상단 PDF Surgical Strategy of Hepatocellular Carcinoma with Bile Duct Tumor Thrombus

Introduction: Caudate lobes are anatomically located between the hepatic hilum and inferior vena cava. Isolated caudate lobectomy is still a challenging procedure for hepatobiliary pancreas surgeons because it is quite complicated depending on the relationship be- tween the surrounding major vascular structures and the biliary tract. In this study, we introduce a various surgical strategy for hepa- tocellular carcinoma located in the caudate lobe, and report the results.

Tel: ＋82-2-440-6135, Fax: ＋82-2-440-6295, E-mail: sunhyung@chol.com cc Journal of the Korean Surgical Society is an Open Access Journal. All articles are distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

combine the data retrieved from different comparative studies with a single endpoint to produce a single pooled result. In this kind of meta-analysis, outcomes are re- ported as binomial proportions, and the most popular measure of effect is the OR. As mentioned in the previous paragraph, the HR is an appropriate measure in comparing survival analysis, and therefore should be considered a natural quantity when undertaking a meta-analysis of sur- vival studies. Nevertheless, there is a limitation to using HRs in meta-analysis when data regarding HRs are not given. Fortunately, an alternative approach has been pro- posed when HRs are not available in original articles. 19 Image extraction software (www.digitizeit.de) is used to extract the coordinates of Kaplan-Meier (KM) curves from the original articles. The numbers at risk at fol- low-up times were calculated using number at risk tables.

Annals of Hepato-Biliary-Pancreatic Surgery ∙ pISSN: 2508-5778ㆍeISSN: 2508-5859 INTRODUCTION Surgical resection for advanced HCC is an uncommon operation and most society recommendations do not have clear guidelines for these tumors due to lack of class I data. We present a case of advanced left lateral segment HCC with atrial tumor thrombus extension, treated surgi- cally with simultaneous resection of liver tumor and tu- mor thrombus extending to right atrium using cardiopul- monary bypass (CPB). Most of the reported cases of liver tumor with atrial extension have historically been right lobe tumor where alternate resection strategies have also been successful.

Haeryoung KIM* Department of Pathology, Seoul National University College of Medicine, Seoul, Korea BP-SY-2-1 Lecture: Extrahepatic bile duct cancer is an aggressive malignant neoplasm with a dismal prognosis, and complete surgical resection of the tumor with microscopically negative (R0) margins is the only potentially curative therapy. Therefore, an accurate evaluation of the resection margin status by the pathologist is an integral part of bile duct cancer surgery, both intraoperatively (frozen section) and post-operatively (permanent section). However, intraoperative frozen section evaluation of bile duct margin status is a challenge even for experienced pathologists. In patients with bile duct cancers, ampullary cancers or pancreatic cancers with bile duct obstruction, the bile ducts proximal to the lesion are often severely inflamed due to obstruction and/or prior procedures (stent, drainage tubes etc). The bile duct mucosa of most cases demonstrate post-procedural reactive atypia, the most extreme examples being ulceration and granula- tion tissue formation related to metallic stent insertion. As a result, the discrimination between severe reactive atypia and high-grade dysplasia or invasive carcinoma at proximal margins is one of the most challenging tasks in frozen section pathology. Post-operative evaluation of the resected specimen may be just as challenging, and it is extremely important to ensure an accurate orientation of the specimen and to understand the surgical procedure. Whenever necessary, adequate communication with the surgeon is important, in order to fully understand the anatomical relationship and clinical context. In this talk, the pathologists’ perspectives on resection mar- gins in the context of extrahepatic bile duct cancer specimens will be discussed.

reveals an increased uptake of FDG. Given that poorly differentiated HCC is more likely to metastasize, FDG-PET is useful to detect distant metastasis. 6 Evidence supports a relationship between FDG-PET imaging and degree of tumor differentiation. In a study of patients that underwent surgical resection for HCC, preoperative FDG-PET imaging was related to tumor differentiation and appeared to predict tumor recurrence and survival rates. 7 There have been many studies reporting clinical usefulness of FDG-PET in the primary neoplasm of anoth- er group of hepatobiliary system, cholangiocarcinoma. It is a more accurate modality for distinguishing intrahepatic duct and common bile duct cancers than CT (88.9% vs.

In low risk group patients, 1 yr and 2 yr overall survival rates were 80.6 % and 52.0 % respectively, and the rates surpass the previously known survival rates of the patients with extrahepatic metastasis. When local treatment was added to the low risk group patients, they survived even longer than those without local intervention. Intermediate risk group patients showed 1 yr and 2 yr survival rate of 34.1 % and 13.7 % and local intervention for lung metastasis has significantly increased treatment result with 1 yr and 2 yr survival of 83.3 % and 50.0% respectively. The result suggests that our GPA score based risk group model can select the patients with promising prognosis and find appropriate candidates for local intervention. In the aspect of treatment strategies, a dozen studies consistently insist that pulmonary metastasectomy in selected patients can result in better survival. Recently in 2016, Japanese retrospective multicenter trial reported 5 yr survival of patients who underwent pulmonary metastasectomy 25 . The inclusion criteria for the study were all of the patients who underwent surgical resection for pulmonary metastasis from HCC after complete resection for primary HCC. 93 patients were evaluated and 77 of them had single pulmonary metastasis. Estimated 5 yr overall survival was 41.4 % with 39.0 months of median survival time after metastasectomy. As most of the studies are dealing with a small number of patients with extrahepatic metastasis, there was a SEER database review of HCC extrahepatic metastasis patients to overcome the limitation of small number of the patients in most of studies. The study dealt with 4396 patients of stage IV HCC from 2010 to 2013 and local treatment to the primary tumor and surgery to the metastatic disease were associated with better overall survival and cancer specific survival 26 .

