steatotic HA had a low risk of complications. Malignant HA was more frequent in men (43%); all patients treated by partial resection survived, without recurrent malignancy, after a mean follow-up period of 78 months. After 109 patients with benign HA revealed recurrence or progression of HA in 8% and regression in 9% of cases. No complications were observed in 11 women who became pregnant during the follow-up period.nnnCONCLUSIONSnPatients with HAs greater than 5 cm, telangiectatic or unclassified subtypes, and men have an increased risk of complicated disease; resection should be restricted to these patients. The risk of complications was not related to the number of HAs, so patients with multiple HAs do not need liver transplantation.

Aiming at minimal invasiveness as a therapeutic strategy for Budd‐Chiari syndrome

The 1‐year spontaneous mortality rate in patients with Budd‐Chiari syndrome (BCS) approaches 70%. No prospective assessment of indications and impact on survival of current therapeutic procedures has been performed. We evaluated a therapeutic strategy uniformly applied during the last 8 years in a single referral center. Fifty‐one consecutive patients first received anticoagulation and were treated for associated diseases. Symptomatic patients were considered for hepatic vein recanalization; then for transjugular intrahepatic portosystemic shunt (TIPS), and finally for liver transplantation. The absence of a complete response led to the next procedure. Assessment was according to the strategy, whether procedures were technically applicable and successful. At entry, median (range) Child‐Pugh score and Clichy prognostic index were 8 (5–12), and 5.4 (3.1–7.7), respectively. A complete response was achieved on medical therapy alone in 9 patients; after recanalization in 6, TIPS in 20, liver transplantation in 9, and retransplantation in 1. Of the 41 patients considered for recanalization, the procedure was not feasible in 27 and technically unsuccessful in 3. Of the 34 patients considered for TIPS, the procedure was considered not feasible in 9 and technically unsuccessful in 4. At 1 year of follow‐up, a complete response to TIPS was achieved in 84%. One‐ and 5‐year survival from starting anticoagulation were 96% (95% CI, 90–100) and 89% (95% CI, 79–100), respectively. In conclusion, excellent survival can be achieved in BCS patients when therapeutic procedures are introduced by order of increasing invasiveness, based on the response to previous therapy rather than on the severity of the patients condition. (HEPATOLOGY 2006;44:1308–1316.)

Sequential arterial and portal vein embolizations before right hepatectomy in patients with cirrhosis and hepatocellular carcinoma.

Selective transarterial chemoembolization (TACE) and portal vein embolization (PVE) could improve the rate of hypertrophy of the future liver remnant (FLR) in patients with chronic liver disease. This study evaluated the feasibility and efficacy of this combined procedure.

Changing trends in malignant transformation of hepatocellular adenoma

Objective Hepatocellular adenomas (HCAs) classically develop in women who are taking oral contraceptives and have a risk of malignant transformation into hepatocellular carcinoma (HCC). HCA with malignant transformation is, however, an ill-defined entity thought to be an anecdotic pathway to HCC. The objective of this study was to characterise malignancy occurring within HCA. Design, setting and patients A series of histology proven HCAs managed between 1993 and 2008 in a tertiary hepato-biliary centre (218 patients, 184 women and 34 men) were screened to identify HCA with malignant transformation. Main outcome measures The incidence of HCA with malignant transformation was analysed through the study period and associated conditions were retrieved. They were sub-typed according to their molecular features and the malignant compartment was mapped. Results Areas of HCC within HCA were observed in 23 patients and the risk of malignant transformation was 4% in women and 47% in men. The number of women whose HCA had malignant changes has remained stable during the study period and oral contraception was the only associated condition. The number of men with such transformation has markedly increased since 2000 and the metabolic syndrome has become the most frequent associated condition. Two-thirds of HCAs with malignant transformation were β-catenin activated and one-third displayed cell atypias. Both features were more prevalent in men. The median diameter of HCA with malignancy was 10u2005cm and only three were 5u2005cm or less. Conclusion Prevalence of malignancy within HCA is 10 times more frequent in men than in women and management of HCA should primarily be based on gender. Whereas oral contraception is a classical cause of HCA in women but a marginal cause of HCC, the metabolic syndrome appears as an emerging condition associated with malignant transformation of HCA in men, and is the likely predisposing condition for HCC in this setting.

AJCC 7th edition of TNM staging accurately discriminates outcomes of patients with resectable intrahepatic cholangiocarcinoma: by the AFC-IHCC-2009 study group

This year, the 7th edition of the AJCC staging manual has for the first time attributed a unique pTNM staging to intrahepatic cholangiocarcinoma (IHCC) that is intended to replace the 2 Western and ideally also the 2 Eastern systems currently in use. This proposal, which has not yet been validated, was tested in the current study.

