RESUMO
OBJECTIVE: This study assessed the cost-effectiveness of radiofrequency ablation compared with percutaneous ethanol injection in patients with early hepatocellular carcinoma in relation to the objective response rate and costs related to the procedure. METHODS: This was a prospective single-center randomized trial. The primary outcome was cost-effectiveness. Secondary outcomes were the complete response rate according to the modified response evaluation criteria in solid tumors 60 days after randomization and the complication rate within 180 60 days. RESULTS: Fifty patients were placed into the following groups: percutaneous ethanol injection (n=23) and radiofrequency ablation (n=27). Fifty-four nodules were randomized (mean follow-up: 205.37 days). The estimated mean hospital cost was US$ 1854.11 and US$ 2770.96 for the Radiofrequency Ablation and Percutaneous Ethanol Injection Groups, respectively. The incremental cost-effectiveness ratio was US$ -2674.59, which is advantageous for radiofrequency ablation. After 60 d, 28 of 29 nodules in the Radiofrequency Ablation Group achieved complete response versus 12 of 22 in the Percutaneous Ethanol Injection Group (RD, 42.01 [95%CI= 20.55-63.24]; p<0.001). Only four early complications were observed among patients treated by percutaneous ethanol injection (p<0.05). Late complications occurred in two and one patient(s) in the Radiofrequency Ablation and Percutaneous Ethanol Injection Groups (p>0.05), respectively. CONCLUSION: Radiofrequency ablation was more cost-effective and achieved higher complete response and lower complication rates than the Percutaneous Ethanol Injection Group within this cohort. REGISTRY OF CLINICAL TRIALS: NCT06450613.
Assuntos
Carcinoma Hepatocelular , Análise Custo-Benefício , Etanol , Neoplasias Hepáticas , Ablação por Radiofrequência , Humanos , Etanol/administração & dosagem , Etanol/economia , Neoplasias Hepáticas/economia , Neoplasias Hepáticas/tratamento farmacológico , Neoplasias Hepáticas/cirurgia , Carcinoma Hepatocelular/economia , Carcinoma Hepatocelular/tratamento farmacológico , Carcinoma Hepatocelular/terapia , Masculino , Feminino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Idoso , Ablação por Radiofrequência/economia , Ablação por Radiofrequência/métodos , Injeções Intralesionais/economia , Ablação por Cateter/economia , Ablação por Cateter/métodosRESUMO
OBJECTIVE: To investigate how individual social determinants of health (SDOH) and cumulative social disadvantage (CSD) affect survival and receipt of liver transplant (LT) in patients with hepatocellular carcinoma (HCC). METHODS: We enrolled 139 adult patients from two Indianapolis hospital systems between June 2019 and April 2022. Structured questionnaires collected SDOH and social risk factor data. We compared SDOH and CSD by race, gender and disease aetiology, assigning one point per adverse SDOH. Multivariable competing risk survival analysis assessed associations between SDOH, CSD, survival and LT receipt. RESULTS: Black patients experienced higher CSD than white patients in the cohort (5.4±2.5 vs 3.2±2.1, p<0.001). Black patients were significantly more likely to have household incomes Assuntos
Carcinoma Hepatocelular
, Letramento em Saúde
, Neoplasias Hepáticas
, Transplante de Fígado
, Determinantes Sociais da Saúde
, Humanos
, Carcinoma Hepatocelular/cirurgia
, Carcinoma Hepatocelular/mortalidade
, Masculino
, Feminino
, Neoplasias Hepáticas/cirurgia
, Neoplasias Hepáticas/mortalidade
, Transplante de Fígado/estatística & dados numéricos
, Pessoa de Meia-Idade
, Letramento em Saúde/estatística & dados numéricos
, Estudos Prospectivos
, Determinantes Sociais da Saúde/estatística & dados numéricos
, Idoso
, Fatores de Risco
, Fatores Socioeconômicos
, Adulto
, Estados Unidos/epidemiologia
, Análise de Sobrevida
RESUMO
BACKGROUND: Surgical resection and liver transplantation (LT) are the most effective curative options for hepatocellular carcinoma (HCC). However, few patients with huge HCC (> 10 cm in diameter), especially those with portal vein tumor thrombus (PVTT), can receive these treatments. Selective internal radiation therapy (SIRT) can be used as a conversion therapy for them because it has the dual benefit of shrinking tumors and increasing residual hepatic volume. However, in patients with huge HCC, high lung absorbed dose often prevents them from receiving SIRT. CASE SUMMARY: A 35-year-old man was admitted because of emaciation and pain in the hepatic region for about 1 month. The computed tomography scan showed a 20.2 cm × 19.8 cm tumor located in the right lobe-left medial lobes with right portal vein and right hepatic vein invasion. After the pathological type of HCC was confirmed by biopsy, two conversions were presented. The first one was drug-eluting bead transarterial chemoembolization plus hepatic arterial infusion chemotherapy and lenvatinib and sintilimab, converted to SIRT, and the second one was sequential SIRT with continued systemic treatment. The tumor size significantly decreased from 20.2 cm × 19.8 cm to 16.2 cm × 13.8 cm, then sequentially to 7.8 cm × 6.8 cm. In the meantime, the ratio of spared volume to total liver volume increased gradually from 34.4% to 55.7%, then to 62.9%. Furthermore, there was visualization of the portal vein, indicating regression of the tumor thrombus. Finally, owing to the new tumor in the left lateral lobe, the patient underwent LT instead of resection without major complications. CONCLUSION: Patients with inoperable huge HCC with PVTT could be converted to SIRT first and accept surgery sequentially.
