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Strand MS, Iannitti DA. HPB ultrasound guidance techniques - Targeting. Surg Open Sci 2024; 19:50-62. [PMID: 38585037 PMCID: PMC10995864 DOI: 10.1016/j.sopen.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/08/2024] [Accepted: 02/28/2024] [Indexed: 04/09/2024] Open
Abstract
Ultrasound is an indispensable tool for intraoperative assessment and treatment of hepatopancreatobiliary pathology. As minimally invasive approaches to HPB surgery continue to expand and the benefits of parenchymal-sparing liver surgery are increasingly appreciated, skillful targeting will play an even bigger role in HPB surgical practice. Techniques for intraoperative targeting of liver lesions for the purposes of biopsy and ablation, particularly in the laparoscopic setting, are the focus of this chapter. Current evidence supports the use of ablation for a variety of liver lesions including hepatocellular carcinoma and metastatic colorectal cancer, particularly for smaller lesions. Successful targeting requires optimization of patient position and port placement. When targeting multiple lesions, thoughtful treatment sequencing is critical to maintaining visualization and optimizing outcomes.
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Affiliation(s)
- Matthew S. Strand
- Department of Surgery, Division of Hepatopancreatobiliary Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David A. Iannitti
- Department of Surgery, Division of Hepatopancreatobiliary Surgery, Carolinas Medical Center, Charlotte, NC, USA
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Trevisani F, Vitale A, Kudo M, Kulik L, Park JW, Pinato DJ, Cillo U. Merits and boundaries of the BCLC staging and treatment algorithm: Learning from the past to improve the future with a novel proposal. J Hepatol 2024; 80:661-669. [PMID: 38266658 DOI: 10.1016/j.jhep.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/03/2023] [Accepted: 01/04/2024] [Indexed: 01/26/2024]
Abstract
In this Expert Opinion, we thoroughly analyse the Barcelona Clinic Liver Cancer (BCLC) staging and treatment algorithm for hepatocellular carcinoma (HCC) that, since 1999, has standardised HCC management, offering a structured approach for the prognostic evaluation and treatment of patients with HCC. The first part of the article presents the strengths and evolutionary improvements of the BCLC staging system. Nevertheless, both patient characteristics and available treatments have changed in the last two decades, limiting the role of the BCLC criteria for treatment allocation in a growing number of patients. As therapeutic options expand and become more effective, the stage-linked treatment decision-making algorithm may lead to undertreatment and suboptimal outcomes for patients with disease beyond early-stage HCC. Consequently, strict adherence to BCLC criteria is limited in expert centres, particularly for patients diagnosed beyond early-stage HCC. Although the BCLC system remains the benchmark against which other therapeutic frameworks must be judged, the era of precision medicine calls for patient-tailored therapeutic decision-making (by a multidisciplinary tumour board) rather than stage-dictated treatment allocation. Acknowledging this conceptual difference in clinical management, the second part of the article describes a novel "multiparametric therapeutic hierarchy", which integrates a comprehensive assessment of clinical factors, biomarkers, technical feasibility, and resource availability. Lastly, considering the increasing efficacy of locoregional and systemic treatments, the concept of "converse therapeutic hierarchy" is introduced. These treatments can increase the feasibility (conversion approach) and effectiveness (adjuvant approach of systemic therapy) of potentially curative approaches to greatly improve clinical outcomes.
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Affiliation(s)
- Franco Trevisani
- Unit of Semetiotics, Liver and Alcohol-related Disease, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Units of Semetiotics, Liver and Alcohol-related disease, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Alessandro Vitale
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy.
