new advances in the treatment of liver tumors: laparoscopic resections
DESCRIPTION
Presentation on New Advances in the Treatment of Liver Tumors (Laparoscopic Resections) by Dr. Kimberly Moore Dalal, Surgical Oncology & General Surgery, Peninsula Medical Center.TRANSCRIPT
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New Advances in the Treatment of New Advances in the Treatment of Liver Tumors: Liver Tumors:
Laparoscopic Resections Laparoscopic Resections
Cancer Care InnovationsCancer Care InnovationsDorothy E. Schneider Cancer CenterDorothy E. Schneider Cancer Center
Mills-Peninsula HospitalMills-Peninsula HospitalApril 23, 2011April 23, 2011
Kimberly Moore Dalal, MD, FACSKimberly Moore Dalal, MD, FACSSurgical Oncology and General SurgerySurgical Oncology and General Surgery
Peninsula Medical ClinicPeninsula Medical ClinicBruce Allen, MD; Aziz Ahmad, MD; Dirk Baumann, MD; John Beare, Bruce Allen, MD; Aziz Ahmad, MD; Dirk Baumann, MD; John Beare,
MD; Pamela Foster, MD; Stephanie Lin, MD; Andrea Metkus, MD; John MD; Pamela Foster, MD; Stephanie Lin, MD; Andrea Metkus, MD; John Rosenman, MD; Randolph Wong, MD; Albert Wetter, MD Rosenman, MD; Randolph Wong, MD; Albert Wetter, MD
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Historical PerspectiveHistorical Perspective
“…“…the liver is so friable, so full of gaping the liver is so friable, so full of gaping
vesselsvessels and so evidently incapable of and so evidently incapable of
being sutured that it seems impossible to being sutured that it seems impossible to
successfully manage large wounds of its successfully manage large wounds of its
substance.” substance.” JW Elliot 1897JW Elliot 1897
Liver cancer
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Historical PerspectiveHistorical Perspective
“…“…20% of patients died in the operating room 20% of patients died in the operating room
because of exsanguinating hemorrhage… because of exsanguinating hemorrhage…
Another 14% died post-operatively as a Another 14% died post-operatively as a
direct consequence of enormous blood loss direct consequence of enormous blood loss
during operation…15% died of liver failure during operation…15% died of liver failure
caused by technical factors other than caused by technical factors other than
hemostasis, including 3 bile duct injuries…”hemostasis, including 3 bile duct injuries…”
Foster JH, Berman MM. Major Problems in Clincal Surgery 1977;1-342.
Liver cancer
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OR Team, Bagram, Afghanistan 2007OR Team, Bagram, Afghanistan 2007
Liver cancer
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MASCAL, October 14, 2007MASCAL, October 14, 200719 Americans injured19 Americans injured
Liver cancer
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Liver Resection TodayLiver Resection TodayAuthorAuthor NN Operative Mortality (%)Operative Mortality (%)
Scheele ‘91Scheele ‘91 219219 66Rosen ‘92Rosen ‘92 280280 44Gayowski ’94Gayowski ’94 204204 00 Scheele ‘95Scheele ‘95 469469 44 Nordlinger ’95Nordlinger ’95 568568 22 Jamison, ‘97Jamison, ‘97 280280 44Fong ’99Fong ’99 10011001 33
Normal livers
Liver cancer
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OutlineOutline
Laparoscopic liver resections for benign and malignant Laparoscopic liver resections for benign and malignant tumorstumors– Benign lesionsBenign lesions– Hepatocellular carcinomaHepatocellular carcinoma– Colorectal cancer metastasesColorectal cancer metastases
Liver cancer
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AnatomyAnatomy
Liver cancer
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Benign Hepatic LesionsBenign Hepatic Lesions
Liver cancer
Tumor Malignant Potential Spontaneous Hemorrhage
Focal nodular hyperplasia No No
Hemangioma No Rare
Cystadenoma Yes No
Adenoma Yes Yes
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Case 1: Cystic Lesion of the LiverCase 1: Cystic Lesion of the Liver
51 year old woman51 year old woman
3.5 cm Liver Cyst, Seg 4, first noted on chest CT in 20013.5 cm Liver Cyst, Seg 4, first noted on chest CT in 2001
Presented with 3 days RUQ painPresented with 3 days RUQ pain
RUQ ultrasound (2/07): complex cystic structure of the RUQ ultrasound (2/07): complex cystic structure of the liver with layeringliver with layering
Triple phase liver CT (2/07): Cystic lesion, Seg 4, 6x8x6 Triple phase liver CT (2/07): Cystic lesion, Seg 4, 6x8x6 cm; Hounsfield units 6 (noncontrast), 11 (iv contrast)cm; Hounsfield units 6 (noncontrast), 11 (iv contrast)
Liver cancer
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UltrasoundComplex cystic structure of liver with layering
Liver cancer
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Triple phase liver CT: Triple phase liver CT: Cystic lesion, Seg 4, 6x8x6 cmCystic lesion, Seg 4, 6x8x6 cm
Liver cancer
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Case 2: Hepatic Adenoma Case 2: Hepatic Adenoma
43 yo F with incidentally discovered right liver 43 yo F with incidentally discovered right liver mass detected on CT of chest for workup of mass detected on CT of chest for workup of cough. cough.
