Parissa Tabrizian

The role of hepatic resection in the treatment of hepatocellular cancer

Current guidelines recommend surgical resection as the primary treatment for a single hepatocellular cancer (HCC) with Childs A cirrhosis, normal serum bilirubin, and no clinically significant portal hypertension. We determined how frequently guidelines were followed and whether straying from them impacted survival. BRIDGE is a multiregional cohort study including HCC patients diagnosed between January 1, 2005 and June 30, 2011. A total of 8,656 patients from 20 sites were classified into four groups: (A) 718 ideal resection candidates who were resected; (B) 144 ideal resection candidates who were not resected; (C) 1,624 nonideal resection candidates who were resected; and (D) 6,170 nonideal resection candidates who were not resected. Median follow‐up was 27 months. Log‐rank and Coxs regression analyses were conducted to determine differences between groups and variables associated with survival. Multivariate analysis of all ideal candidates for resection (A+B) revealed a higher risk of mortality with treatments other than resection. For all resected patients (A+C), portal hypertension and bilirubin >1 mg/dL were not associated with mortality. For all patients who were not ideal candidates for resection (C+D), resection was associated with better survival, compared to embolization and “other” treatments, but was inferior to ablation and transplantation. Conclusions: The majority of patients undergoing resection would not be considered ideal candidates based on current guidelines. Not resecting ideal candidates was associated with higher mortality. The study suggests that selection criteria for resection may be modestly expanded without compromising outcomes, and that some nonideal candidates may still potentially benefit from resection over other treatment modalities. (Hepatology 2015;62:440–451

Predicting recurrence after liver transplantation in patients with hepatocellular carcinoma exceeding the up-to-seven criteria.

The up‐to‐seven (Up‐to‐7) criteria [with 7 being the sum of the size and number of tumors for any given hepatocellular carcinoma (HCC)] have been recently proposed to identify potential candidates for liver transplantation (LT) among patients exceeding the Milan criteria. The aim of this study was to compare the ability of the available pathologic staging systems (the Milan, University of California San Francisco, and Up‐to‐7 criteria) to predict recurrence. A study population of 479 HCC transplanted patients was identified from prospectively collected databases at Mount Sinai Medical Center (New York, NY) and the University of Padua (Padua, Italy). The best pathologic staging system was identified with log rank, proportion separation index (PSEP), and Cox analyses. Pathologic tumor characteristics (tumor number, tumor size, sum of diameters, macroscopic and microscopic vascular invasion, and grading) were then tested by univariate and multivariate Cox analyses in the prognostic subgroups within and beyond the calculated criteria. The Up‐to‐7 criteria performed as the best pathologic staging system, the calculated 1‐, 3‐, and 5‐year recurrence probabilities being 4%, 8%, and 14% within the criteria (n = 355) and 22%, 45%, 51% beyond the criteria (n = 124; P < 0.0001) and the calculated PSEP being 0.27 (95% confidence interval = 0.23‐0.31). In multivariate analysis, only biological variables (vascular invasion and tumor grade) significantly predicted recurrence beyond the Up‐to‐7 criteria. A 3‐stage pathologic staging system with a potential to be applied in the preoperative setting was thus created: within the Up‐to‐7 criteria (recurrence rate = 8%), beyond the Up‐to‐7 criteria without macrovascular invasion and poorly differentiated grade (recurrence rate = 24%), and beyond the Up‐to‐7 criteria with macrovascular invasion and/or poorly differentiated grade (recurrence rate = 45%). In conclusion, HCC patients within the pathologic Up‐to‐7 criteria were associated with a low risk of recurrence after LT. Beyond these criteria, however, a significant proportion of patients with a good HCC biological profile had an acceptable risk of recurrence. Liver Transpl 15:1278–1287, 2009.

Recurrence of hepatocellular cancer after resection: patterns, treatments, and prognosis.

