Liver Cancer Surgery

January 22, 2021

Information

Liver Symposium | January 21, 2021

Kevin Billingsley, MD, MBA

ID6096

To CiteDCA Citation Guide

00:00Offered by the smile or Liver
00:03cancer program and we want to.
00:07Go in the next three months,
00:10go through some of the aspects that
00:14are more novel in the treatment of
00:18able to sell a carcinoma liver cancer,
00:22and we asked some of our faculty,
00:25like Doctor
00:26Billingslea, another Madoff
00:28and Doctor Stein too.
00:30Teach us the novelty in their respective
00:33field as you know about the cell
00:37carcinoma is on the rise is becoming
00:40one of the most frequent and and
00:43little two models on our latitudes.
00:46And what is important to understand
00:49is that treatment of hepatocellular
00:52carcinoma is complex is a moving target.
00:55And then it takes a village.
00:58Here you see some of the our colleagues
01:01working with us to go through the
01:05different possible approaches to this
01:07patient an I have to tell you that
01:11this picture are in defect with.
01:13There are many other.
01:15Colleagues said they work with
01:18us with this patient,
01:20but today today we have the
01:23pleasure of having Doctor Kevin
01:25Billingslea carrying as a great
01:28pedigree in terms of these studies,
01:32they went to Stanford and then
01:35John Hopkins enjoy in the surgery
01:38residency at the Oregon Health.
01:41And after a fellowship at NCI an MSA KCC,
01:46he joined the faculty at the
01:48University of Washington Ann and
01:51became Chief of Surgical Oncology.
01:53Focusing of effort to be Jerry surgery,
01:56an anchoring Carissa for almost 16 year,
02:00and then we were.
02:02Fortunate enough to be able to recruit
02:06him as a Chief medical officer of the
02:10Smiler Hospital Ann You Cancer Center.
02:14And he came at the beginning of the year,
02:19and was instrumental in all our
02:21transformation that we went
02:23through because of the covid.
02:26And but in a way that made
02:29as reminding of our patients,
02:31so that nobody will be left behind.
02:35That. In addition,
02:36if I have to have had a personal note,
02:40is a really pleasant colleague. It's it's.
02:43It's just a joy working with them.
02:47And you always participate to
02:49our two more boards with the
02:53extremely helpful insight.
02:55And so.
02:57Without further
02:58ado, I'll I'll, I'll leave
03:00the stage to Doctor Billingslea.
03:06Coming.
03:10Oreo, thank you very much for that
03:16really gracious introduction.
03:18Let me just make sure that.
03:23Everyone seeing my slides.
03:30Has that look under folks? Yep, OK.
03:36Well, you know, thank you again.
03:38It's been an absolute absolute pleasure
03:41being here at yell for the past year and I
03:44am delighted to be here in a leadership role,
03:48but I will say one of the highlights
03:50of my clinical life,
03:52which is very important to me,
03:54has been the opportunity to participate
03:57in this liver tumor program.
03:59You know, under Mario's leadership and with
04:01the contribution of many other people, this.
04:04Program really represents that what we
04:07are aiming to develop in all of our of
04:12our disease sites and disease centers,
04:15which is a collaborative,
04:17multidisciplinary team that meets regularly,
04:20plans treatment prospectively collects
04:22data and continuously examines what we're
04:26doing to improve and optimize treatment
04:29for patients and moving the field forward.
04:32So it's it's it really is is
04:35a pleasure and an honor.
04:36So I'm a surgical oncologist by background,
04:40in clinical practice,
04:41and is Martin shared I've spent.
04:44The majority of my time in the past over.
04:49Close to 20 years focusing on both
04:52liver cancer and pancreatic cancer,
04:54but primarily liver cancer in liver surgery,
04:57and I think the management of this
05:00group of patients with a paddle
05:02cellular carcinoma in some ways is
05:05the most complicated set of patients
05:07I'm involved with because not only is
05:10the surgery technically complicated,
05:12will touch on that a little bit,
05:15but the decision-making about who to
05:17operate window operate who transplants.
05:20And who to treat with alternative?
05:22You know,
05:23oblativa or arterial therapies
05:25is also extremely complicated,