Assuntos
Carcinoma Hepatocelular , Neoplasias Hepáticas , Transplante de Fígado , Invasividade Neoplásica , Veia Porta , Humanos , Carcinoma Hepatocelular/patologia , Carcinoma Hepatocelular/terapia , Carcinoma Hepatocelular/cirurgia , Carcinoma Hepatocelular/diagnóstico por imagem , Masculino , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/terapia , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/diagnóstico por imagem , Veia Porta/patologia , Veia Porta/diagnóstico por imagem , Veia Porta/cirurgia , Transplante de Fígado/métodos , Adulto , Resultado do Tratamento , Quimioembolização Terapêutica/métodos , Compostos de Fenilureia/uso terapêutico , Compostos de Fenilureia/administração & dosagem , Tomografia Computadorizada por Raios X , Fígado/patologia , Fígado/diagnóstico por imagem , Fígado/cirurgia , QuinolinasRESUMO
BACKGROUND: One of the main limitations to achieving a complete tumor resection in patients with technically resectable liver tumors is the presence of a small future liver remnant (FLR). Portal vein embolization (PVE) allows hypertrophy of the non-embolized lobe, reducing the risk of postoperative liver failure. AIM: To describe the experience of portal embolization prior to hepatectomy and its effectiveness in converting advanced unresectable liver tumors into resectable tumors. METHODS: Non-concurrent cohort study. All patients who underwent PVE before hepatectomy between 2016 and 2020 in our center were included. Demographic and diagnostic variables, pre and post-PVE volumes, perioperative variables, and global and disease-free survival were analyzed. RESULTS: Nineteen patients were included. Median age 66 (54-72) years and 57.9% (n= 11) were women. Bilateral metastases were present in 78.9% (n= 15). Sixteen patients (84.2%) received neoadjuvant chemotherapy. One patient (5.3%) had a complication after PVE. The median time between embolization and volumetry was 5.3 weeks (4.7-7.1). Median FLR before and after PVE were 19.8% (16.2-27.7) and 30% (25.2-40.5), respectively. The median percentage of hypertrophy was 48% (40.4-76.5). Fifteen patients (78.9%) underwent hepatectomy. Significant complications occurred in 26.6% (n= 4); among them, three patients (20%) presented postoperative liver failure. CONCLUSIONS: PVE is safe and effective in promoting FLR hypertrophy in the presence of chemotherapy, allowing patients with advanced liver tumors to undergo surgery with curative intent.