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
| | | | - Joon-Won Park
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea
| | - David J Pinato
- Department of Surgery & Cancer, Imperial College London, London, UK; Division of Oncology, Department of Translational Medicine (DIMET), The University of Piemonte Orientale "A. Avogadro", Novara, Italy
| | - Umberto Cillo
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
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Senzolo M, Shalaby S, Grasso M, Vitale A, Pizzirani E, Barbiero G, Zanetto A, Feltracco P, Simioni P, Burra P, Cillo U. Role of nonneoplastic PVT in the natural history of patients with cirrhosis and first diagnosis of HCC. Hepatology 2024; 79:355-367. [PMID: 37505218 DOI: 10.1097/hep.0000000000000538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 07/01/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND AND AIMS HCC can increase the risk of nonneoplastic PVT in cirrhosis. However, the natural history of PVT and its prognostic role in HCC patients are unknown. APPROACH AND RESULTS Consecutive HCC patients with cirrhosis undergoing laparoscopic ablation were retrospectively evaluated and followed up to 36 months. HCC and PVT characteristics and evolution were reviewed. PVT was categorized according to lumen occupancy (≤50%, >50% <100%, and = 100%) and extension to other veins. The evolution of thrombosis was considered at 1 year from diagnosis. Variables associated with the presence of PVT and evolution patterns were analyzed, as well as their impact on survival. In all, 750 patients were included, 88 of whom had PVT. On multivariate analysis, the occurrence of PVT at HCC diagnosis was associated with pretreatment total tumor volume ( p < 0.001) and clinically significant portal hypertension ( p = 0.005). During the follow-up, 46 de novo PVT occurred, 27/46 (58.7%) in the presence of a viable tumor. Among 115 PVT diagnosed in the presence of HCC, 83 had available radiological follow-up, and 22 were anticoagulated. The "complete/progressive" evolution pattern was associated with nonresponse to HCC treatment in non-anticoagulated patients. The presence of PVT was independently associated with lower overall survival, particularly when progressive or occlusive ( p < 0.001). A higher competing risk of death emerged for "complete and progressive" PVT, both for HCC-related ( p < 0.001) and non-HCC-related ( p = 0.002) death. CONCLUSIONS HCC represents an independent risk factor for the occurrence and progression of PVT in cirrhosis. Since progressive and occlusive PVT seems to be an independent factor associated with mortality, screening and prompt treatment of this complication should be considered.
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Affiliation(s)
- Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Sarah Shalaby
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Marco Grasso
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Alessandro Vitale
- General Surgery 2-Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Padova University Hospital, Padova, Italy
| | - Enrico Pizzirani
- Institute of Radiology, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Giulio Barbiero
- Institute of Radiology, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Alberto Zanetto
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Paolo Feltracco
- Anesthesiology and Intensive Care in Complex Surgery and Transplantology, Padova University Hospital, Padova, Italy
| | - Paolo Simioni
- General Internal Medicine, Hemorrhagic and Thrombotic Diseases Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Umberto Cillo
- General Surgery 2-Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Padova University Hospital, Padova, Italy
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Muglia R, Marra P, Pinelli D, Dulcetta L, Carbone FS, Barbaro A, Celestino A, Colledan M, Sironi S. Technical and Clinical Outcomes of Laparoscopic-Laparotomic Hepatocellular Carcinoma Thermal Ablation with Microwave Technology: Case Series and Review of Literature. Cancers (Basel) 2023; 16:92. [PMID: 38201536 PMCID: PMC10778313 DOI: 10.3390/cancers16010092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/21/2023] [Accepted: 12/23/2023] [Indexed: 01/12/2024] Open
Abstract
PURPOSE To evaluate technical and clinical outcomes of intraoperative (laparoscopic/laparotomic) microwave ablation on HCC. MATERIALS AND METHODS This is a retrospective single-center study evaluating consecutive patients treated for very early/early-stage HCC with intraoperative microwave ablation from 1 July 2017 to 30 June 2023. In these patients, a percutaneous US-guided approach was excluded due to the nodule's suboptimal visibility or harmful location and liver resection for a deep position or adherences. Data about the clinical stage, surgical approach, liver pathology and nodules characteristics, technical success, complications, and follow-up were collected. Technical success was intended as the absence of locoregional persistence at follow-up CT/MRI controls. RESULTS A total of 36 cirrhotic patients (M:F = 30:6, median age 67 years) were enrolled; 18/36 (50%) had a single nodule, 13/36 (36%) had two, 4/36 had three (11%), and 1/36 had four (3%). Among the patients, 24 (67%) were treated with laparoscopy, and 12/36 (33%) with a laparotomic approach. Sixty HCCs of 16.5 mm (6-50 mm) were treated for 7 min (2-30 min) with 100 W of power. A total of 55 nodules (92%) were treated successfully and showed no residual enhancement at the first postoperative follow-up; the other 5/60 (8%) underwent chemo/radioembolization. There was one complication (3%): a biliary fistula treated with percutaneous drainage and glue embolization. The average hospital stay was 3.5 days (1-51 days), and patients were followed up on average for 238 days (13-1792 days). During follow-up, 5/36 patients (14%) underwent liver transplantation, 1/36 (2%) died during hospitalization and 1 after discharge. CONCLUSIONS Laparoscopic/laparotomic intraoperative HCC MW ablation is feasible in patients unsuitable for percutaneous approach or hepatic resection, with rare complications and with good technical and clinical outcomes.
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Affiliation(s)
- Riccardo Muglia
- Department of Radiology, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (P.M.); (L.D.); (F.S.C.)