05:27and we'll talk more as we go along.
05:31But it it very much involves complex
05:34multidisciplinary decision making.
05:39You know, so was Mario
05:42indicated in the introduction?
05:44Apparel Center carcinoma remains one
05:46of our most daunting global public
05:49health challenges in the cancer arena.
05:52And if you look at this graphic.
05:56The incidence of the disease is going up.
06:01Only in North American,
06:04but basically around the world.
06:06And like many diseases,
06:08there is a greater burden of disease
06:11in under represented minorities
06:13and vulnerable populations.
06:15Although you know the overall incidence
06:19is creeping up in almost across the board.
06:24You know this is to a large degree due to
06:27the the underlying burden of viral hepatitis,
06:31principally hepatitis C.
06:33Here in North America and Europe.
06:36hepatitis B more in Asia.
06:38But really,
06:39the looming crisis on the
06:41horizon is the explosion of non
06:44alcoholic fatty liver disease,
06:46or so-called knaflich from a
06:48variety of sources and etiologies.
06:51But Nah fled is on track to.
06:54Be the largest and most
06:56significant indication for liver
06:58transplant in the coming years,
07:00and it is probably going to be
07:03the most prominent underlying
07:04contributor to a parasailer carcinoma,
07:07particularly as our antiviral
07:10therapies improve.
07:12So my focus today is going to be
07:15on surgical therapy and you know.
07:18Where do we stand in surgical
07:20treatment for for HTC in 2021?
07:23Well,
07:23I think there are many things that
07:27we can be proud of and be excited
07:30about and are causes for optimism.
07:33Surgical treatment for HCC as well
07:36as other liver tumors have really
07:39developed in the past 2020 years.
07:41In a in a number of ways we've
07:43seen a renaissance related to the
07:46introduction of minimally invasive
07:49techniques for liver surgery.
07:51I'm going to talk about both laparoscopic
07:54and robotic approaches in some detail.
07:57The way we action surgically come
07:59through the liver and divide,
08:01deliver surgically has changed.
08:03You know,
08:04we used to use a lot of crush plant.
08:08Now we almost do everything with
08:10energy sources and and more refined
08:13techniques such as acusa or herby.
08:16Our understanding of the anesthesia
08:18anesthesiology anesthetic component of
08:20this patient management is improved
08:22and we've minimized look blood
08:24loss through the use of low CVP.
08:27Anaesthesia taken together
08:28these developments as well as
08:31improved surgical training,
08:32expertise of lowered overall
08:35surgical mortality into the range
08:38of 1 to 3% after liver resection.
08:41Experience centers.
08:42Unfortunately,
08:43due to the nature of the disease,
08:46relatively few patients who present
08:48with HTC are surgical candidates,
08:51and this is due to the severity
08:54underlying liver disease of
08:56any variety of etiologies,
08:58viral hepatitis,
08:59as well as the extent of disease.
09:02Sometimes patients have smaller
09:04early stage disease,
09:06but it is not uncommon for us to see
09:09extensive and infiltrating disease with.
09:12Portal vein invasion and other
09:15sites of disease in the liberal
09:18or extra padick disease.
09:20So this combination of things often limits.
09:24The surgical candidacy of a variety
09:27of of many of the patients.
09:30So in my talk this evening,
09:32I'm going to really highlight a
09:34couple of a number of key areas
09:37of our current status.
09:38We're going to spend some time talking
09:41about the fact that this really
09:43is a dual challenge for surgeons,
09:45but also for every specialty who's
09:48involved in the care of this group of
09:51patients because we have to treat the
09:53underlying liver disease and the cancer
09:56were not just on cologist, we are.
09:58Hepatology oncologist dealing
10:00with both disease entities.
10:02You know, very few of our patients are nuts.
10:05Erotics in the western world,
10:07only about 5% of them.
10:09In Asia, about 40% of patients
10:11with HCC or non cirrhotic,
10:13so it's a different kind of clinical
10:16picture in other parts of the world.
10:18But for what we deal with
10:21many patients or cirrhotics.
10:23We will spend a brief bit of time talking