AFP and CEA normal. LFTs normal.AFP and CEA normal. LFTs normal.
CT and MRI CT and MRI – 4.2x2.1x2.0 cm mass, Seg 7, consistent with a 4.2x2.1x2.0 cm mass, Seg 7, consistent with a
hepatic adenoma.hepatic adenoma.
Liver cancer
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Liver cancer
Triple phase liver CT: Seg 7, 4x2x2 cmTriple phase liver CT: Seg 7, 4x2x2 cm
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Traditional Open “Chevron” IncisionTraditional Open “Chevron” Incision
Liver cancer
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Exposure in an Open ResectionExposure in an Open Resection
Liver cancer
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Laparoscopic Port Placement for Laparoscopic Port Placement for Right Liver LesionsRight Liver Lesions
Cho JY, et al., Arch Surg 2009; 144(1):25-29.
Liver cancer
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Laparoscopic View of the LiverLaparoscopic View of the Liver
Liver cancer
Machado MA, et al., Surg Endosc, 2009; 23:2615-2619.
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Case 2: Hepatic Adenoma, Segment 7 Case 2: Hepatic Adenoma, Segment 7 Laparoscopic Resection…9 Months LaterLaparoscopic Resection…9 Months Later
Liver cancer
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EstablishedEstablishedDiagnosis/StagingDiagnosis/StagingFenestration of Simple CystsFenestration of Simple Cysts
EvolvingEvolvingMinor resections (≤ 2 segments) for tumorMinor resections (≤ 2 segments) for tumorMajor hepatic resections Major hepatic resections Tumor ablationTumor ablation
Laparoscopic Liver SurgeryLaparoscopic Liver Surgery
Liver cancer
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Laparoscopic Liver ResectionLaparoscopic Liver ResectionTheoretical AdvantagesTheoretical Advantages
Less post-operative painLess post-operative pain
Less post-operative morbidityLess post-operative morbidity
Shorter hospital stayShorter hospital stay
Improved cosmesisImproved cosmesis
Quicker return to normal activityQuicker return to normal activity
Quicker initiation of adjuvant therapiesQuicker initiation of adjuvant therapies
Liver cancer
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Laparoscopic Liver ResectionLaparoscopic Liver ResectionTheoretical DisadvantagesTheoretical Disadvantages
Loss of tactile senseLoss of tactile senseMarginsMarginsStagingStaging
Limited access/instrumentationLimited access/instrumentationExposureExposureControl of major pedicles/hepatic Control of major pedicles/hepatic veinsveins
Time and moneyTime and money
Liver cancer
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Laparoscopic Liver ResectionLaparoscopic Liver ResectionSolutionsSolutions
Loss of tactile senseLoss of tactile senseMarginsMargins
StagingStaging
LaparoscopicUltrasound
Hand-assisted techniques
Liver cancer
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Laparoscopic Liver ResectionLaparoscopic Liver ResectionSolutionsSolutions
Limited access/instrumentationLimited access/instrumentationExposureExposure
Control of major pedicles/hepatic veinsControl of major pedicles/hepatic veins
Fear of major hemorrhageFear of major hemorrhage
• Hand-assisted techniques
• Ligaments intact• Improved
retractors
HarmonicScalpel
VascularStapler
LigasureDevice
Tissuelink
Argon Beam Coagulator
Water Jet
Liver cancer
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Laparoscopic Liver ResectionLaparoscopic Liver ResectionSolutionsSolutions
Time and moneyTime and money
Comparison to open surgery in trials
Liver cancer
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•Segmental resection: 27 pts (61%)
2
7853
•1 segment: 17 pts (38%)
•>1segment: 10 pts (22%)
•Left lateral: 6 pts (13%)
Laparoscopic Hepatectomy
MSKCC Results (n=44)
D’Angelica, MD, et al., AHPBA 2006
Liver cancer
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Benign 21 pts (47%)
Malignant 23 pts (53%)
23 pts: Negative margins (100%). No local recurrence.