Seung Eun Lee 1 , Yoo Shin Choi 1 , Mi Kyung Kim 2 , Hyoung-Chul Oh 3 , and Jae Hyuk Do 3 1 Department of Surgery, 2 Department of Pathology and 3 Devision of Gastroenterology, Chung-Ang University College of Medicine, Seoul, Korea Ovarian metastases represent about 3-5% of all ovarian malignancies. Most of these tumors originate in the digestive tract and cholangiocarcinoma rarely involves the ovary. A 60-year-old woman was admitted for the investigation of abdominal distension that had lasted 1 week. One and a half years prior, the patient had undergone choledochal cyst excision, Roux-en Y hepaticojejunostomy and cholecystectomy. Computed tomography scans of the abdomen revealed a papillary mass in the remnant distal common bile duct and enlargement of both ovaries with a huge amount of ascites. An explorative laparotomy disclosed no peritoneal seeding with resectable cholangiocarcinoma and bilateral ovarian mass. Pylorus-preserving pancreatoduodenectomy and bilateral salphingo-oophorectomy with hysterectomy were performed. Histologically, it was a well-differentiated adenocarcinoma and all surgical margins were free of tumor.

Performance of concurrent extrahepatic bile duct resection In this study, EHBD resection was performed according to surgeons’ preference and surgical findings, thus not be- ing randomly assigned. The extent of liver resection, ex- tended cholecystectomy or segment 4a＋5 hepatectomy, was also determined by surgeons’ preference. Tumor cell presence at the cystic duct resection margin upon intra- operative frozen-section biopsy was absolutely indicated for EHBD resection. To avoid reconstruction-related bili- ary complications, the proximal EHBD was transected at the hilar confluence portion and reconstructed with Roux- en-Y choledochojejunostomy. No external biliary drainage was applied in this series.

A third hypothesis, suggests that the higher incidence of microvascular invasion in patients with HCC with bile duct invasion may be a reason for the poor prognosis of patients. The findings of our study supported this hypoth- esis, although our study included only those patients with complete resection. Considering the mechanisms of hep- atic tumor growth, it is not surprising that the majority of cases of bile duct invasion of HCC are accompanied by microvascular invasion. 1 Therefore, gross bile duct in- vasion could be considered as vascular invasion in several staging systems for HCC. In a study involving a group of patients with liver cancer classified according to the Japanese staging systems for HCC (3 rd edition) based on preoperative image findings, the presence of bile duct in- vasion upon preoperative imaging increased the T classi- fication by 1 grade. 19,20 In early stage HCC, if bile duct invasion does not accompany microvascular invasion, it can result in undetected or hidden microvascular invasion.

two procedures. Following surgical treatment of bile duct cancers, the two most important prognostic factors are tumor involve- ment of the longitudinal and radial RMs and lymph node metastasis. 6 While EHBD resection appears beneficial for obtaining a tumor-free longitudinal bile duct RM, involve- ment of the radial bile duct RM is another risk factor when the tumor extends to the periductal soft tissue. It has been reported that a 10-mm RM in both the proximal and distal longitudinal directions of the bile duct is re- quired to eradicate invasive carcinoma cells, and that a 20-mm RM is required for removal of non-invasive carci- noma cells. 7 Carcinoma in-situ or severe dysplasia at the bile duct RM is also associated with late local recu- rrence. 8 For mid bile duct cancers, obtainment of a tu- mor-free distal bile duct RM as long as 10-20 mm is im- practical without performing pancreaticoduodenectomy.

CT scan shows well defined soft tissue mass within the distal common bile duct (arrows)... 정석태 외 : 간외담관의 원빌성 간세포암.[r]

Furthermore, latest molecular targeting therapy (Lemvatinib) showed better response in patients with recurrent HCC after tumor thrombectomy when the HCC cells showed positive for EGFR.[r]

Radiotherapy can be used for treating PVTT. In most clinical situations, EBRT has been used as an adjuvant therapy to improve sur- vival outcomes. In a large nationwide study from South Korea, median overall survival (OS) of patients with PVTT was 10.2 months in combination with intra-arterial therapies. Recently, a randomized trial from South Korea showed a significantly prolonged OS and time to progression (TTP) with TACE plus EBRT versus sorafenib alone. In other series, the addition of radiotherapy to TACE often resulted in promising OS in comparison with TACE alone. Despite the promising results for the use of radiotherapy to treat PVTT, few have been obtained with a high level of evidence. Currently, EBRT alone, or in combination with other therapies is recommended for the treatment of HCC and PVTT in only eastern guidelines, but not in western guidelines.

After another working port insertion, cystic ducts were pulled with laparoscopic grasper to easily expose CBD and CBD was opened longitudinally, approximately 1 to 1.5 cm with laparoscopic scissors. After the identification of CBD stones through a 5-mm flexible choledochoscope, we removed them by flushing method with sterile saline, stone basket, Fogarty catheter, and/or electro-hydraulic lithotripsy. After the stone removal, the choledochotomy site was closed by continuous suture, using vicryl 3-0, with or without T-tube insertion and cholecystectomy was performed. After this, we ended the operation with 6-mm penrose drain insertion into the operation site. For the pa- tients with T-tube, we performed cholangiography through T-tube seven days after operation to identify any remnant stones. If residual stones were identified, they were re- moved through T-tube under local anesthesia. But if there was no abnormality, T-tube was removed immediately af- ter cholangiography. Mostly T-tubes were used prior to 2006. Recently, with the development of choledocoscope, there are fewer instances of uncertainty as to complete elimination stones, which was one of the results of T-tube insertion after LCBDE. Thus, we had inserted T-tubes in only some cases, such as possibility of postoperative stric- ture or transient outflow obstruction due to severe in- flammation existing since 2006.