Assuntos
Embolização Terapêutica , Hepatectomia , Neoplasias Hepáticas , Veia Porta , Humanos , Hepatectomia/métodos , Feminino , Embolização Terapêutica/métodos , Pessoa de Meia-Idade , Masculino , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/terapia , Idoso , Chile , Resultado do Tratamento , Estudos Retrospectivos , Intervalo Livre de Doença , Cuidados Pré-Operatórios/métodosRESUMO
OBJECTIVE: The purpose of this study was to determine and compare the performance of pre-treatment clinical risk score (CRS), radiomics models based on computed (CT), and their combination for predicting time to recurrence (TTR) and disease-specific survival (DSS) in patients with colorectal cancer liver metastases. METHODS: We retrospectively analyzed a prospectively maintained registry of 241 patients treated with systemic chemotherapy and surgery for colorectal cancer liver metastases. Radiomics features were extracted from baseline, pre-treatment, contrast-enhanced CT images. Multiple aggregation strategies were investigated for cases with multiple metastases. Radiomics signatures were derived using feature selection methods. Random survival forests (RSF) and neural network survival models (DeepSurv) based on radiomics features, alone or combined with CRS, were developed to predict TTR and DSS. Leveraging survival models predictions, classification models were trained to predict TTR within 18 months and DSS within 3 years. Classification performance was assessed with area under the receiver operating characteristic curve (AUC) on the test set. RESULTS: For TTR prediction, the concordance index (95% confidence interval) was 0.57 (0.57-0.57) for CRS, 0.61 (0.60-0.61) for RSF in combination with CRS, and 0.70 (0.68-0.73) for DeepSurv in combination with CRS. For DSS prediction, the concordance index was 0.59 (0.59-0.59) for CRS, 0.57 (0.56-0.57) for RSF in combination with CRS, and 0.60 (0.58-0.61) for DeepSurv in combination with CRS. For TTR classification, the AUC was 0.33 (0.33-0.33) for CRS, 0.77 (0.75-0.78) for radiomics signature alone, and 0.58 (0.57-0.59) for DeepSurv score alone. For DSS classification, the AUC was 0.61 (0.61-0.61) for CRS, 0.57 (0.56-0.57) for radiomics signature, and 0.75 (0.74-0.76) for DeepSurv score alone. CONCLUSION: Radiomics-based survival models outperformed CRS for TTR prediction. More accurate, noninvasive, and early prediction of patient outcome may help reduce exposure to ineffective yet toxic chemotherapy or high-risk major hepatectomies.
Assuntos
Neoplasias Colorretais , Neoplasias Hepáticas , Tomografia Computadorizada por Raios X , Humanos , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/cirurgia , Neoplasias Colorretais/patologia , Neoplasias Colorretais/diagnóstico por imagem , Neoplasias Colorretais/cirurgia , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Tomografia Computadorizada por Raios X/métodos , Estudos Retrospectivos , Prognóstico , Recidiva Local de Neoplasia/diagnóstico por imagem , Recidiva Local de Neoplasia/patologia , Resultado do Tratamento , Adulto , RadiômicaRESUMO
Sarcomas are challenging and conventionally referred to sarcoma specialist centres. In select cases with required surgical expertise, collaboration with a quaternary sarcoma centre rather than an upfront transfer of care may reduce logistic challenges without compromising patient care.We present a case series of three rare tumours of hepatobiliary origin-two cases of undifferentiated embryonal liver sarcoma in adults and one case of follicular dendritic sarcoma of the cystic lymph node.All three patients underwent surgery in a non-sarcoma specialist centre by hepatobiliary specialist surgeons with concurrent remote referrals to a sarcoma specialist quaternary centre. Both centres belong to the same cluster. R0 resection and no significant postoperative morbidity were achieved. All three patients currently remain disease-free.The unique and integrated healthcare systems within Singapore render cross-institution management possible. This case series suggests that an established setup for cross-centre collaboration facilitates wholistic patient care with good outcomes.
Assuntos
Hospitais de Ensino , Neoplasias Hepáticas , Sarcoma , Humanos , Sarcoma/cirurgia , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/patologia , Masculino , Feminino , Adulto , Singapura , Pessoa de Meia-Idade , Hepatectomia/métodosRESUMO
BACKGROUND: Evaluation of the influence of the age of the patients upon the outcomes of liver resection (LR) for hepatocellular carcinoma (HCC). METHODS: HCC patients who underwent LR between 2010 and 2020 were analyzed. They were divided into 3 groups depending on the patient's age. Group I (patients less than 60 years), Group II (patients between 60 and 69 years), and Group III (patients equal to or more than 70 years). RESULTS: 364 patients were included. A significantly higher serum bilirubin and alpha feto-protein were noted in Group I and serum creatinine was noted in Group III. The study groups did not show any significant differences regarding HCC site, number, macrovascular invasion, the extent of LR, Pringle maneuver, and perioperative blood transfusions. Longer operation time was found in Groups II and III, while more blood loss was noted in Group (I) Group I patients had longer hospital stays. Higher postoperative morbidities were noted in both Group I and Group (II) Higher incidence of post-hepatectomy liver dysfunction was noted in Group I. More early mortalities were found in Group I, related to liver failure. We did not experience early mortality in Group (III) Late Mortalities occurred in 117 patients (32.1%). HCC recurrence occurred in 165 patients (45.3%). Regarding the overall- and tumor-free survival, we did not experience any significant differences among the 3 groups (Log Rank: p = 0.371 and 0.464 respectively). CONCLUSIONS: Curative LR can be safely performed in selected elderly patients with HCC. An advanced patient's age should not be considered as a contraindication for curative LR.