10:25about reception versus transplant.
10:28I'm not a transplant surgeon and I'm not.
10:31I won't claim a mantle of expertise in this,
10:34but I think any discussion of
10:36surgery in this disease has to
10:39at least mention transplant.
10:40Given its great importance in the
10:43management of this group of patients.
10:46I'm going to spend a fair bit of time
10:48talking about the process of patient
10:51selection for reception because it
10:53is truly a complex art and science
10:55that requires the input of a lot of
10:58people and will discuss that some.
11:00Talk about these technical developments,
11:02primarily the role evolving role
11:04of minimally invasive techniques.
11:06Talk some about techniques for
11:08patient optimization,
11:09and then I'm going to spend a bit of
11:11time talking about a few key special
11:15clinical populations who actually
11:17are good surgical candidates and we
11:19need to be keeping an eye out for.
11:22As we look at patients with
11:25liver disease in HCC,
11:27it is important to understand how we
11:30as clinicians think about the severity
11:33of their underlying liver disease
11:36because that is going to be one of the
11:40key drivers of our decision-making.
11:41You know,
11:42the classic clinical system is the
11:45so-called Child Pugh classification
11:47of cirrhosis.
11:48This was this is a very clinically
11:51driven system that relies on.
11:533 lab tests, bilirubin,
11:55albumin,
11:56prothrombin time as well as
11:58two clinical assessments.
11:59The presence of in severity of
12:02ascites and Vatican several opathy
12:04the child Pugh system was originally
12:07developed to predict mortality
12:09for portosystemic shunt surgery,
12:11but it has evolved over years to predict
12:14mortality after other interventions,
12:17including liver resection, patients are
12:19assigned one up to one to three points.
12:23For each of these criteria.
12:25Adding up to a scale in their
12:29classified Childs AB or C.
12:31In more recent years,
12:33particularly relating the transplant arena,
12:36we've adopted the MELD classification so
12:39called model for in stage liver disease.
12:42The MELD score is less subjective,
12:45it is there's no.
12:48Wrote clinical assessment.
12:49It relies on 3 lab values,
12:53creatinine,
12:53bilirubin and INR.
12:55Anna calculation and is used and is
12:58used predominantly as a risk predictor
13:01in a mortality predictor for patients
13:05awaiting liver transplantation.
13:07Both of these indices.
13:11Provide somewhat different but very accurate.
13:17Guides for predicting complications
13:20and mortality for liver surgery in
13:23the setting of sarot SIS.
13:25So if you compare them again,
13:28as I indicated this, this is actually.
13:32Prediction outcomes based on these
13:35classifications after replacement of a
13:37tips device that transjugular prophetic
13:40portal systemic shunt for ascites,
13:43both for patients stratified for child Pugh
13:47score as well as meld above or less than 18.
13:52And you can see that you know there
13:56these are different cut offs,
13:59but they're both quite.
14:02Predictive of outcome.
14:04You actually compare them.
14:06At least this group did,
14:08and there you know they're very similar.
14:12The area under the receiver operator
14:15Curve is essentially equivalent,
14:17so although one is more clinical,
14:19one is more strictly lab based.
14:22They're both very useful and I find them
14:27somewhat overlapping ways to assess
14:30risk and underlying liver function.
14:33So let's turn for a minute
14:36to liver transplant,
14:37because this discussion would not
14:40be complete without mentioning the
14:42profound importance of evaluating
14:44patients for liver transplant candidacy.
14:47And having that in the background in
14:51and preparing them in moving them
14:54towards transplant and effective way,
14:57if they are candidates.
14:59So the the I think the key.
15:04Data from the literature is the so
15:07called Milan study that established the
15:10Milan criteria which was published in 1996.
15:13This really established transplant as
15:15the gold standard for patients with
15:18significant underlying liver disease
15:20related to cirrhosis and limited.
15:23HCC, Milan criteria include patients
15:25who have one tumor that is.
15:29Equal or lesser than 5 centimeters
