Management of patients with colorectal liver metastasis in eleven questions and answers

Introduction: Colorectal liver metastasis (CRLM) is the most frequent indication for liver resection in many centers. Recent improvements in oncology, surgery, interventional radiology, pathology and anesthesiology allow curative treatment in a larger proportion of patients with CRLM.

Areas covered: We illustrate the various aspects of the management of CRLM through 11 questions that summarize the topic, from the current obtained survival to future perspectives such as transplantation. The limits of a curative treatment are also presented from different angles, such as the benefits of pathology, the surgical options for extreme resections, the available chemotherapies and their efficacy, or the non-surgical ablative treatments.

Expert commentary: Given the increasing therapeutic possibilities, we strengthen the importance to analyze the situation of each patient with CRLM in a dedicated multidisciplinary team, in order to offer the best individualized treatment combination.     

紧贴肝门大血管的肝癌切除术

Objective To study the surgical experience with resection of a hilar liver cancer close to major vessels and how to improve the therapeutic result. Methods From January 1990 to June 1997, 58 hilar liver tumors (segment I, IV, V, VIII) were resected. The tumors in these 58 patients were within a distance of 1 cm to major hepatic vessels (retrothepatic inferior vena cava, root of hepatic veins, and left or right trunk of portal vein). The diameter of the tumors was > 5 cm in 42 cases and < 5 cm in 16 cases, respectively. The size of the largest tumor was 20 cm × 18 cm × 18 cm. The surgical techniques are summarized, and the prevention and treatment of postoperative complications are discussed. Results All operations have been carried out successfully and had a regular follow-up until now with 1−, 3− and 5− year survival rate of 71%, 38% and 25%, respectively. Conclusion While hilar liver surgery is quite difficult and risky, the safety and therapeutic of surgery could be improved by observing a meticulous surgical technique, and by preventing and treating postoperative complications by multimodal measures.     

Features predicting unresectability in hepatoblastoma

BACKGROUND: Approximately 20% of patients who have hepatoblastoma (HB) still have unresectable disease after preoperative chemotherapy (POC). In these circumstances, orthotopic liver transplantation (OLT) should be performed 1 month after POC. The authors sought to identify presenting features that would predict unresectability in patients with HB and to provide suggestions for early referral and listing for OLT. METHODS: Notes, radiology films, and histology from patients who were treated over the previous 20 years were reviewed. Unfeasible resection was defined by bilobar involvement, vascular extension, and metastatic disease after POC. Failed conservative treatment (FCT) was used to categorize patients who were not disease-free with their native liver > or =1 year after surgery. RESULTS: Of 28 patients who were studied, 14 patients underwent resection, and 10 patients required OLT. Four patients did not undergo any type of surgery because of tumor progression. Overall, the 5-year survival rate was 76% (95% confidence interval, 54.8-89%). Predictors of FCT were multifocality (P = .006), a high pretreatment extent of tumor (PRETEXT) score (III or IV; P = .006), portal vein involvement (P = .02), hepatic vein involvement (P = .02), or vena cava involvement (P = .05). Patients who achieved a curative resection presented at a younger age (median, 0.7 years vs 4.2 years, P = .02). Patients who had multifocal lesions and those who had an alpha-fetoprotein (alphaFP) level <100 ng/mL survived only if they underwent transplantation. CONCLUSIONS: Patients with HB who were managed by combined chemotherapy and surgery has a high survival rate. Older patients who had multifocal tumors, high PRETEXT scores, involvement of major liver vessels, and alphaFP levels <100 ng/mL were less likely to achieve curative resection. These findings at presentation should lead the clinicians to liaise early with a transplantation center.     