Assuntos
Carcinoma Hepatocelular , Hepatectomia , Neoplasias Hepáticas , Humanos , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/mortalidade , Carcinoma Hepatocelular/cirurgia , Carcinoma Hepatocelular/mortalidade , Hepatectomia/métodos , Idoso , Masculino , Feminino , Pessoa de Meia-Idade , Fatores Etários , Estudos Retrospectivos , Resultado do Tratamento , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Idoso de 80 Anos ou mais , Adulto , Duração da Cirurgia , Tempo de Internação/estatística & dados numéricosRESUMO
BACKGROUND: Hepatocellular adenoma (HCA) is a rare benign neoplasm, seldom ascribed as the cause of endocrine and metabolic derangement. We herein report a case of primary amenorrhea, growth arrest and metabolic syndrome. En bloc resection of the tumor normalized all the disturbances. CASE PRESENTATION: A 16-year-old girl complained of primary amenorrhea and growth arrest for the past 2 years. Her height and weight were at the 3rd percentile, whereas waist circumference was at the 90th percentile for chronological age. She was hypertensive on admission. Plasma cholesterol, triglyceride and uric acid were elevated. Evaluation of GH/IGF-1 axis showed extremely low IGF-1 concentration, which was unresponsive to hGH stimulation. Computer tomography identified a huge liver mass (18.2 cm×13.7 cm×21 cm). The patient underwent an uneventful open right hepatic lobectomy. The tumor was en bloc resected. Immunohistochemistry indicated an unclassified HCA, which was confirmed by genetic screening. IGF-1 concentration, blood pressure, lipid profile and ovarian function were all normalized after surgery, and the girl had reduction in waist circumference and gain in height during the follow up. CONCLUSION: We provide evidence that liver-derived IGF-1 has a direct effect on skeletal and pubertal development, blood pressure, visceral adiposity and dyslipidemia independent of insulin resistance and obesity in the circumstance of undernutrition. Though rare, we propose the need to look into HCA cases for the existence of IGF-1 deficiency and its impact on metabolic derangement.
Assuntos
Adenoma de Células Hepáticas , Amenorreia , Fator de Crescimento Insulin-Like I , Neoplasias Hepáticas , Síndrome Metabólica , Humanos , Feminino , Síndrome Metabólica/complicações , Adolescente , Fator de Crescimento Insulin-Like I/metabolismo , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/complicações , Adenoma de Células Hepáticas/patologia , Adenoma de Células Hepáticas/cirurgia , Adenoma de Células Hepáticas/complicações , Adenoma de Células Hepáticas/etiologia , Amenorreia/etiologia , Seguimentos , Transtornos do Crescimento/etiologia , Transtornos do Crescimento/complicações , Transtornos do Crescimento/patologia , Prognóstico , Peptídeos Semelhantes à InsulinaRESUMO
BACKGROUND: Colorectal cancer ranks among the most prevalent malignancies globally. Accurate prediction of metachronous liver metastasis is crucial for optimizing postoperative management. Tripartite motif-containing protein 27 (TRIM27), an E3 ubiquitin ligase, is implicated in diverse cellular functions and tumorigenesis. METHODS: This study aimed to develop and validate a TRIM27-based nomogram for prognostication in colorectal cancer patients. Transcriptome sequencing of five paired tumor and normal tissue samples identified TRIM27 as a potential prognostic biomarker. Immunohistochemistry was employed to assess TRIM27 expression in colorectal cancer cohorts from two institutions. RESULTS: TRIM27 expression correlated significantly with both the prognosis of colorectal cancer patients and the occurrence of metachronous liver metastasis. A nomogram incorporating TRIM27 and clinical factors was constructed and demonstrated robust predictive accuracy in an independent validation cohort. CONCLUSION: The TRIM27-based nomogram is a valuable prognostic tool for predicting prognosis and metachronous liver metastasis in colorectal cancer patients, aiding in personalized treatment decisions.