Influence of surgical margins on outcome in patients with intrahepatic cholangiocarcinoma: a multicenter study by the AFC-IHCC-2009 study group

Objective:Define the optimal surgical margin in patients undergoing surgery for intrahepatic cholangiocarcinoma (IHCC). Background Data:Surgery is the most effective treatment for IHCC. However, the influence of R1 resection on outcome is controversial and that of margin width has not been evaluated. Methods:We studied 212 patients undergoing curative resection of mass-forming–type IHCC. The respective influences on survival of resection status (R0 vs R1), surgical margin width, pTNM stage, and the latters components were evaluated. Results:Incidence of R1 resection was 24%. Overall, R1 resection was not an independent predictor of survival [odds ratio (OR) 1.2 (0.7–2.1)] in contrast to the pTNM stage [OR 2.10 (1.2–3.5)]. In the 78 pN+ patients, survival was similar after R0 and R1 resections (median: 18 vs 13 months, respectively, P = 0.1). In the 134 pN0 patients, R1 resection was an independent predictor of poor survival [OR 9.6 (4.5–20.4)], as was the presence of satellite nodules [OR 1.9 (1.1–3.2)]. In the 116 pN0 patients with R0 resections, median survival was correlated with margin width (⩽1 mm: 15 months; 2–4 mm: 36 months; 5–9 mm: 57 month; ≥10 mm: 64 month, P < 0.001) and a margin >5 mm was an independent predictor of survival [OR 2.22 (1.59–3.09)]. Conclusion:Patients undergoing surgery for IHCC are at high risk of R1 resections. In pN0 patients, R1 resection is the strongest independent predictor of poor outcome and a margin of at least 5 mm should be created. The survival benefits of resection in pN+ patients and R1 resection in general are very low.

Multicentre European study of preoperative biliary drainage for hilar cholangiocarcinoma

Indications for preoperative biliary drainage (PBD) in the context of hepatectomy for hilar malignancies are still debated. The aim of this study was to investigate current European practice regarding biliary drainage before hepatectomy for Klatskin tumours.

Malignant Transformation of Liver Adenoma: An Analysis of the Literature

As adenoma in other locations, hepatic adenoma (HA) may transform into hepatocellular carcinoma (HCC) and hepatocyte dysplasia is most probably the intermediate step between both conditions. Malignant HA may appear as microscopic or macroscopic areas of HCC within the HA. These areas are typically well differentiated and without vascular extension or satellite nodules. AFP measurements are not reliable as they are usually normal. The risk of malignant transformation of HA cannot be reliably quantified yet. Several series are concordant to show that approximately 5% of patients whose HA have been resected had pathological evidence of HCC within their HA. This figure however does not take into account fully transformed HA where evidence of the preexisting benign lesion might have disappeared. The risk of malignant transformation is correlated with the diameter of the HA and it is very unusual when it is <5 cm and the same holds true for patients with multiple HA. These results suggest that small HA could be safely observed as they are also at low risk of bleeding. These conclusions might not apply to male patients who are at lower risk of HA, except in specific conditions, but appear to be at a much higher risk of malignant changes.

2012 Liver resections in the 21st century: we are far from zero mortality

OBJECTIVESnRecent improvements in surgical technique have extended the indications for liver resection. The aims of this study were to assess whether this extension is associated with a changing patient profile and to evaluate how this potential shift has influenced mortality after liver resection in order to define standard expectations for hepatectomy.nnnMETHODSnThe characteristics and postoperative outcomes of all patients undergoing elective hepatectomy from 2000 to 2009 were reviewed retrospectively. Multivariate analysis was conducted to determine the factors associated with mortality in the subgroup of patients with malignant disease.nnnRESULTSnAmong the 2012 patients in whom hepatectomies were performed, the percentage of patients operated for malignancy increased from 66.4% in 2000 to 82.3% in 2009 (P < 0.001). These patients experienced higher mortality (4.5% versus 0.7%; P < 0.001), were significantly older, and displayed greater comorbidity and underlying parenchymal disease compared with those with benign lesions. Mortality over the entire study period was 3.5% and was fairly stable, dropping from 3.8% in 2000 to 3.1% in 2009 (P = 0.686). On multivariate analysis, age of >60 years, an American Society of Anesthesiologists score of ≥3, major resection, vascular procedure, severe fibrosis (F3-F4) and steatosis of >30% were associated with increased mortality in patients with malignant disease.nnnCONCLUSIONSnThe profile of patients undergoing liver resection has changed and now includes more high-risk patients with diseased parenchyma undergoing major hepatectomy for malignancy. This change in patient profile is responsible for the stability in mortality rates over the years.