1 tumor 36 pts (81%)
> 1 tumor 8 pts (18%)
Laparoscopic Hepatectomy
MSKCC Results (n=44)
Liver cancer
D’Angelica, MD, et al., AHPBA 2006
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LLR(n=44)
OLR(n=91) p
OR time (minutes) 199 161 0.01
Pringle time (minutes) 31 22 0.04
Pringle 45% 75% <0.01
EBL (ml) 161 521 <0.01
Transfusion 2.2% 26% <0.01
Operative Outcome
Laparoscopic Hepatectomy
MSKCC Results: Comparison to Open
Liver cancer
D’Angelica, MD, et al., AHPBA 2006
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LLR(n=44)
OLR(n=91) p
Length of stay (days) 5.1 6.7 <0.01
Morbidity 13% 28% 0.08
Regular diet (days) 3 3 0.7
Oral analgaesia (days) 3.1 3.5 0.1
Mortality 0% 0% 0
Laparoscopic Hepatectomy
MSKCC Results: Comparison to Open
Post-operative Outcome
Liver cancer
D’Angelica, MD, et al., AHPBA 2006
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For well-selected patients, laparoscopic liver For well-selected patients, laparoscopic liver resection is safe and does not compromise resection is safe and does not compromise operative or oncologic outcomes. operative or oncologic outcomes.
While laparoscopic liver resection is associated While laparoscopic liver resection is associated with some benefits, these can only be with some benefits, these can only be definitively proven in randomized controlled definitively proven in randomized controlled trials. trials.
SummarySummary
Liver cancer
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OutlineOutline
Laparoscopic liver resections for benign and malignant Laparoscopic liver resections for benign and malignant tumorstumors– Benign lesionsBenign lesions– Hepatocellular carcinomaHepatocellular carcinoma– Colorectal cancer metastasesColorectal cancer metastases
Liver cancer
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Epidemiology of Hepatobiliary CancerEpidemiology of Hepatobiliary Cancer
Estimated U.S. incidence in 2010: 24,120 Estimated U.S. incidence in 2010: 24,120 cases/yearcases/year11
Annual incidence of HCC with Hepatitis Annual incidence of HCC with Hepatitis C cirrhosis is 2-8%, Hepatitis B cirrhosis C cirrhosis is 2-8%, Hepatitis B cirrhosis 2.5%.2.5%.
18,910 deaths in men and women18,910 deaths in men and women
Jemal A, et al., CA Cancer J Clin, 2010; 60:27-300.
Liver cancer
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Diagnosis and Workup for HCCDiagnosis and Workup for HCC
Often asymptomatic.Often asymptomatic.
Nonspecific symptoms: Nonspecific symptoms: anorexia, weight loss, malaise, anorexia, weight loss, malaise, upper abdominal pain. upper abdominal pain.
Paraneoplastic syndromes: Paraneoplastic syndromes: hypercholesterolemia, hypercholesterolemia, erythrocytosis, hypercalcemia, erythrocytosis, hypercalcemia, hypoglycemia. hypoglycemia.
Physical signs: Physical signs: jaundice, jaundice, ascitesascites
AFP>200 ng/mL + liver AFP>200 ng/mL + liver mass =HCCmass =HCC
Liver cancer
Zhang BH et al., J Cancer Res Clin Oncol. 2004; 130:417-422.
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Child-Pugh Class A Patients are Child-Pugh Class A Patients are Candidates for ResectionCandidates for Resection
Liver cancer
1 2 3
Encephalopathy None 1-2 3-4
Ascites None Slight Moderate
Albumin (g/dL) >3.5 2.8-3.5 <2.8
Prothrombin time (sec) 1-4 4-6 >6
Bilirubin (mg/dL) 1-2 2-3 >3
Class A = 5-6 points Good operative riskClass B = 7-9 points Moderate operative riskClass C = 10-15 points Poor operative risk
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Case 3: Hepatocellular CarcinomaCase 3: Hepatocellular Carcinoma
74 yo M with Hepatitis C x 30 years from a blood 74 yo M with Hepatitis C x 30 years from a blood transfusion, treated with interferon for one yeartransfusion, treated with interferon for one year
Developed pneumonia and asked PCP to Developed pneumonia and asked PCP to investigate for cirrhosis.investigate for cirrhosis.