OBJECTIVE We sought to determine the factors associated with survival after recurrence of hepatocellular cancer (HCC) after resection and the outcome of our prospectively applied treatment protocol. BACKGROUND Very little is known about the prognosis of HCC that recurs after resection and the outcomes associated with treatments applied to recurrent tumors. METHODS A total of 661 HCC patients undergoing resection from January 1988 to January 2011 were reviewed to identify those with recurrence. Single recurrences with preserved liver function, and no portal hypertension were treated with resection. Patients with multiple intrahepatic tumors or poor liver function and no major comorbidities were listed for transplantation. Patients with up to 3 tumors, each 4 cm or smaller, and not eligible for transplantation, received ablation. Patients not eligible for ablation received embolization. Other treatments such as systemic therapy and radiation were used in remaining patients, but not in a systematic manner. RESULTS Recurrent HCC developed in 356 (54%) patients at a median time of 22 months from primary resection. Median survival from time of recurrence to death was 21 months. Variables independently associated with survival from recurrence included time from primary resection to recurrence, alpha-fetoprotein more than 100 ng/mL at recurrence, recurrent tumor larger than 3 cm, BCLC stage at recurrence, and type of treatment rendered for the recurrence. All variables except treatment modality were significantly correlated with characteristics of the original primary tumor. CONCLUSIONS Most of the variables associated with outcome after recurrence are linked to the primary tumor at initial presentation. Nevertheless, meaningful survival can be achieved with appropriate treatment of recurrent tumors.

Management and Treatment of Iliopsoas Abscess

HYPOTHESIS Even with improved diagnostic modalities, the optimum management strategy for iliopsoas abscess (IPA) is not uniform, and a better understanding of treatment options is needed. DESIGN Retrospective case series. SETTING Academic center. PATIENTS Sixty-one consecutive patients diagnosed as having IPA at the Mount Sinai Medical Center, New York, New York, from August 1, 2000, to December 30, 2007. MAIN OUTCOME MEASURES Development and cause of IPA, the need for additional interventions, morbidity, and mortality. RESULTS The mean age of the patients was 53 years. Most patients were initially seen with pain (95% [58 of 61]), gastrointestinal tract complaints (43% [26 of 61]), and lower extremity pain (30% [18 of 61]). Primary and secondary abscesses occurred in 11% (7 of 61) and 89% (54 of 61), respectively. The most frequent underlying cause of secondary abscesses was inflammatory bowel disease. Broad-spectrum antibiotics were prescribed in all patients. Computed tomography was the most common diagnostic modality used. Abscesses were larger than 6 cm in 39% of patients (24 of 61), bilateral in 13% (8 of 61), and multiple in 25% (15 of 61). Nine patients were treated using antibiotics alone, with a success rate of 78% (7 of 9). Forty-eight patients initially underwent percutaneous drainage, which was successful in 40% (19 of 48). Among those with unresolved IPAs, 71% of patients ultimately required surgery, and the IPAs were typically associated with underlying gastrointestinal tract causes. Seven percent (4 of 61) of patients directly underwent exploratory surgery and drainage, and all of these interventions were successful. The overall mortality was 5% (3 of 61). CONCLUSIONS Iliopsoas abscess remains a therapeutic challenge. Gastrointestinal tract disease is the most common cause, with computed tomography as the diagnostic modality of choice. Percutaneous drainage remains the initial treatment modality but is rarely the sole therapy required. Patients with inflammatory bowel disease are likely to require ultimate operative management.

Differences in surgical outcomes between hepatitis B- and hepatitis C-related hepatocellular carcinoma: a retrospective analysis of a single North American center.