合并肝硬化肝癌切除术中几个问题的讨论（附335例报告）

１９８６年１月～１９９４年６月切除合并肝硬化的肝癌３３５例，占同期肝癌切除的８８．２％。对术中常遇到的几个基本问题如麻醉的选择，输血的质、量、途径和时间，输液的成分与数量，血流控制的方法及其适应证，切除量的多少，切除的范围，以及合并门静脉高压症的同时治疗等，结合临床资料和文献进行了较详细的讨论，并提出了一些新的见解。     

Preliminary report on surgical technique in hepatic parenchymal transection for liver tumors in the elderly: a lesson learned from living-related liver transplantation

BACKGROUND AND OBJECTIVES: Availability of hi-tech surgical devices has elaborated the technique of parenchymal transection during hepatectomy from classic crushing clamp technique 1,2 to a combination of an ultrasonic dissection with special type of cautery 3,4. We have developed a new technique to resect hepatic parenchyma using an ultrasonic surgical aspirator in association with a monopolar floating ball. This combination has been utilized in 42 liver resections. METHODS: A retrospective analysis of perioperative mortality, length of hospitalization, and blood transfusion during surgery in two patient groups who underwent liver resection was carried out. We divided the patient population into Group A (42 patients), who underwent the new technique, and Group B (107 patients), who experienced the crushing clamp technique. A second analysis was performed, where we divided the same patient population group in Group 1 with age less than 65, and Group 2 including patients older than 65 years. RESULTS: We found that the new technique reduced length of stay, procedure length, and use of perioperative blood. We determined that the two age groups performed similarly in comparison to LOS, length of procedure, blood use, and complications. CONCLUSION: This enforces the fact that the elderly can receive such surgical treatment without hesitation.     

National trends in surgical procedures for hepatocellular carcinoma: 1998-2008

BACKGROUND:

The incidence of hepatocellular carcinoma (HCC) is rising, and the options for surgical therapy of HCC have evolved recently, but use of surgical therapy has not been characterized on a representative, nationwide basis. We quantified trends in use, mortality, and patient and hospital characteristics for 3 surgical therapies for HCC (resection, ablation, and transplantation) in the United States from 1998 to 2008.

METHODS:

Hospital discharge data from the Nationwide Inpatient Sample were used to quantify procedure‐related data for each year. Trends over time were summarized as the average annual percent change (AAPC) and corresponding 95% confidence interval (CI).

RESULTS:

The number of surgical procedures for HCC increased from 1416 to 6769 (AAPC, 13.5%; 95% CI, 10.2%‐16.8%). Volumes increased for all surgical procedures, most notably for ablation (AAPC, 17.3%; 95% CI, 6.6%‐29.2%) and transplantation (AAPC, 20.9%; 95% CI, 14.1%‐28.1%). When analyzed as a proportion of total procedures, there were declines in the relative use of major hepatectomy (35% to 16%; AAPC, ?7.2%, 95% CI, ?8.8% to ?5.6%) and wedge resection (37% to 22%; AAPC, ?4.8%; 95% CI, ?6.2% to ?3.4%), while the proportion accounted for by transplantation increased (16% to 35%; AAPC, 4.4%; 95% CI, 0.2%‐8.9%). Inpatient mortality decreased for each procedure individually and overall from 7.3% to 4.6% (AAPC, ?7.7%; 95% CI, ?10.8% to ?4.5%), despite increasing age and comorbidity burden.

CONCLUSIONS:

The use of surgical therapy for HCC has increased dramatically over the last decade, with a relative shift away from liver resection and toward liver transplantation. These therapeutic modalities must be better targeted to make the most appropriate use of limited health care resources. Cancer 2012;. © 2011 American Cancer Society.     

Hepatic metastasectomy in children

BACKGROUND: There are little data regarding the safety and efficacy of hepatic metastasectomy for solid tumors in childhood. We reviewed our institutional experience to assess operative mortality and morbidity, technique of resection, local control, and survival in pediatric patients undergoing liver resection for metastases. METHODS: All pediatric patients who underwent hepatic resection for metastatic disease from August 1988 to July 2005 were retrospectively identified and clinical data were collected. RESULTS: Fifteen patients were identified during this period and primary malignancies included neuroblastoma (7), Wilms tumor (3), osteogenic sarcoma (2), malignant gastric epithelial tumor (1), and desmoplastic small round cell tumor (2). Twelve patients underwent anatomical hepatic resections and 3 had wedge resections. There were no intraoperative or postoperative deaths. The 2 postoperative complications included 1 wound infection and 1 bile collection. The median follow-up after hepatic resection was 1.6 years (0.2-7 years). Three patients remain alive. Eleven patients died of progressive disease; 4 patients suffered local recurrence. One patient died from enterocolitis and sepsis and was without evidence of malignancy at the time of death. CONCLUSIONS: Hepatic metastasectomy in children is feasible and is associated with a low operative mortality and morbidity. In this small group of patients anatomic hepatectomy was associated with better local control compared with wedge resection. Overall prognosis in these patients remains poor and the decision to perform hepatic metastasectomy should be highly selective.     