AFP: 4690.AFP: 4690.
Abd US: 3.4 x 2.4 x 3.1 cm mass, left lateral Abd US: 3.4 x 2.4 x 3.1 cm mass, left lateral segment of liver.segment of liver.
Triple phase Liver CT: 3.5 x 2.5 cm mass, Triple phase Liver CT: 3.5 x 2.5 cm mass, segment 3. segment 3. (CT of abdomen and pelvis 3 months earlier negative).(CT of abdomen and pelvis 3 months earlier negative).
Liver cancer
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Triphasic Liver CT: Segment III 3.5 cm massTriphasic Liver CT: Segment III 3.5 cm mass
Liver cancer
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Principles of Surgery for HCCPrinciples of Surgery for HCC
Mortality <5%Mortality <5%
Five-year survival rates > 50%Five-year survival rates > 50%– 70% in patients with early 70% in patients with early
stage HCC and preserved stage HCC and preserved liver function. liver function.
Recurrence at 5 yrs>75%Recurrence at 5 yrs>75%
Careful patient selection: Careful patient selection: – ComorbiditiesComorbidities– Tumor characteristicsTumor characteristics– Size and function of future Size and function of future
liver remnantliver remnant
Liver transplantation for Liver transplantation for patients meeting UNOS criteria patients meeting UNOS criteria – Single lesion Single lesion << 5cm 5cm– 2 or 3 lesions 2 or 3 lesions << 3 cm 3 cm
Liver cancer
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Case 3: Hepatocellular CarcinomaCase 3: Hepatocellular Carcinoma
Laparoscopic resection of Laparoscopic resection of segment IIIsegment III
Length of stay 5 daysLength of stay 5 days
Bone metastasis @ 7 mos Bone metastasis @ 7 mos
Liver cancer
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Epidemiology of Colorectal CancerEpidemiology of Colorectal Cancer
Estimated U.S. incidence of Estimated U.S. incidence of colorectal cancer: 142,570/yearcolorectal cancer: 142,570/year11
51,370 deaths51,370 deaths
50% of patients will be 50% of patients will be diagnosed with liver metastases diagnosed with liver metastases
Liver resection->long-term Liver resection->long-term survivalsurvival – 5 year survival: 25-58%5 year survival: 25-58%
– Surgical techniquesSurgical techniques
– ChemotherapyChemotherapy
– Unresectable->resectableUnresectable->resectable
1Jemal A, et al., CA Cancer J Clin, 2010; 60:27-300.2 http://www.hopkinsmedicine.org.
Liver cancer
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Determinants of Outcome for CRC Determinants of Outcome for CRC Liver Metastases: Fong ScoreLiver Metastases: Fong Score
• Extrahepatic disease• Positive margins• Node (+) colorectal primary• Disease-free interval < 1 year• More than 1 hepatic tumor• Largest hepatic tumor > 5 cm• CEA > 200 ng/mL
Fong et al Ann Surg 1999;230:309
Liver cancer
Fong Y, et al., Ann Surg. 1999 Sep;230(3):309-318.
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Preoperative Portal Vein Embolization Can Preoperative Portal Vein Embolization Can Increase the Future Liver RemnantIncrease the Future Liver Remnant
PVEPVE
1Chun YS, et al., J Gastrointest Surg. 2008 Jan;12(1):123-8.
Liver cancer
Percent ResectionPercent Resection– FLR/TLV 0.20 (20%)FLR/TLV 0.20 (20%)11
>40% for cirrhotics, Child’s A>40% for cirrhotics, Child’s A
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>1 cm Margins are Preferred, >1 cm Margins are Preferred, but > 1 mm Margins are Favorablebut > 1 mm Margins are Favorable
• Multivariate analysis (n=1019)• > 1 tumor
• Size > 5 cm
• Node positive primary
• Bilateral resection
• Margins
Margin N (%) Median survival (mo) P
Involved/<1mm 112 (11) 30 mos Ref
1 – 10 mm 563 (55) 42 mos <0.01
> 10 mm 344 (33) 55 mos <0.01
1Are C, et al., Ann Surg. 2007 Aug;246(2):295-300.
