multidisciplinary management of hepatocellular carcinoma · multidisciplinary management of...
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Multidisciplinary Management of Hepatocellular Carcinoma
Zeljka Jutric MD Department of Surgery
Division of Hepatobiliary and Pancreas Surgery
February 29th, 2020
Introduction
• Management of HCC is challenging • Underlying liver disease Cirrhosis • Variations in expertise and local resources
• Multidisciplinary Approach • Leads to improved outcomes
Diagnosis of HCC – All about imaging
* AASLD Criteria: Do not need biopsy with diagnostic imaging in patients with cirrhosis
Barcelona Clinic Liver Cancer (BCLC)
Forner et al. Treatment of intermediate stage HCC. Nature Reviews. 2014Llovet et al. The Barcelona Approach. Liver Transplantation . 2004
Median OS > 60 mo OS 20 mo OS 11 mo OS < 3 mo
Liver Transplant
• Based on MELD scores • Points for HCC moving target • Milan Criteria• Expanded Criteria
Transplantation for HCC• Advantages
–Treatment of underlying liver disease–Better long-term patient survival–Removes synchronous tumors –Lower risk of positive margin
• Disadvantages–Donor organ availability region dependent –Long-term immuno-suppression–Higher cost
Liver Resection for HCC
• Valuable curative option for HCC patients • Historically, balance between operative
risk and oncologic prognosis limited selection
Resection vs.Transplantation for HCC
• 413 pts over 10 yrs in Miami (low MELD)• 106 resection• 270 transplant• 37 listed but not transplanted
• Median time to transplant = 48 days
Koniaris LG et al. Ann Surg 2015
Refinement of Current Guidelines
• Sophisticated assessment of liver function• Postoperative liver failure
• Improvements in preoperative management• Use of volume modulation
• Refinements in surgical technique • Laparoscopy
Use of Laparoscopy
• 10-20% of all liver resections performed laparoscopically • Initial concerns with patient safety, adequate
oncologic results • Laparoscopic Approach is Safe in Expert
Centers • Decreased hospital length of stay• Less post operative complications • Decreased ascites
Ablation: Radiofrequency and Microwave
Used for primary treatment (smaller tumors) and
bridge to transplant
Chemoembolization Hepatic parenchyma derives 70% of bloodflow from
portal vein Primary hepatic malignancies derive 70% of bloodflow
from the hepatic artery