Assuntos
Biomarcadores Tumorais , Neoplasias Colorretais , Neoplasias Hepáticas , Nomogramas , Humanos , Neoplasias Colorretais/patologia , Neoplasias Colorretais/cirurgia , Neoplasias Colorretais/genética , Neoplasias Colorretais/metabolismo , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/metabolismo , Neoplasias Hepáticas/genética , Masculino , Feminino , Prognóstico , Pessoa de Meia-Idade , Biomarcadores Tumorais/metabolismo , Biomarcadores Tumorais/genética , Idoso , Período Pós-Operatório , Ubiquitina-Proteína Ligases/metabolismo , Ubiquitina-Proteína Ligases/genética , Segunda Neoplasia Primária/patologia , Segunda Neoplasia Primária/metabolismo , Segunda Neoplasia Primária/genética , Proteínas com Motivo Tripartido , Proteínas de Ligação a DNA , Proteínas NuclearesRESUMO
BACKGROUND: The prognostic implications of the RAS status in colorectal cancer liver metastasis (CRLM) remain unclear. This study investigated the prognostic significance of RAS status after curative hepatectomy, focusing on surgical controllability. METHODS: This retrospective study included liver-only CRLM patients who underwent the first hepatectomy between 2015 and 2022 at the National Cancer Center Hospital. Recurrence-free survival (RFS), surgically controllable period (SCP), and overall survival (OS) were compared between RAS wild-type (RAS-wt) and mutant (RAS-mt) patients. Multivariate analyses were conducted to identify independent prognostic factors for each outcome and independent risk factors for less than 1 year SCP. RESULTS: A total of 150 patients were evaluated, comprising 63 patients with RAS-mt status. There was no significant difference in RFS between RAS-mt and RAS-wt (7.00 vs. 8.03 months, p = 0.48). RAS-mt patients exhibited worse SCP (11.80 vs.21.13 months, p < 0.001) and OS (44.03 vs. 70.03 months, p < 0.001) compared to RAS-wt. Multivariate analysis identified RAS-mt as an independent prognostic factor for both OS (hazard ratio [HR]: 3.37, p < 0.001) and SCP (HR: 2.20, p < 0.001), and as an independent risk factor for less than 1 year of SCP (odds ratio, 2.31; p = 0.03). CONCLUSIONS: CRLM with RAS mutations should be considered for strict surgical indications with preoperative chemotherapy and thorough examination, considering the possibility of short SCP.
Assuntos
Neoplasias Colorretais , Hepatectomia , Neoplasias Hepáticas , Mutação , Humanos , Estudos Retrospectivos , Masculino , Neoplasias Colorretais/patologia , Neoplasias Colorretais/genética , Neoplasias Colorretais/cirurgia , Neoplasias Colorretais/mortalidade , Feminino , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/genética , Neoplasias Hepáticas/mortalidade , Pessoa de Meia-Idade , Hepatectomia/métodos , Prognóstico , Taxa de Sobrevida , Idoso , Seguimentos , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/genética , Recidiva Local de Neoplasia/cirurgia , Recidiva Local de Neoplasia/epidemiologia , Adulto , Biomarcadores Tumorais/genéticaRESUMO
Local ablation for hepatocellular carcinoma, a non-surgical option that directly targets and destroys tumor cells, has advanced significantly since the 1990s. Therapies with different energy sources, such as radiofrequency ablation, microwave ablation, and cryoablation, employ different mechanisms to induce tumor necrosis. The precision, safety, and effectiveness of these therapies have increased with advances in guiding technologies and device improvements. Consequently, local ablation has become the first-line treatment for early-stage hepatocellular carcinoma. The lack of organized evidence and expert opinions regarding patient selection, preprocedure preparation, procedural methods, swift post-treatment evaluation, and follow-up has resulted in clinicians following varied practices. Therefore, an expert consensus-based practical recommendation for local ablation was developed by a group of experts in radiology and hepatology from the Research Committee of the Korean Liver Cancer Association in collaboration with the Korean Society of Image-Guided Tumor Ablation to provide useful information and guidance for performing local ablation and for the pre- and post-treatment management of patients.