- School of Medicine, University of Milano-Bicocca, 20126 Milano, Italy (A.C.)
| | - Paolo Marra
- Department of Radiology, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (P.M.); (L.D.); (F.S.C.)
- School of Medicine, University of Milano-Bicocca, 20126 Milano, Italy (A.C.)
| | - Domenico Pinelli
- Department of General Surgery, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (D.P.); (M.C.)
| | - Ludovico Dulcetta
- Department of Radiology, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (P.M.); (L.D.); (F.S.C.)
| | - Francesco Saverio Carbone
- Department of Radiology, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (P.M.); (L.D.); (F.S.C.)
| | - Alessandro Barbaro
- School of Medicine, University of Milano-Bicocca, 20126 Milano, Italy (A.C.)
| | - Antonio Celestino
- School of Medicine, University of Milano-Bicocca, 20126 Milano, Italy (A.C.)
| | - Michele Colledan
- Department of General Surgery, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (D.P.); (M.C.)
| | - Sandro Sironi
- Department of Radiology, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (P.M.); (L.D.); (F.S.C.)
- School of Medicine, University of Milano-Bicocca, 20126 Milano, Italy (A.C.)
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Vitale A, Cabibbo G, Iavarone M, Viganò L, Pinato DJ, Ponziani FR, Lai Q, Casadei-Gardini A, Celsa C, Galati G, Gambato M, Crocetti L, Renzulli M, Giannini EG, Farinati F, Trevisani F, Cillo U. Personalised management of patients with hepatocellular carcinoma: a multiparametric therapeutic hierarchy concept. Lancet Oncol 2023; 24:e312-e322. [PMID: 37414020 DOI: 10.1016/s1470-2045(23)00186-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/07/2023] [Accepted: 04/20/2023] [Indexed: 07/08/2023]
Abstract
Advances in the surgical and systemic therapeutic landscape of hepatocellular carcinoma have increased the complexity of patient management. A dynamic adaptation of the available staging-based algorithms is required to allow flexible therapeutic allocation. In particular, real-world hepatocellular carcinoma management increasingly relies on factors independent of oncological staging, including patients' frailty, comorbid burden, critical tumour location, multiple liver functional parameters, and specific technical contraindications impacting the delivery of treatment and resource availability. In this Policy Review we critically appraise how treatment allocation strictly based on pretreatment staging features has shifted towards a more personalised treatment approach, in which expert tumour boards assume a central role. We propose an evidence-based framework for hepatocellular carcinoma treatment based on the novel concept of multiparametric therapeutic hierarchy, in which different therapeutic options are ordered according to their survival benefit (ie, from surgery to systemic therapy). Moreover, we introduce the concept of converse therapeutic hierarchy, in which therapies are ordered according to their conversion abilities or adjuvant abilities (ie, from systemic therapy to surgery).
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Affiliation(s)
- Alessandro Vitale
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy.
| | - Giuseppe Cabibbo
- Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, Gastroenterology & Hepatology Unit, University of Palermo, Palermo, Italy.
| | - Massimo Iavarone
- Division of Gastroenterology and Hepatology, Foundation Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Luca Viganò
- Hepatobiliary Unit, Department of Minimally Invasive General & Oncologic Surgery, Humanitas Gavazzeni University Hospital, Bergamo, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - David J Pinato
- Department of Surgery & Cancer, Imperial College London, London, UK; Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Francesca Romana Ponziani
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, Azienda Ospedaliero-Universitaria Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Andrea Casadei-Gardini
- Department of Oncology, Istituto di Ricovero Cura a Carattere Scientifico San Raffaele Scientific Institute Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Ciro Celsa
- Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, Gastroenterology & Hepatology Unit, University of Palermo, Palermo, Italy; Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Giovanni Galati
- Unit of Clinical Medicine and Hepatology, University Campus Bio-Medico, Rome, Italy
| | - Martina Gambato
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Laura Crocetti
- Department of Radiology and Interventional Radiology, University of Pisa, Pisa, Italy
| | - Matteo Renzulli
- Department of Radiology, Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genova, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Policlinico San Martino, Genova, Italy
| | - Fabio Farinati
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Franco Trevisani
- Unit of Semeiotics, Liver and Alcohol-related diseases, Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Umberto Cillo
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
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Textbook Outcome of Laparoscopic Microwave Ablation for Hepatocellular Carcinoma. Cancers (Basel) 2023; 15:cancers15020436. [PMID: 36672385 PMCID: PMC9856576 DOI: 10.3390/cancers15020436] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/28/2022] [Accepted: 01/07/2023] [Indexed: 01/11/2023] Open
Abstract
In the context of spreading interest in textbook outcome (TO) evaluation in different fields, we aimed to investigate an uncharted procedure, that is, laparoscopic microwave ablation (MWA) for hepatocellular carcinoma (HCC). Absence of post-MWA complications, a hospital stay of three days, no mortality nor readmission within 30 days, and complete response of the target lesion at post-MWA CT scan defined TO achievement. Patients treated between January 2014 and March 2021 were retrospectively reviewed, and of the 521 patients eligible for the study, 337 (64.7%) fulfilled all the quality indicators to achieve the TO. The absence of complications was the main limiting factor for accomplishing TO. At multivariable analysis, Child-Pugh B cirrhosis, age of more than 70 years old, three nodules, and MELD score ≥ 15 were associated with decreased probabilities of TO achievement. A score based on these factors was derived from multivariable analysis, and patients were divided into three risk groups for TO achievement. At survival analysis, overall survival (OS) was significantly (p = 0.001) higher in patients who achieved TO than those who did not. Moreover, OS evaluation in the three risk groups showed a trend coherent with TO achievement probability. The present study, having assessed the first TO for laparoscopic MWA for HCC, encourages further broader consensus on its definition and, on its basis, on the development of clinically relevant tools for managing treatment allocation.