Objective:Compare surgical outcomes for hepatitis B virus (HBV)-hepatocellular carcinoma (HCC) versus hepatitis C virus (HCV)-hepatocellular carcinoma (HCC). Background:HCC is the second leading cause of death from cancer worldwide and is associated with hepatitis virus infection in 80% of cases. Methods:Between 1997 and 2011, 1008 patients with hepatitis B (HBV, n = 431) or hepatitis C (HCV, n = 577) underwent resection (n = 567) or transplantation (n = 441). Resection was indicated for Childs A patients with single HCC; transplantation was indicated for patients within Milan criteria. Univariate and multivariate analyses were performed as well as survival and recurrence analysis using log-rank test. Results:Based on uniform application of these criteria, resection: transplantation ratio was 3.6 for patients with HBV and 0.67 for patients with HCV. Resection: Patients with HBV had larger tumors and higher &agr;-fetoprotein but less satellites and macrovascular invasion; 68% of HBV versus 89% of HCV were cirrhotic. Survival was better (P < 0.001) and recurrence was lower (P = 0.009) for HBV. Independent predictors of death included HCV (P = 0.024), transfusion (P = 0.013), and HCC of greater than 5 cm (P = 0.013). Limiting analysis to patients with cirrhosis, survival with HBV remained superior (P = 0.020) but recurrence did not. Transplantation: Tumors were similar in HBV and HCV. Survival was better (P = 0.002) for HBV; recurrence was similar. Independent predictors of death were HCV (P < 0.001), poor differentiation (P = 0.049), vascular invasion (P = 0.002), and outside Milan (P = 0.032). Limiting analysis to patients within Milan, HBV survival remained better for both resection (P = 0.030) and transplantation (P = 0.002). Conclusions:Survival after both resection and transplantation for HCC was better in HBV- than in HCV-related HCC whereas recurrence was also lower for HBV-HCC in the resection group, these differences are influenced by both liver and tumor factors.

Hepatic Resection for Primary Hepatolithiasis: A Single-Center Western Experience

BACKGROUND The incidence (0.6% to 1.3%) of primary hepatolithiasis (PHL), also known as Oriental cholangiohepatitis, is increasing in Western countries and the treatment remains challenging. We analyzed the outcomes of patients undergoing hepatic resection (HR) for PHL at a single Western center. STUDY DESIGN The records of all patients undergoing HR for PHL between August 1998 and January 2012 were reviewed. Patients were required to have preserved liver function (Child-Pugh class A) with no evidence of portal hypertension. Diagnosis of disease recurrence was based on radiographic and clinical findings. RESULTS Of the 30 patients who underwent HR, 63.3% presented with earlier failed therapeutic strategies. The majority of the patients were female (63.3%), presented with cholangitis (66.6%), left-sided (66.6%), and unilateral (90.0%) disease, and underwent left-sided hepatic resection (76.6%). Previously created choledochoduodenostomies (13.3%) were all revised into Roux-en-Y hepaticojejunostomy anastomoses in conjunction with the HR. The incidence of concomitant cholangiocarcinoma was 23.3%, with a mean tumor size of 4.2 cm. Perioperative morbidity and mortality rates were 6.6% and 0%, respectively. At a median follow-up of 35 months, all patients had complete intrahepatic stone clearance. One patient required postoperative ERCP. Of the 7 patients with cholangiocarcinoma, 2 had cancer recurrence within the first year of the HR. The remaining patients are disease-free at a median follow-up of 21 months. CONCLUSIONS Hepatic resection is a safe and definitive treatment option in the management of PHL. It achieves excellent short- and long-term results. The high incidence of concomitant cholangiocarcinoma makes a compelling argument for resection of all involved hepatic segments, when possible.

Current management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide and leading cause of death among patients with cirrhosis. Treatment guidelines are based according to the Barcelona Clinic Liver Cancer staging system. The choice among therapeutic options that include liver resection, liver transplantation, locoregional, and systemic treatments must be individualized for each patient. The aim of this paper is to review the outcomes that can be achieved in the treatment of HCC with the heterogeneous therapeutic options currently available in clinical practice.

