Hepatobiliary Surgery JC064: A Large Liver: Liver Cancer Flashcards

Question

Evolution of HCC treatment

Answer 1

1. Open to Laparoscopic liver resection —> Early tumours: Minimally invasive approach 2. Improvement in open surgical techniques due to development of living donor liver transplantation —> Advanced tumours: Transplantation techniques, Complement resections

Answer 2

Resection techniques: 1. Anterior approach 2. Use of automatic vascular staplers 3. Use of energy device (Thunderbeat, Harmonic-ace) Living donor liver transplantation techniques: 1. Control of IVC (isolate liver from IVC) 2. Venoplasty techniques (joining 2 veins together) 3. Haemodynamic control under IVC clamping without veno-venous bypass (important role by anaesthetist) 4. Parenchymal transection with patent inflow (living donor hepatectomy) 5. Understanding of small for size graft (i.e. partial graft) for recipient / remnant liver for donor

Answer 3

ALPPS: Associating Liver Partition and Portal vein Ligation for Staged hepatectomy Indication Major liver resection but ***insufficient future liver remnant (future liver remnant FLR <30%) (i.e. resection >= 3 Couinaud segments) 1. Ligate right portal vein —> allow blood shunted to left liver —> left liver hypertrophy (in 7 days) 2. Remove right liver

Answer 4

1. ***Hep B (80% of HCC in HK) 2. Hep C (predominant in Japan) 3. ***Cirrhosis 4. ***Aflatoxin (fungi: misstorage of food) HBV —(10 years if not cleared)—> Chronic hepatitis —(20 years)—> Cirrhosis —(20-30 years (Cirrhotic nodule —> Dysplastic nodule))—> HCC or HBV —> HCC Epidemiology: - Peak age: 50-70 - M>>F

Answer 5

Macroscopic appearance: 1. ***Massive type - in ***non-cirrhotic liver - in ***younger age group - ***large tumour with adjoining nodules - variegated cut surface 2. ***Nodular type - multiple greyish white, yellow / brown nodules in cirrhotic liver - follow sequence of regeneration nodules —> dysplastic nodules —> ***cirrhosis 3. Diffuse type - least common - indistinguishable from cirrhosis - more associated with HCV pathway

Answer 6

1. Local invasion - ***Portal vein (Intrahepatic metastasis: spread to adjacent segment / contralateral lobe —> surgery resection need to resect all downstream liver segments) - ***Hepatic vein - ***Bile duct 2. Lymphatic spread - 1/4 of patients 3. Transperitoneal spread - Rare 4. Haematogenous spread - Lung - Bone

Answer 7

Tumour: 1. Subclinical (majority) 2. ***Vague epigastric distension 3. Abdominal mass (usually 10cm before can be felt (stage T3: >5cm)) 4. ***Paraneoplastic syndrome - Diarrhoea (vasoactive intestinal peptide) - Hypoglycaemia (impaired gluconeogenesis) - Hyperglycaemia (impaired glycogenesis) - Hypercalcaemia (PTH-rP) - Polycythaemia (Erythropoietin) 5. Weight loss Cirrhosis: 6. ***Ascites (∵ decompensated cirrhosis / occlusion of portal vein by tumour thrombus / external tumour compression) 7. ***GI bleeding (variceal bleeding from cirrhosis portal hypertension, stress ulcer formation due to portal vein tumour thrombosis) Complications: 8. ***Secondaries in lung, bone (e.g. cough, bone pain, but usually detected by PET scan) 9. ***Sharp pain due to bleeding (Tumour rupture)

Answer 8

Surgical treatment: 1. Partial hepatectomy 2. Liver transplantation (after total hepatectomy) Locoregional treatment: 3. Local ablative therapy (RFA / Microwave) (realisable, predictable, repeatable) (still Curative intent) 4. Transarterial oily chemoembolisation (TACE) (2nd line) 5. Percutaneous intralesional alcohol injection (largely replaced by Local ablative therapy)

Answer 9

1. Patient factor: ***General status - Age (not a CI to surgery) - Concomitant medical disease - Hidden medical disease (e.g. CVS disease) —> ***ECG, Spirometry, Astrup (ABG), Glucose, RFT etc. —> Aim to define whether the patient is fit for GA 2. Patient factor: ***Liver function status - Clinical examination (signs of liver decompensation) - Liver biochemistry (Albumin, Bilirubin) - PT - Platelet - ***Child-Pugh classification (anything beyond Child A —> risky for major liver resection) - ***ICG clearance test (>14% remaining after 15 mins —> cannot tolerate major liver resection) —> Aim to define whether liver function is sufficient for the patient to tolerate hepatectomy 3. Disease factor: ***Tumour status - USG (only for screening) - CT (provide better spatial resolution than MRI, ∵ short scanning time —> no need to hold breath) - MRI - +/- Hepatic arteriography (Angiography, obsolete, ∵ invasive, replaced by CT angiogram) - CXR (lung metastasis) - PET scan (FDG + C-11 acetate) —> Aim to define whether tumour still confined to one side of liver / whether technically feasible to resect / classify tumour, study anatomy before planning of surgery 4. Surgeon factor Surgery (Laparoscopy / Laparotomy) can be done if: 1. General condition is good 2. Liver function is satisfactory 3. Tumour is confined to one lobe

Answer 10

FDG: - longer t1/2, easier to prepare - good accuracy in CRC but poor sensitivity in HCC (∵ different cell type: well differentiated / moderately differentiated / poorly differentiated HCC —> only poorly differentiated is easily detected by FDG) C-11 acetate: - short t1/2 (~30 mins), harder to prepare - high sensitivity