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Finotti M, D’Amico FE, Romano M, Brizzolari M, Scopelliti M, Zanus G. Colorectal Liver Metastases: A Literature Review of Viable Surgical Options with a Special Focus on Microwave Liver Thermal Ablation and Mini-Invasive Approach. J Pers Med 2022; 13:jpm13010033. [PMID: 36675694 PMCID: PMC9866288 DOI: 10.3390/jpm13010033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/28/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
Colorectal cancer (CRC) is the third most common tumor worldwide and it is characterized in 20-30% of cases by liver involvement, which strongly affects the long-term patient outcome. There are many available therapies for liver colorectal metastases (CRLMs); the current standard of care is represented by liver resection, and when feasible, associated with systemic chemotherapy. Microwave thermal ablation (MWA) is a viable option in unresectable patients or to achieve treatment with a parenchymal spearing approach. A literature review was performed for studies published between January 2000 and July 2022 through a database search using PUBMED/Medline and the Cochrane Collaboration Library with the following MeSH search terms and keywords: microwave, ablation, liver metastases, colorectal neoplasm, and colon liver rectal metastases. The recurrence rate and overall patients' survival were evaluated, showing that laparoscopic MWA is safe and effective to treat CRLMs when resection is not feasible, or a major hepatectomy in fragile patients is necessary. Considering the low morbidity of this procedure, it is a viable option to treat patients with recurrent diseases in the era of effective chemotherapy and multimodal treatments.
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Affiliation(s)
- Michele Finotti
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy
- Baylor Scott & White Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical, Dallas, TX 75204, USA
- Correspondence:
| | | | - Maurizio Romano
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy
| | - Marco Brizzolari
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy
| | - Michele Scopelliti
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy
| | - Giacomo Zanus
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy
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Zanus G, Tagliente G, Rossi S, Bonis A, Zambon M, Scopelliti M, Brizzolari M, Grossi U, Romano M, Finotti M. Pulsed Microwave Liver Ablation: An Additional Tool to Treat Hepatocellular Carcinoma. Cancers (Basel) 2022; 14:cancers14030748. [PMID: 35159014 PMCID: PMC8833939 DOI: 10.3390/cancers14030748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/26/2022] [Accepted: 01/29/2022] [Indexed: 12/15/2022] Open
Abstract
Simple Summary Hepatocellular carcinoma (HCC) is the seventh most frequent neoplasm and the second most common oncologic cause of death, mostly in patients with end-stage liver disease. HCC treatment is complex and different solutions are available, ranging from liver transplants to local therapies. In this study, we analyze the role of pulsed microwave liver ablation as an additional treatment option. Abstract This study aimed to analyze the outcomes of HCC patients treated with a novel technique—pulsed microwave ablation (MWA)—in terms of safety, local tumor progression (LTP), intrahepatic recurrence (IHR), and overall survival (OS). A total of 126 pulsed microwave procedures have been performed in our center. We included patients with mono- or multifocal HCC (BCLC 0 to D). The LTP at 12 months was 9.9%, with an IHR rate of 27.8% at one year. Survival was 92.0% at 12 months with 29.4% experiencing post-operative complications (28.6% Clavien–Dindo 1–2, 0.8% Clavien–Dindo 3–4). Stratifying patients by BCLC, we achieved BCLC 0, A, B, C, and D survival rates of 100%, 93.2%, 93.3%, 50%, and 100%, respectively, at one year, which was generally superior to or in line with the expected survival rates among patients who are started on standard treatment. The pulsed MWA technique is safe and effective. The technique can be proposed not only in patients with BCLC A staging but also in the highly selected cases of BCLC B, C, and D, confirming the importance of the concept of stage migration. This procedure, especially if performed with a minimally invasive technique (laparoscopic or percutaneous), is repeatable with a short postoperative hospital stay.