肝X受体与肝癌研究进展

原发性肝癌是我国最常见消化系统肿瘤之一,肝癌侵袭性强且复发率高,总体疗效往往不满意。肝X受体(liver X receptors,LXRs)是核受体超家族成员之一,最初发现其参与可调节胆固醇代谢及免疫应答。目前,细胞及分子生物学研究不断深入并取得新的进展,LXR在肝脏疾病尤其是肝癌的发生发展中作用明显,提示LXR是肝癌治疗中潜在的新治疗靶点,为肝癌治疗提供新的思路。     

Mucoepidermoid carcinoma arising from a preexisting cyst of the liver

A case of mucoepidermoid carcinoma of the liver of a 46-year-old female is described. The resected mass from the left lobe of the liver measured 3 X 3 X 2 cm. The cut surface showed a well demarcated white, round shape, and a cystic formation measuring 1.8 X 1.4 cm was present in the center of the mass. Microscopically, the mass showed high-grade-type mucoepidermoid carcinoma, which consisted of squamous cells, mucus-producing cells, and glandular cells. The cystic wall was lined with apparently benign glandular, mucus-producing cells, squamous metaplastic cells, and tumor cells. The tumor was intimately contiguous with the cyst and gradual transition between tumor cells and cystic lining cells was recognized. It is suggested that the mucoepidermoid carcinoma of the liver in the present case was derived from malignant transformation of a preexisting cyst of the liver.     

逆行肝切除治疗难切性肝癌244例报道

目的　逆行肝切除是治疗难切性肝癌的有效方法 ,本文报道了 2 44例临床经验。方法　常规肝切除方法切除困难的 2 44例巨大、显露困难或下腔静脉受累的肝癌采用逆行切肝法结合血管外科技术予以切除 (A组 ) ,同期临床特征类似的 31例肝癌采用常规切肝法切除 ,作为对照 (B组 )。结果　两组均无手术死亡 ,A组与B组相比 ,术中出血量较少 ( 12 90± 998ml比 2 2 86± 136 3ml)、术后胸水发生率 ( 2 6 /2 44比 10 /31)、腹水发生率 ( 72 /2 44比 19/31)、中度到重度黄疸率 ( 14 /2 44比 5 /31)、手术区积液率 ( 17/2 44比 7/31)、膈下感染率 ( 3/2 44比 1/31)、胆漏发生率 ( 2 /2 44比 1/31)、切口感染率 ( 3/2 44比 1/31)以及ALT恢复时间 ( 13.8± 5 .1天比 18.9± 8.9天 )均较低 ,差别具有统计学意义 (P <0 .0 1)。结论　对于难切性肝癌而言 ,逆行肝切除是安全有效的手术方法。     

肝移植治疗原发性肝细胞癌的进展

肝移植已经成为治疗肝癌的重要手段.选择合适的病人是一个重要的问题,国际通行的是米兰标准,我国一般公认的适应证主要包括:合并有肝硬变失代偿、不能接受肝切除治疗的小肝癌患者和肿瘤多发且波及左右两叶、肝功能严重损害、行切除术后肿瘤容易复发或出现肝功能衰竭者.血管侵犯,细胞分化程度等因素可以影响治疗的预后.围手术期辅助治疗(经皮肝动脉化学栓塞、经皮无水酒精瘤内注射、射频消融,氩氦刀治疗)对于提高肝移植的疗效有一定的意义.