Laparoscopic Management and Longterm Outcomes of Gastrointestinal Stromal Tumors

BACKGROUND Surgery remains the standard for nonmetastatic gastrointestinal stromal tumors (GISTs). Laparoscopic surgery should be considered for these tumors, because their biologic behavior lends them to curative resection without requiring large margins or extensive lymph-adenectomies. STUDY DESIGN A retrospective review was performed of patients who underwent laparoscopic treatment of GISTs at Mount Sinai Medical Center from 2000 to 2007. Kaplan-Meier method was used for survival analysis. Chi-square analysis was used to identify factors associated with poor outcomes. RESULTS Laparoscopic surgery was attempted in 76 patients. The average age was 66 years, and 39 were men. Forty-two percent of patients presented with gastrointestinal bleeding. Tumors were located in the stomach (72%) and in the small bowel (28%). Mean tumor sizes were 4.2 and 3.9 cm, respectively. Operations included laparoscopic wedge resection (26%), partial gastrectomy (25%), sleeve (9%) gastrectomy, and small bowel resection (22%). Reasons for conversions (14%) were invasion of tumor into adjacent organs, adhesions, proximity to the gastroesophageal junction, large tumor size, or coincidental pathology. There was 1 mortality and a 10% morbidity rate, including an evisceration, obstruction, and pelvic hematoma requiring reoperation. Mean followup was 41 months (range, 3 to 102 months). The overall survival rate was 89%. Gastric and small bowel survival rates were the same (89%). The recurrence rate was 6%. The overall disease-free survival was 78% (77% gastric versus 82% small bowel). Three percent of patients died of metastatic disease. Adjuvant therapy was used on patients initially diagnosed with metastatic disease (n=5) and recurrent disease (n=4). CONCLUSIONS Laparoscopic resection of GISTs is considered safe and effective. The longterm disease-free survival of 78% establishes this minimally invasive approach as comparable to open techniques.

Resection of large hepatocellular carcinoma (≥10 cm): A unique western perspective

Few Western centers have surgically treated a high volume of large hepatocellular carcinoma 10 cm or more in diameter. The study aim was to analyze a large Western cohort of these patients, and to present our outcomes in the context of the more extensive Eastern experience.

Outcomes for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the elderly.

BACKGROUND Cytoreductive surgery (CRS) with heated intraperitoneal chemotherapy (HIPEC) has gained acceptance in the treatment of peritoneal carcinomatosis (PC) with reported morbidity and mortality rates of 27-56% and 0-11% respectively. The safety and outcome of such major operation in the elderly remains unclear. We report our experience at a high volume tertiary center. METHOD A total of 170 consecutive patients underwent CRS-HIPEC for peritoneal carcinomatosis between March 2007 and July 2012. Mitomycin C (88.8%) was administered intraperitoneally at 42 °C for 90 min. Patients were categorized into two groups according to the age at the time of surgery: Group 1 (≤65 years-old) and Group 2 (>65 years-old). Differences between the groups were analyzed. Univariate and multivariate analyses were performed to identify variables associated with major morbidity. RESULTS Of the 170 patients, 35 were older than 65 years. The two most common tumor sites were colorectal and appendiceal cancer. The perioperative morbidity and mortality rates in the elderly were 18.8% and 8.6% respectively. Gender, tumor type, estimated blood loss >400 mL, intraoperative blood transfusion, operative time >6 h, bowel anastomosis, intraoperative PCI >16, and extent of cytoreduction (Δ PCI) were not associated with major morbidity in the older group (p > 0.05). At a median follow-up of 15.7 months (0.2-53.5 months), recurrence rate for colorectal/appendiceal PC at 1 year was 48.0% in Group 1 and 44.3% in Group 2 (p = NS). Median survival for the colorectal/appendiceal carcinomatosis patients in Group 1 (n = 81) was 29.79 (SE 4.7) months and in Group 2 (n = 20) was 21.2 (SE 3.0) months, (p = 0.06, NS). CONCLUSION CRS-HIPEC procedures for peritoneal carcinomatosis in the elderly demonstrate comparable perioperative outcome in well-selected patients. Optimal cytoreduction was achieved in the majority of cases and survival was not significantly different from that of the younger group.