Assuntos
Carcinoma Hepatocelular , Consenso , Neoplasias Hepáticas , Neoplasias Hepáticas/cirurgia , Humanos , Carcinoma Hepatocelular/cirurgia , República da Coreia , Técnicas de Ablação/métodos , Seleção de Pacientes , Ablação por Cateter/métodos , Ablação por Radiofrequência/métodosRESUMO
Introduction: This study aims to use machine learning to conduct in-depth analysis of key factors affecting the recurrence of HCC patients with high preoperative systemic immune-inflammation index (SII) levels after receiving ablation treatment, and based on this, construct a nomogram model for predicting recurrence-free survival (RFS) of patients. Methods: This study included clinical data of 505 HCC patients who underwent ablation therapy at Beijing You'an Hospital from January 2014 to January 2020, and accepted 65 HCC patients with high SII levels from Beijing Ditan Hospital as an external validation cohort. 505 patients from Beijing You'an Hospital were divided into low SII and high SII groups based on the optimal cutoff value of SII scores. The high SII group was further randomly divided into training and validation cohorts in a 7:3 ratio. eXtreme Gradient Boosting (XGBoost), random survival forest (RSF), and multivariate Cox regression analysis, were used to explore the factors affecting the post-ablation RFS of HCC patients. Based on the identified key factors, a nomogram model were developed to predict RFS in HCC patients, and their performance were evaluated using the concordance index (C index), receiver operating characteristic curve (ROC), calibration curve, and decision curve analysis (DCA). The optimal cutoff value for nomogram scores was used to divide patients into low- and high-risk groups, and the effectiveness of the model in risk stratification was evaluated using Kaplan-Meier (KM) survival curves. Results: This study confirmed that age, BCLC stage, tumor number, and GGT level were independent risk factors affecting RFS in HCC patients. Based on the selected risk factors, an RFS nomogram was successfully constructed. The C-index, ROC curve, calibration curve, and DCA curve each demonstrated the discrimination, accuracy, and decision-making utility of the nomogram, indicating that it has good predictive performance. KM curve revealed the nomogram could significantly differentiate patient populations with different recurrence risk. Conclusion: We developed a reliable nomogram that can accurately predict the 1-, 3-, and 5-year RFS for HCC patients with high SII levels following ablation therapy.
Assuntos
Carcinoma Hepatocelular , Neoplasias Hepáticas , Aprendizado de Máquina , Recidiva Local de Neoplasia , Nomogramas , Humanos , Neoplasias Hepáticas/imunologia , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/diagnóstico , Carcinoma Hepatocelular/imunologia , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/cirurgia , Carcinoma Hepatocelular/patologia , Masculino , Feminino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/imunologia , Prognóstico , Inflamação/imunologia , Idoso , Fatores de Risco , AdultoRESUMO
BACKGROUND: We have previously reported a saline-linked bipolar clamp-crush technique as a novel robotic liver resection method. Herein, we present the surgical techniques and outcomes of robotic left hepatectomy using the Glissonean approach and our liver transection technique. METHODS: The key procedures included the following: (1) encircling the left Glissonean pedicle using the Tip-Up fenestrated grasper, (2) dissecting the liver parenchyma using the saline-linked bipolar clamp-crush technique, (3) moving the endoscope one trocar to the right to facilitate visualisation of the liver transection plane, and (4) stapling the left pedicle and left hepatic vein. Seven robotic left hepatectomies were performed. RESULTS: The median operative time and estimated blood loss were 395 min and 50 mL, respectively. The median length of postoperative hospital stay was 9 days. Pneumothorax was the only severe postoperative complication. CONCLUSIONS: Robotics left hepatectomy using the Glissonean approach and the saline-linked bipolar clamp-crush technique appears safe and feasible.
Assuntos
Hepatectomia , Duração da Cirurgia , Procedimentos Cirúrgicos Robóticos , Hepatectomia/métodos , Humanos , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Robóticos/instrumentação , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Fígado/cirurgia , Perda Sanguínea Cirúrgica/prevenção & controle , Neoplasias Hepáticas/cirurgia , Tempo de Internação , Adulto , Resultado do Tratamento , Instrumentos CirúrgicosRESUMO