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Affiliation(s)
- Giacomo Zanus
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
| | - Giovanni Tagliente
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
| | - Serena Rossi
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
| | - Alessandro Bonis
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
| | - Mattia Zambon
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
| | - Michele Scopelliti
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
| | - Marco Brizzolari
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
| | - Ugo Grossi
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
| | - Maurizio Romano
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
| | - Michele Finotti
- 4th Surgery Unit, Regional Hospital Treviso, University of Padua, DISCOG, 31100 Padua, Italy; (G.Z.); (G.T.); (S.R.); (A.B.); (M.Z.); (M.S.); (M.B.); (U.G.); (M.R.)
- Baylor Scott & White Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX 75204, USA
- Correspondence:
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Local control of hepatocellular carcinoma and colorectal liver metastases after surgical microwave ablation without concomitant hepatectomy. Langenbecks Arch Surg 2021; 406:2749-2757. [PMID: 34076718 DOI: 10.1007/s00423-021-02219-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/27/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE Microwave ablation (MWA) is an accepted technique in the multimodal treatment of hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM). Study endpoints were to evaluate the local efficacy of surgical MWA in selected patients with oligonodular disease without the combination of liver resection to allow a clear interpretation of the follow-up imaging and compare it to the results on percutaneous MWA available in the literature. METHODS Consecutive MWA-only procedures performed between May 2013 and May 2018 for HCC and CRLM with free-hand ultrasound guidance were identified. MWA systems with 2450 MHz were used. Incomplete ablation (IA) was defined as residual disease within 1 cm of the ablation site at the first post-ablation imaging and local recurrence (LR) as the presence of disease after at least one tumor-free imaging. RESULTS A total of 70 tumors in 47 patients were treated with 46 laparoscopic and 1 open procedures. Each patient had no more than 3 tumors, and median size of the lesions was 15 mm (IQR: 10-22). After a median follow-up of 26 months (IQR: 12-40), IA rate was 8.6% and LR rate was 29.4%. Multivariable analysis showed that vascular proximity (OR = 3.4; 95% CI = 1.26-9.22; p=0.016) was the only significant predictor of the combined outcome IA or LR. DISCUSSION In the present study, after mostly laparoscopic MWA, LR was higher than the rates available in the literature for percutaneous MWA of HCC but lower than in the limited studies analyzing isolated percutaneous MWA of liver metastases. Future developments may help establish the role of each therapeutic modality per tumor, in order to improve the outcomes.
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Borghi E, Tognon C, Marchini A, Virgone C, Cillo U, Gamba P. Videolaparoscopic MicroWave Ablation: An innovative technique to treat pancreatoblastoma liver metastases in children. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2021. [DOI: 10.1016/j.epsc.2021.101876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Sustained Complete Response after Biological Downstaging in Patients with Hepatocellular Carcinoma: XXL-Like Prioritization for Liver Transplantation or "Wait and See" Strategy? Cancers (Basel) 2021; 13:cancers13102406. [PMID: 34067521 PMCID: PMC8156031 DOI: 10.3390/cancers13102406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/22/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary The XXL trial has recently shown that biological downstaging is an effective strategy to also allow liver transplantation into patients with more advanced hepatocellular carcinoma without alternative curative options. Some potential limits of the XXL downstaging protocol are (a) the rather high downstaging failure rate (i.e., 32%), and (b) the additional prioritization of transplantation for patients with a potential good prognosis without transplant, i.e., those obtaining a complete response to downstaging. In this study, we showed that, using aggressive surgical downstaging, it is possible to considerably decrease the downstaging failure rate. Moreover, we showed that it is possible to avoid an immediate prioritization of transplantation for patients with a sustained complete response to downstaging by applying a “wait and see” policy. This policy seems to spare a relevant number of organs without worsening patient outcome. Abstract The XXL trial represents the first prospective validation of “biological downstaging” in liver transplantation (LT) for hepatocellular carcinoma. The aim of this study was to compare the Padua downstaging protocol to the XXL protocol in terms of downstaging failure rates and patient outcome. A total of 191 patients undergoing aggressive surgical downstaging and potentially eligible for LT from 2012 to 2018 at our center were retrospectively selected according to XXL trial criteria. Unlike the XXL trial, patients with a complete response to downstaging did not receive any prioritization for LT. Downstaging failure was defined as stable progressive disease or post-treatment mortality. The statistical method of “matching-adjusted indirect comparison” was used to match the study group to the XXL population. Downstaging failure rate was considerably lower in the study group than in the XXL trial (12% vs. 32%, d value = |0.683|). The survival curves of our LT group (n = 68) overlapped with those of the LT-XXL group (p = 0.846). Survival curves of non-LT candidates with a sustained complete response (n = 64) were similar to those of transplanted patients (p = 0.281). Our study represents a validation of the current Padua and Italian policies of denying rapid prioritization to patients with complete response to downstaging. Such a policy seems to spare organs without worsening patient outcome.