Answer 11

Stage 1: <2cm Stage 2: 2-5cm Stage 3: >5cm Stage 4: Extrahepatic spread

Answer 12

Indications: 1. ***Unilobar involvement 2. ***No invasion into IVC / Portal vein 3. Acceptable liver function for major hepatectomy - ***Child A - ***ICG retention 15 min <14% 4. No severe chronic medical illness - Mortality rate 5% - Morbidity rate 30% - Hepatectomy can offer cure and is associated with a 5-year survival of 50%

Answer 13

1. Liver remnant (80%) 2. Extra-hepatic (50%) 3. Both (5-10%)

Answer 14

Now mainstream in small HCC 1. Pneumoperitoneum can compress on surface of hepatic vein —> less bleeding 2. New instruments for liver resection —> Clips and staplers 3. Laparoscopic CUSA 4. High definition monitor Result: - Less bleeding - Comparable survival to open resection

Answer 15

Treat both HCC + Cirrhosis at the same time Indications: 1. Tumour <5cm single / <3cm up to 3 nodules (***Milan criteria) 2. ***Child C cirrhosis

Answer 16

Indications: 1. ***Tumour <5cm 2. Satisfactory liver function reserve 3. ***CI to Laparoscopic / Open approach for HCC near to viscera - Localised thermal treatment technique (Percutaneous / Open approach) - RFA / Microwave (HIFU) - Replacing Percutaneous intralesional alcohol injection - Heating tumour cells to 45-50oC for >3 mins causes ***protein denaturation + irreversible cell damage - Induces tumour destruction by heating tumour tissue to temp >60oC —> if up to ~70oC —> soot formation —> insulator of heat —> prevent dissipation of heat —> Cool-tip RF system using disposable electrodes (17G) - USG / CT-guidance for introduction of electrodes + monitoring of ablation process HIFU: - ~Magnifying glass - Oscillatory energy at focal point —> Coagulation necrosis - USG energy transmitted through high density medium (e.g. water) —> patient put in waterbath RFA vs HIFU: - Similar effectiveness + survival benefit RFA: - Adhesion in subsequent operation - Needle track - ***CI in patients with ascites - Ablation volume not as precise HIFU: - No adhesion in subsequent operation - No needle track - ***Favourable in patients with ascites - Precise localisation, little collateral damage

Answer 17

Purpose: 1. ***Palliative intention (TACE cannot kill all cancer cells) 2. Augment liver remnant for future hepatectomy Indications: 1. ***Bilobar involvement without distant spread, without complete portal vein obstruction / IVC involvement 2. ***Unilobar involvement but liver function not acceptable for hepatectomy / RFA Puncture femoral artery —> Catheter into hepatic artery —> Cisplatin + Lipiodol emulsion mixture to tumour (cell membrane of tumour absorb Lipiodol —> take in Cisplatin) —> Block feeding vessel by Gelfoam (block blood supply —> ischaemia) Complications (Felix Lai): 1. Post-embolisation syndrome (most common) (60-80%) - Due to hepatocytes + tumour necrosis and ischemic damage to normal liver parenchyma - Fever, N+V, abdominal pain, deranged LFT with ↑ AST/ALT (2:1) transiently for ***1-2 days - Full recovery is typically within 7-10 days - Cover with antibiotics but should perform USG to exclude ***liver abscess if symptoms persist for 1 week 2. ***Liver failure (Hepatic decompensation) (most serious) (20-30%) - Treatment-induced ischemic damage to non-tumour bearing liver is responsible for precipitating or exacerbating liver failure - Usually reversible but it may be irreversible in 2% of cases - Clinically suspected by ↑ ***bilirubin + ↑ ***PT (INR) 3. Ischaemic ulceration (due to disturbed GI blood supply) - Gastritis / Cholecystitis / Pancreatitis - ***Acalculous cholecystitis due to damage to the cholecystic artery

Answer 18

Indications: 1. ***Tumour <3cm 2. ***Tumour number <3 - Need to ***repeat 3-5 times before see effect - Ethanol induce ***dehydration + ***coagulation necrosis of cancer cells —> fibrotic degeneration

Answer 19

Previously used: 1. Chemotherapy (Doxorubicin) 2. Hormonal therapy (Tamoxifen, Octreotide) 3. Immunotherapy (IFN) - None proven to give survival benefit Current: 1. ***Sorafenib (Molecular targeting drug: RAF kinase + VEGF receptor) - currently only approved drug for HCC - prolong survival for 3 months in clinical trials 2. ***Anti-PD1 / PDL1 - new in 2020

Answer 20

Suspicion of HCC rupture (abdominal pain, pallor, history of Hep B/C, history of HCC, screening USG result) —> Diagnosis of HCC rupture by ***contrast CT —> No ongoing blood loss —> ***Conservative management —> Ongoing blood loss —> Haemodynamically unstable for TACE (TAE?) —> ***Surgical intervention —> Haemodynamically stable for TACE (TAE?) —> ***TACE (TAE?) —> Successful haemostasis —> Work-up for definitive treatment —> Unsuccessful haemostasis —> ***Surgical intervention Surgical intervention: 1. ***Ligation of hepatic artery (associated with risk of liver failure) + Hepatectomy 2. ***RFA in open approach (stop bleeding by coagulation + treat cancer) —> less risky in a shock patient + much better survival