Liver cancer
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SummarySummary
Laparoscopic liver resections are safe and oncologically Laparoscopic liver resections are safe and oncologically sound in highly selected patients in the hands of surgeons sound in highly selected patients in the hands of surgeons with a laparoscopic skill set.with a laparoscopic skill set.
Patients with malignant liver tumors (primary or metastatic) Patients with malignant liver tumors (primary or metastatic) can be considered for resection based on tumor can be considered for resection based on tumor characteristics, future liver remnant size and function, and characteristics, future liver remnant size and function, and patient comorbidities.patient comorbidities.
Liver cancer
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Radiofrequency AblationRadiofrequency Ablation
High-frequency alternating current flows High-frequency alternating current flows from electrical probe through tissue to from electrical probe through tissue to groundground– Ionic agitation results in frictional heating and Ionic agitation results in frictional heating and
coagulation of surrounding tissuecoagulation of surrounding tissue
Probe insertion
Extension of prongs
RF current application
Liver cancer
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Radiofrequency AblationRadiofrequency Ablation
Liver cancer
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Pre-ablation 3-days post 2 months post
Radiofrequency AblationRadiofrequency Ablation
Liver cancer
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Radiofrequency AblationRadiofrequency Ablation
AdvantagesAdvantages– Performed Performed
percutaneously, percutaneously, laparoscopically, or at laparoscopically, or at laparotomylaparotomy
– Low complication rateLow complication rateMay be related to size May be related to size of ablation (<3 cm)of ablation (<3 cm)
DisadvantagesDisadvantages– Poor performance Poor performance
near blood vesselsnear blood vessels– One probeOne probe
Many tumors require Many tumors require multiple, overlapping multiple, overlapping ablationsablations
– SlowSlow
Liver cancer
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Microwave AblationMicrowave Ablation
Theoretical advantages over RFATheoretical advantages over RFA– Larger zone of active heatingLarger zone of active heating
Possibly better performance near blood vesselsPossibly better performance near blood vessels
– Hotter temperatureHotter temperature– Use of multiple probesUse of multiple probes
Liver cancer
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Microwave AblationMicrowave Ablation
Liver cancer
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Factors Determining Factors Determining Resectability of CRC MetsResectability of CRC Mets
Fong Score (CRC mets)Fong Score (CRC mets)– Fong et al. Fong et al. Ann Surg Ann Surg 19991999
••Functional hepatic reserveFunctional hepatic reserve– Child-Pugh scoreChild-Pugh score– MELD scoreMELD score– Volumetric calculationsVolumetric calculations
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Resectability of Colorectal Cancer Resectability of Colorectal Cancer MetastasesMetastases
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After portal vein embolization, left liver hypertrophied and right liver atrophied
Metastases resected
Staged ResectionsStaged Resections
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Hepatocellular CarcinomaHepatocellular CarcinomaRisk FactorsRisk Factors
Hepatitis B viral infectionHepatitis B viral infection– Asia and AfricaAsia and Africa
Hepatitis C viral infectionHepatitis C viral infection– Europe, Japan, North AmericaEurope, Japan, North America
Inherited errors of metabolismInherited errors of metabolism– Hemochromatosis, alpha 1-antitrypsin deficinecy, Wilson’s diseaseHemochromatosis, alpha 1-antitrypsin deficinecy, Wilson’s disease
Autoimmune hepatitisAutoimmune hepatitis
Primary biliary cirrhosisPrimary biliary cirrhosis
Excessive alcohol intakeExcessive alcohol intake
Aflatoxin exposureAflatoxin exposure
Non-alcoholic fatty liver diseaseNon-alcoholic fatty liver disease
Liver cancer
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Margins and HCCMargins and HCCRandomized prospective trialRandomized prospective trial
169 patients randomized169 patients randomized
2 cm vs 1 cm margin2 cm vs 1 cm margin
Actual margin 1.9 vs 0.7 cmActual margin 1.9 vs 0.7 cm
Well matchedWell matched
Improved survival in wide marginImproved survival in wide margin
Shi M, et al., Ann Surg 2007, 245(1):36-43.
Liver cancer
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Local Recurrence Rates for RFALocal Recurrence Rates for RFA
Mulier S, et al., Ann Surg. 2005 Aug;242(2):158-71.
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Liver cancer