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Santambrogio R, Barabino M, D'Alessandro V, Iacob G, Opocher E, Gemma M, Zappa MA. Micronvasive behaviour of single small hepatocellular carcinoma: which treatment? Updates Surg 2021; 73:1359-1369. [PMID: 33821430 DOI: 10.1007/s13304-021-01036-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 03/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Microinvasion (MI), defined as infiltration of the portal or hepatic vein or bile duct and intrahepatic metastasis are accurate indicators of a poor prognosis for mall hepatocellular carcinomas (HCC). A previous study showed that intraoperative ultrasound (IOUS) definition of MI-HCC had a high concordance with histological findings. Aim of this study is to evaluate overall survival and recurrence patterns of patients with MI-HCC submitted to hepatic resection (HR) or laparoscopic ablation therapies (LAT). METHODS A total of 171 consecutive patients (78 h; 93 LAT) with single, small HCC (< 3 cm) with a MI pattern at IOUS examination were compared analyzing overall survival and recurrence patterns using univariate and multivariate analysis and weighting by propensity score. RESULTS Overall recurrences were similar in the 2 groups (HR: 51 patients (65%); LAT: 66 patients (71%)). The rate of local tumor progression in the HR group was very low (5 pts; 6%) in comparison to LAT group (22 pts; 24%; p = 0.002). The overall survival curves of HR are significantly better than that of the LAT group (p = 0.0039). On the propensity score Cox model, overall mortality was predicted by the surgical treatment with a Hazard ratio 1.68 (1.08-2.623) (p = 0.022). CONCLUSIONS If technically feasible and in patients fit for surgery, HR with an adequate tumor margin should be preferred to LAT in patients with MI-HCC at IOUS evaluation, to eradicate MI features near the main nodule, which are relatively frequent even in small HCC (< 3 cm).
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Affiliation(s)
- Roberto Santambrogio
- ASST Fatebenefratelli Sacco, Chirurgia Generale Ospedale Fatebenefratelli, Piazza Principessa Clotilde 3, 20121, Milano, Italy.
| | - Matteo Barabino
- Chirurgia Epato-Bilio-Pancreatica Ospedale San Paolo Università Di Milano, Milano, Italy
| | - Valentina D'Alessandro
- ASST Fatebenefratelli Sacco, Chirurgia Generale Ospedale Fatebenefratelli, Piazza Principessa Clotilde 3, 20121, Milano, Italy
| | - Giulio Iacob
- ASST Fatebenefratelli Sacco, Chirurgia Generale Ospedale Fatebenefratelli, Piazza Principessa Clotilde 3, 20121, Milano, Italy
| | - Enrico Opocher
- Chirurgia Epato-Bilio-Pancreatica Ospedale San Paolo Università Di Milano, Milano, Italy
| | - Marco Gemma
- Anestesia E Rianimazione Ospedale Fatebenefratelli, Milano, Italy
| | - Marco Antonio Zappa
- ASST Fatebenefratelli Sacco, Chirurgia Generale Ospedale Fatebenefratelli, Piazza Principessa Clotilde 3, 20121, Milano, Italy
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Cillo U, Finotti M, Di Renzo C, Vitale A, Zanus G, Gringeri E, Bertacco A, Polacco M, D'Amico F. Thoracoscopic Ablation of Critically Located Liver Tumors: A Safety and Efficacy Cohort Study. Front Surg 2021; 8:626297. [PMID: 33816545 PMCID: PMC8010311 DOI: 10.3389/fsurg.2021.626297] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/15/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Liver resection represents the first curative treatment to treat primary and secondary hepatic tumors. Thoracoscopic liver ablation is a viable and minimally invasive alternative treatment, especially for patients with previous multiple abdominal surgeries. The aim of the study was to evaluate the safety and efficacy of thoracoscopic ablation for liver tumors. Methods: Retrospective analysis of a prospective database of patients with liver tumors, treated with thoracoscopic trans-diagrammatic ablation (MWA or RFA) at our institution from 2012 to 2018. The primary endpoint was post-operative mortality