BACKGROUND: Despite the increasing efficacy of chemotherapy, permanently unresectable colorectal liver metastases are associated with poor long-term survival. We aimed to assess whether liver transplantation plus chemotherapy could improve overall survival. METHODS: TransMet was a multicentre, open-label, prospective, randomised controlled trial done in 20 tertiary centres in Europe. Patients aged 18-65 years, with Eastern Cooperative Oncology Group performance score 0-1, permanently unresectable colorectal liver metastases from resected BRAF-non-mutated colorectal cancer responsive to systemic chemotherapy (≥3 months, ≤3 lines), and no extrahepatic disease, were eligible for enrolment. Patients were randomised (1:1) to liver transplantation plus chemotherapy or chemotherapy alone, using block randomisation. The liver transplantation plus chemotherapy group underwent liver transplantation for 2 months or less after the last chemotherapy cycle. At randomisation, the liver transplantation plus chemotherapy group received a median of 21·0 chemotherapy cycles (IQR 18·0-29·0) versus 17·0 cycles (12·0-24·0) in the chemotherapy alone group, in up to three lines of chemotherapy. During first-line chemotherapy, 64 (68%) of 94 patients had received doublet chemotherapy and 30 (32%) of 94 patients had received triplet regimens; 76 (80%) of 94 patients had targeted therapy. Transplanted patients received tailored immunosuppression (methylprednisolone 10 mg/kg intravenously on day 0; tacrolimus 0·1 mg/kg via gastric tube on day 0, 6-10 ng/mL days 1-14; mycophenolate mofetil 10 mg/kg intravenously day 0 to <2 months and switch to everolimus 5-8 ng/mL), and postoperative chemotherapy, and the chemotherapy group had continued chemotherapy. The primary endpoint was 5-year overall survival analysed in the intention to treat and per-protocol population. Safety events were assessed in the as-treated population. The study is registered with ClinicalTrials.gov (NCT02597348), and accrual is complete. FINDINGS: Between Feb 18, 2016, and July 5, 2021, 94 patients were randomly assigned and included in the intention-to-treat population, with 47 in the liver transplantation plus chemotherapy group and 47 in the chemotherapy alone group. 11 patients in the liver transplantation plus chemotherapy group and nine patients in the chemotherapy alone group did not receive the assigned treatment; 36 patients and 38 patients in each group, respectively, were included in the per-protocol analysis. Patients had a median age of 54·0 years (IQR 47·0-59·0), and 55 (59%) of 94 patients were male and 39 (41%) were female. Median follow-up was 59·3 months (IQR 42·4-60·2). In the intention-to-treat population, 5-year overall survival was 56·6% (95% CI 43·2-74·1) for liver transplantation plus chemotherapy and 12·6% (5·2-30·1) for chemotherapy alone (HR 0·37 [95% CI 0·21-0·65]; p=0·0003) and 73·3% (95% CI 59·6-90·0) and 9·3% (3·2-26·8), respectively, for the per-protocol population. Serious adverse events occurred in 32 (80%) of 40 patients who underwent liver transplantation (from either group), and 69 serious adverse events were observed in 45 (83%) of 54 patients treated with chemotherapy alone. Three patients in the liver transplantation plus chemotherapy group were retransplanted, one of whom died postoperatively of multi-organ failure. INTERPRETATION: In selected patients with permanently unresectable colorectal liver metastases, liver transplantation plus chemotherapy with organ allocation priority significantly improved survival versus chemotherapy alone. These results support the validation of liver transplantation as a new standard option for patients with permanently unresectable liver-only metastases. FUNDING: French National Cancer Institute and Assistance Publique-Hôpitaux de Paris.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica , Neoplasias Colorretais , Neoplasias Hepáticas , Transplante de Fígado , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias Colorretais/patologia , Neoplasias Colorretais/tratamento farmacológico , Terapia Combinada , Imunossupressores/uso terapêutico , Imunossupressores/administração & dosagem , Neoplasias Hepáticas/tratamento farmacológico , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/cirurgia , Estudos Prospectivos , Resultado do TratamentoRESUMO
Objective The influence of macrovascular invasion on the therapeutic efficacy of Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) in hepatocellular carcinoma (HCC) patients has not been previously reported. This study primarily examines the therapeutic effect of ALPPS in treating HCC with macrovascular invasion. Methods 89 patients who underwent ALPPS at the First Affiliated Hospital of Guangxi Medical University from December 2016 to December 2021 were included. Patients were categorized into three groups based on macrovascular invasion status: pure HCC, HCC with portal vein tumor thrombus (PVTT), and HCC with hepatic vein tumor thrombus (HVTT). Outcome measures such as postoperative complications, liver hyperplasia rates, and survival times were compared across the groups. Results The study comprised 44 patients without macrovascular invasion and 45 cases with it, including 37 PVTT and 8 HVTT cases. Patients with PVTT or HVTT had a higher rate of complications and liver failure after the first ALPPS stage compared to those without macrovascular invasion (P = 0.018, P = 0.036). This trend was also observed in the stratified analysis of severe complications. However, no significant differences were found in these outcomes after the second ALPPS stage among the groups. The volume and rate of future liver remnant proliferation between the two stages of ALPPS were not statistically different among the groups, with median overall survival times of 42, 39, and 33 months, and progression-free survival times of 30, 24, and 14 months, respectively (P = 0.412 and P = 0.281). Conclusion ALPPS for HCC with macrovascular invasion was considered safe, feasible, and effective, as it achieved therapeutic effects comparable to those in cases without macrovascular invasion.
