Korean J Hepatobiliary Pancreat Surg.  2011 Nov;15(4):218-224. 10.14701/kjhbps.2011.15.4.218.

What we learned from difficult hepatectomies in patients with advanced hepatic malignancy

• Jung BH
• Lee JH
• Lee SY
• Song DK
• Hwang JW
• Hwang DW
• Lee YJ
• Park KM

• KMID: 2244128
• DOI: http://doi.org/10.14701/kjhbps.2011.15.4.218

Abstract

BACKGROUNDS/AIMS
By reviewing difficult resections for advanced hepatic malignancies, we discuss the effectiveness and extended indications for hepatectomy in such patients.
METHODS
We reviewed 7 patients who underwent extensive surgery between July 2008 and March 2011 for advanced hepatic malignancies. They had stage IV disease, except for in one case that was a stage IIIC (T4N0M0) hepatocellular carcinoma (HCC).
RESULTS
Patient 1 with intrahepatic cholangiocarcinoma (IHCC) underwent right hemihepatectomy and resection of the bile duct and left portal vein. At 39 months after surgery, she had no recurrence or metastasis. Patient 2 with HCC underwent palliative right trisectionectomy. At 38 months after surgery, he is alive despite residual pulmonary metastases. Patient 3 with HCC invading the hepatic vein and diaphragm underwent right trisectionectomy and caval venoplasty. At 12 months after surgery, he had no recurrence or metastasis. Patient 4, who had 2 large HCCs and pulmonary thromboembolism, underwent a right trisectionectomy. At 7 months after surgery, he had no evidence of recurred HCC. Patient 5, who had IHCC invading her inferior vena cava and main portal vein, underwent preoperative radiotherapy, left hemihepatectomy, and caval resection. At 20 months after surgery, she is well despite a caval thrombus. Patient 6 and 7 underwent repeated surgery due to a recurred IHCC and metastatic colon cancer, respectively. In addition, they are alive during each 20 and 17 months after surgery.
CONCLUSIONS
Despite macroscopic extrahepatic metastases or major vessel involvement, extensive surgery for advanced hepatic malignancy may result in relatively favorable outcomes and be important modality for improving of survival in such patients.

Keyword

Hepatocellular carcinoma; Intrahepatic cholangiocarcinoma; Hepatectomy

MeSH Terms

Bile Ducts
Carcinoma, Hepatocellular
Cholangiocarcinoma
Colonic Neoplasms
Diaphragm
Glycosaminoglycans
Hepatectomy
Hepatic Veins
Humans
Liver Neoplasms
Neoplasm Metastasis
Portal Vein
Pulmonary Embolism
Recurrence
Thrombosis
Vena Cava, Inferior
Glycosaminoglycans
Liver Neoplasms

Figure

• 

  Fig. 1 Images of patient 3. (A, B) Initial liver dynamic CT scan showing a huge hepatocellular carcinoma with thrombi in the right hepatic vein and portal vein and intrahepatic metastases. (C) Photograph of the gross specimen, showing a multinodular confluent, trabecular, and hepatic type of hepatocellular carcinoma, of Edmondson-Steiner grade 4/3, measuring 11.5×10×6.8 cm with invasion of diaphragm, and portal vein thrombus. (D) CT scan of 12 months after surgery showing no evidence of recurrence or metastasis in the retained left hepatic lobe.

• 

  Fig. 2 Images of patients 5. (A, B) Initial CT scan showing an intrahepatic cholangiocarcinoma on the caudate lobe with intrahepatic inferior vena cava invasion and abutting the main portal vein. (C-G) Intraoperative photographs during left hemihepatectomy, caudate lobectomy, inferior vena cava resection and interposition graft and total vascular exclusion through individual approach. (H) Photograph of a gross specimen, showing that the tumor was a mass forming type of cholangiocarcinoma with poor differentiation, measuring 5.8×5.0×4.2 cm and invading the inferior vena cava.

Reference

1. Borie F, Bouvier AM, Herrero A, et al. Treatment and prognosis of hepatocellular carcinoma: a population based study in France. J Surg Oncol. 2008; 98:505–509. PMID: 18932235.

2. Lau WY, Lai EC. Salvage surgery following downstaging of unresectable hepatocellular carcinoma--a strategy to increase resectability. Ann Surg Oncol. 2007; 14:3301–3309. PMID: 17891443.

3. Chen XP, Qiu FZ, Wu ZD, et al. Effects of location and extension of portal vein tumor thrombus on long-term outcomes of surgical treatment for hepatocellular carcinoma. Ann Surg Oncol. 2006; 13:940–946. PMID: 16788755.