at 30 days, while secondary endpoints were morbidity and efficacy of ablation (i.e., response rate evaluated according to mRECIST criteria, and overall patient survival). Patient demographics, operational characteristics, and complications were recorded. Results: A total of 13 nodules were treated in 10 patients with a median age of 65.5 years. Post-operative mortality was 0%, and overall morbidity was 40% (Clavien-Dindo I complications 30%, II 0%, III 10%, IV 0%). Complete radiological response was obtained in 83.3% of nodules at 3 months. After a median follow-up of 20.95 months, the local tumor progression rate was 30%, with an intra-segmental-recurrence of 30%, and an intra-hepatic-recurrence of 30%. The overall 1-, 2-, and 3-years survival rates were 80%, 58%, and 58%. Conclusion: Thoracoscopic trans-diaphragmatic ablation proved to be a safe and effective way to treat liver tumors when abdominal approach is not feasible. Considering the low morbidity, it is a viable option to treat patients with recurrent disease and/or previous multiple abdominal surgeries.
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Affiliation(s)
- Umberto Cillo
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation, Padova University, Padova, Italy
| | - Michele Finotti
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation, Padova University, Padova, Italy
| | - Chiara Di Renzo
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation, Padova University, Padova, Italy
| | - Alessandro Vitale
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation, Padova University, Padova, Italy
| | - Giacomo Zanus
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation, Padova University, Padova, Italy
| | - Enrico Gringeri
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation, Padova University, Padova, Italy
| | - Alessandra Bertacco
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation, Padova University, Padova, Italy
| | - Marina Polacco
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation, Padova University, Padova, Italy
| | - Francesco D'Amico
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation, Padova University, Padova, Italy.,Department of Surgery, Immunology and Transplantation Unit, Yale University, New Haven, CT, United States
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Modern therapeutic approaches for the treatment of malignant liver tumours. Nat Rev Gastroenterol Hepatol 2020; 17:755-772. [PMID: 32681074 DOI: 10.1038/s41575-020-0314-8] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2020] [Indexed: 02/06/2023]
Abstract
Malignant liver tumours include a wide range of primary and secondary tumours. Although surgery remains the mainstay of curative treatment, modern therapies integrate a variety of neoadjuvant and adjuvant strategies and have achieved dramatic improvements in survival. Extensive tumour loads, which have traditionally been considered unresectable, are now amenable to curative treatment through systemic conversion chemotherapies followed by a variety of interventions such as augmentation of the healthy liver through portal vein occlusion, staged surgeries or ablation modalities. Liver transplantation is established in selected patients with hepatocellular carcinoma but is now emerging as a promising option in many other types of tumour such as perihilar cholangiocarcinomas, neuroendocrine or colorectal liver metastases. In this Review, we summarize the available therapies for the treatment of malignant liver tumours, with an emphasis on surgical and ablative approaches and how they align with other therapies such as modern anticancer drugs or radiotherapy. In addition, we describe three complex case studies of patients with malignant liver tumours. Finally, we discuss the outlook for future treatment, including personalized approaches based on molecular tumour subtyping, response to targeted drugs, novel biomarkers and precision surgery adapted to the specific tumour.