Assuntos
Carcinoma Hepatocelular , Hepatectomia , Neoplasias Hepáticas , Invasividade Neoplásica , Veia Porta , Humanos , Hepatectomia/métodos , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/mortalidade , Carcinoma Hepatocelular/cirurgia , Carcinoma Hepatocelular/patologia , Carcinoma Hepatocelular/mortalidade , Masculino , Veia Porta/cirurgia , Veia Porta/patologia , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Ligadura/métodos , Taxa de Sobrevida , Seguimentos , Prognóstico , Complicações Pós-Operatórias/etiologia , Idoso , AdultoRESUMO
BACKGROUND: Microwave ablation (MWA) is widely used to eliminate colorectal liver metastases (CRLM). However, the risk of tumor recurrence is difficult to predict due to lack of reliable clinical and biological markers. Elevation of gamma-glutamyl transferase (GGT) and aspartate transaminase (AST) provides signals for liver inflammation and cancer progression. The present study evaluated the association between pre-ablation GGT to AST ratio index (GSR) and hepatic recurrence in patients with CRLM after MWA. METHODS: A retrospectively analyzed 192 CRLM patients who underwent MWA from January 2013 to December 2017. Pre-ablation GSR was classified into high (≤ 2.34) or low (> 2.34) using the upper quartile value. The prognostic value of GSR and other risk factors for liver progression-free survival (LPFS) and cancer-specific survival (CSS) were evaluated by univariate and multivariate analyses. RESULTS: High GSR was significantly associated with males (P = 0.041), the presence of cholelithiasis (P = 0.012), but not pre-ablation chemotherapy (P = 0.355), which caused significantly increased levels of GGT (P = 0.015) and AST (P = 0.008). GSR showed a significant association with LPFS and CSS through univariate analysis (P = 0.002 and 0.006) and multivariate analysis (P = 0.043 and 0.037). The subgroup analysis demonstrated no interaction between GSR and all variables except for distribution in the sub-analysis of LPFS. CONCLUSIONS: Our findings suggest that the pre-ablation GSR can be considered as a promising prognostic indicator for poor prognosis of patients with CRLM underwent MWA. TRIAL REGISTRATION: Not applicable.
Assuntos
Aspartato Aminotransferases , Neoplasias Colorretais , Neoplasias Hepáticas , Micro-Ondas , gama-Glutamiltransferase , Humanos , Masculino , Feminino , gama-Glutamiltransferase/sangue , Neoplasias Colorretais/patologia , Neoplasias Colorretais/sangue , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/sangue , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/mortalidade , Estudos Retrospectivos , Micro-Ondas/uso terapêutico , Pessoa de Meia-Idade , Aspartato Aminotransferases/sangue , Idoso , Prognóstico , Recidiva Local de Neoplasia/sangue , Biomarcadores Tumorais/sangue , Fatores de Risco , Adulto , Idoso de 80 Anos ou mais , Técnicas de AblaçãoRESUMO
INTRODUCTION: Robotic-assisted surgery has become increasingly popular because of its potential benefits. Anatomical liver resection (ALR) is a valuable strategy in hepatocellular carcinoma (HCC) management. ALR with indocyanine green (ICG) fluorescence navigation was reported as an effective solution for segment identification. We reported a simple and convenient "preoperative positive staining technique" for laparoscopic ALR to overcome some limitations. To our knowledge, this is the first report of robotic-assisted surgery in which ALR was performed using this technique. MATERIALS AND SURGICAL TECHNIQUE: A 69-year-old man presented with a 12-mm HCC in segment 8. Preoperative three-dimensional simulation images showed that the fourth-order branch of the portal vein was a tumor-bearing portal pedicle. After anesthesia induction, 1 mL of 0.025 mg/mL ICG was injected percutaneously into this branch under B-mode ultrasound guidance before pneumoperitoneum. A robotic laparoscope was inserted. The preoperative positive staining area was clearly stained on the liver surface with the Firefly mode on the da Vinci Xi system. Based on the demarcation line, the liver parenchymal resection was started. The ICG fluorescence staining area was checked frequently on the resected side of the liver transection plane. Subsequently, the fourth-order portal branch was identified with the ICG fluorescence technique and ligated. Finally, the specimen was resected. The operation took 352 min, with 10 mL of blood loss, and was completed without any operative problems. DISCUSSION: Although many cases are required, the proposed preoperative positive staining technique appears useful for accurate and precise surgery given the increasing application of robotic-assisted hepatectomy.