4. Ng KK, Vauthey JN, Pawlik TM, et al. International Cooperative Study Group on Hepatocellular Carcinoma. Is hepatic resection for large or multinodular hepatocellular carcinoma justified? Results from a multi-institutional database. Ann Surg Oncol. 2005; 12:364–373. PMID: 15915370.

5. Chirica M, Scatton O, Massault PP, et al. Treatment of stage IVA hepatocellular carcinoma: should we reappraise the role of surgery? Arch Surg. 2008; 143:538–543. PMID: 18559745.

6. Ruzzenente A, Capra F, Pachera S, et al. Is liver resection justified in advanced hepatocellular carcinoma? Results of an observational study in 464 patients. J Gastrointest Surg. 2009; 13:1313–1320. PMID: 19418103.

7. Liu CL, Fan ST, Lo CM, Ng IO, Poon RT, Wong J. Hepatic resection for bilobar hepatocellular carcinoma: is it justified? Arch Surg. 2003; 138:100–104. PMID: 12511161.

8. Pawlik TM, Poon RT, Abdalla EK, et al. Hepatectomy for hepatocellular carcinoma with major portal or hepatic vein invasion: results of a multicenter study. Surgery. 2005; 137:403–410. PMID: 15800485.

9. Lau WY, Ho SK, Yu SC, Lai EC, Liew CT, Leung TW. Salvage surgery following downstaging of unresectable hepatocellular carcinoma. Ann Surg. 2004; 240:299–305. PMID: 15273555.

10. Tang ZY, Zhou XD, Ma ZC, et al. Downstaging followed by resection plays a role in improving prognosis of unresectable hepatocellular carcinoma. Hepatobiliary Pancreat Dis Int. 2004; 3:495–498. PMID: 15567731.

11. Torzilli G, Del Fabbro D, Palmisano A, Marconi M, Makuuchi M, Montorsi M. Salvage hepatic resection after incomplete interstitial therapy for primary and secondary liver tumours. Br J Surg. 2007; 94:208–213. PMID: 17149716.

12. Lee JM, Park KM, Choi J, Chon SH, Hwang DW, Lee YJ. Palliative hepatectomy for advanced hepatocelluar carcinoma with multiple metastases: a case report. Korean J Hepatobiliary Pancreat Surg. 2009; 13:295–300.

13. Llovet JM, Burroughs A, Bruix J. Hepatocellular carcinoma. Lancet. 2003; 362:1907–1917. PMID: 14667750.

14. Liver Cancer Study Group of Japan. Primary liver cancer in Japan. Clinicopathologic features and results of surgical treatment. Ann Surg. 1990; 211:277–287. PMID: 2155591.

15. Shimada K, Sano T, Sakamoto Y, Esaki M, Kosuge T, Ojima H. Surgical outcomes of the mass-forming plus periductal infiltrating types of intrahepatic cholangiocarcinoma: a comparative study with the typical mass-forming type of intrahepatic cholangiocarcinoma. World J Surg. 2007; 31:2016–2022. PMID: 17687597.

16. Lang H, Sotiropoulos GC, Frühauf NR, et al. Extended hepatectomy for intrahepatic cholangiocellular carcinoma (ICC): when is it worthwhile? Single center experience with 27 resections in 50 patients over a 5-year period. Ann Surg. 2005; 241:134–143. PMID: 15622001.

17. Shimada M, Yamashita Y, Aishima S, Shirabe K, Takenaka K, Sugimachi K. Value of lymph node dissection during resection of intrahepatic cholangiocarcinoma. Br J Surg. 2001; 88:1463–1466. PMID: 11683741.

18. House MG, Ito H, Gönen M, et al. Survival after hepatic resection for metastatic colorectal cancer: trends in outcomes for 1,600 patients during two decades at a single institution. J Am Coll Surg. 2010; 210:744–752. 752–755. PMID: 20421043.

19. Sakamoto Y, Fujita S, Akasu T, et al. Is surgical resection justified for stage IV colorectal cancer patients having bilobar hepatic metastases?--an analysis of survival of 77 patients undergoing hepatectomy. J Surg Oncol. 2010; 102:784–788. PMID: 20872814.

20. Jaeck D, Oussoultzoglou E, Rosso E, Greget M, Weber JC, Bachellier P. A two-stage hepatectomy procedure combined with portal vein embolization to achieve curative resection for initially unresectable multiple and bilobar colorectal liver metastases. Ann Surg. 2004; 240:1037–1049. PMID: 15570209.

21. Ishiguro S, Akasu T, Fujimoto Y, et al. Second hepatectomy for recurrent colorectal liver metastasis: analysis of preoperative prognostic factors. Ann Surg Oncol. 2006; 13:1579–1587. PMID: 17003958.