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Santambrogio R, Farina G, D'Alessandro V, Iacob G, Gemma M, Zappa MA. Guidelines Adaptation to the COVID-19 Outbreak for the Management of Hepatocellular Carcinoma. J Laparoendosc Adv Surg Tech A 2020; 31:266-272. [PMID: 32810426 DOI: 10.1089/lap.2020.0559] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: COVID-19 pandemic rendered the surgical approach as well as the surgical indication very complex due to the outstanding consumption of public health system' resources, especially in the intensive care subdivision. A multidisciplinary team-based strategy is necessary to adapt guidelines and medical practices to the actual situation. The aim of this study is to evaluate the changes in the therapeutic algorithm in a small group of patients with hepatocellular carcinoma (HCC) enlisted for surgery during the COVID-19 outbreak. Materials and Methods: A multidisciplinary strategy has been adopted to allocate HCC patients to a treatment that permitted to reduce the risk of complications and the hospital stay, thus preventing contamination by the virus. Nasopharyngeal swab and a chest radiograph were performed in all patients within 48 hours before the surgical procedure: in the suspected cases with negative COVID tests, we prudently postponed surgery and repeated the diagnostic tests after 15 days. Results: During the emergency state, 11 HCC patients were treated (8 laparoscopic ablations and 3 hepatic resections). We reported only 1 postoperative complication (hemothorax) and 1 death during the follow-up for COVID pneumonia. Comparing our performances with those in the same time frame in the past 4 years, we treated a similar number of HCC patients, obtaining a decrease in operative timing (P = .0409) and hospital stay (P = .0412) (Fig. 2b) with similar rates of immediate postoperative complications, without ICU admissions. Conclusions: An adapted algorithm for the treatment of HCC to COVID outbreak permitted to manage safely these patients by identifying those most at risk of evolution of the neoplastic disease.
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Affiliation(s)
| | | | | | - Giulio Iacob
- UOC di Chirurgia Generale, ASST Fatebenefratelli Sacco, Milano, Italy
| | - Marco Gemma
- UOC di Anestesia e Rianimazione, ASST Fatebenefratelli Sacco, Milano, Italy
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Santambrogio R, Barabino M, De Nicola E, Galfrascoli E, Giovenzana M, Zappa MA. Laparoscopic ablation therapies for hepatocellular carcinoma: could specific indications for the laparoscopic approach influence the effectiveness? Updates Surg 2020; 72:435-443. [DOI: 10.1007/s13304-020-00759-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 03/27/2020] [Indexed: 12/21/2022]
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Santambrogio R, Barabino M, D'Alessandro V, Galfrascoli E, Zappa MA, Piccolo G, Zuin M, Opocher E. Laparoscopic thermoablation for hepatocellular carcinoma in patients with liver cirrhosis: an effective procedure for tricky tumors. Med Oncol 2020; 37:32. [PMID: 32193636 DOI: 10.1007/s12032-020-1342-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/28/2020] [Indexed: 12/23/2022]
Abstract
The optimal treatment for hepatocellular carcinoma (HCC) is surgical resection. However, only a small percentage of patients are amenable to this option. Percutaneous radiofrequency interstitial thermal ablation (TA) proved to be effective in the treatment of unresectable HCC. Recent advances in laparoscopic ultrasound have improved the accuracy in detecting small intrahepatic HCC nodules missed by pre-operative imaging techniques. Our objective was to evaluate an operative combination of laparoscopic ultrasound with laparoscopic thermoablation (LTA) in the treatment of HCC not amenable to liver resection. The aim of our review was to evaluate the advantages and limits of the laparoscopic approach according the criteria of the evidence-based medicine. LTA of HCC proved to be a safe and effective technique both in the short- and long-term follow-up period. This technique may be indicated in selected cases when the percutaneous approach to the lesion is very difficult or contraindicated.
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Affiliation(s)
| | - Matteo Barabino
- Hepatobiliary Surgery Unit, Department of Surgery, San Paolo Hospital, University of Milan, Via Di Rudinì 8, 20142, Milan, Italy.
| | | | | | | | - Gaetano Piccolo
- Hepatobiliary Surgery Unit, Department of Surgery, San Paolo Hospital, University of Milan, Via Di Rudinì 8, 20142, Milan, Italy
| | - Massimo Zuin
- Hepato-Gastroenterology Unit, San Paolo Hospital, University of Milan, Milan, Italy
| | - Enrico Opocher
- Hepatobiliary Surgery Unit, Department of Surgery, San Paolo Hospital, University of Milan, Via Di Rudinì 8, 20142, Milan, Italy
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Giorgio A, Gatti P, De Luca M, Matteucci P, Giorgio V. Editorial on "Role of thermal ablation in the management of colorectal liver metastasis". Hepatobiliary Surg Nutr 2020; 9:62-64. [PMID: 32142060 PMCID: PMC7026782 DOI: 10.21037/hbsn.2019.10.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 10/21/2019] [Indexed: 08/29/2023]
Affiliation(s)
- Antonio Giorgio
- Liver Unit and Interventional Ultrasound Unit, Athena Clinical Institute, Piedimonte Matese (CE), Italy
| | - Pietro Gatti
- Internal Medicine Unit, Brindisi General Hospital, Brindisi, Italy
| | | | | | - Valentina Giorgio
- Fondazione Policlinico A. Gemelli IRCCS, Department of Woman and Child Health and Public Health, Roma, Italy
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