15:32in diameter,
15:33or three or fewer tumors,
15:35all equal to or lesser
15:38less than 3 centimeters.
15:40Patients who fit within that criteria
15:43enjoy excellent post transplant survival,
15:46ranging around 70 to 75%.
15:51So even though the focus of this
15:53topic is is reception specifically,
15:56it is important to understand that
15:58transplant in many ways remains
16:00the optimal treatment for patients
16:02with limited HCC and cirrhosis.
16:04For all these reasons,
16:06patients have an excellent survival.
16:08Of course, there's nothing like
16:10a transplant to treat their
16:12underlying liver failure and.
16:14One of the shining lights here is that
16:18living donation does hold future promise
16:22for increasing organ availability.
16:24Challenges of course.
16:26Our organ availability is limited.
16:29Transplant post transplant care with
16:32person intensive fault and support.
16:35And we do have.
16:37We have learned that extended criteria
16:39are possible and may allow selective
16:43increase in eligibility for patients
16:46who downstage During the course of
16:49aggressive pre transplant therapies.
16:53Before we switch to the kind of
16:56evaluation of patients for reception,
16:58I think one of the things that
17:00is unique about HTC that is
17:03really important to understand,
17:05and I spend a lot of time talking
17:07to my residence about this,
17:10is that these tumors love to invade
17:12the portal venous system and that.
17:15You can see that radiographically
17:17as expensive,
17:18bulky thrombus is probably in acute thrombus.
17:21This is a more chronic thrombus and.
17:25The thrombus maybe tumor itself,
17:27or a mixture to Marie plot.
17:31It is in some ways the cynic Winona,
17:35this disease.
17:36Acute thrombosis may cause abrupt liver
17:39decompensation more chronic thrombosis
17:41like this patient often results in
17:43liver atrophy in the affected lobar
17:46segment with compens atory hypertrophy,
17:49and you're seeing that in the
17:51left liver in this patient who
17:54has a right portal vein thrombus.
17:58This is clearly a marker of
18:00high risk disease.
18:02Often these patients you need
18:04to look for lung lesions.
18:06That's going to be the next sighted disease,
18:10but in some ways we as surgeons can
18:12exploit this atrophy and hypertrophy
18:15for reception in selected candidates.
18:21So as we start to think about how do we
18:25choose patience for potential reception?
18:30We need to talk about the Barcelona
18:33Clinic liver Cancer staging system.
18:35The BCLC, as we often call it, there are
18:39a variety of of other staging systems.
18:43But I think most of us who do
18:46this work on a weekly basis,
18:49relying on the Barcelona system,
18:51kind of as our principle go to
18:54in the decision-making process.
18:56It's not perfect,
18:57but I think it's clinically very useful,
19:00so stage A patients or patients with
19:04early HCC, relatively small lesions,
19:06or a few single lesions.
19:09And these A1 patients are.
19:10This is really the group we want to operate.
19:13No portal hypertension.
19:14Normal billirubin, essentially no sarot sis.
19:17As we go up and stage,
19:19the patients tend to get some
19:22degree of liver disease.
19:24They may have portal hypertension
19:26or may they maybe have mild.
19:29Disease according to Child
19:31Pugh classifications,
19:32as we get into stage B2 mercies
19:36or larger tumors,
19:38but this stage B classification
19:41includes a variety of severity
19:44in the liver disease stage,
19:46sees advanced cancer and state Steve.
19:49This is, of course in stage disease.
19:56So. Is HPB surgeons.
20:00We are trying to extract as much
20:03information as we can to make
20:06safe decisions about reception.
20:09And there is a real kind of diversity
20:12of approaches between the Western
20:15western surgeons in in the Asians.
20:18Surgeons in China and Japan
20:20often rely on in design,
20:22and green retention is a kind of a
20:26biologic measure of liver function.
20:29Signing in green clearance seems to be
20:31less useful in our Western patients,
20:34although she centers use it,
20:36it seems to be more effective in this
20:39group of patients with hep B related disease.
20:43So there's a disparity in the usage.
20:46We in the western world tend
20:48to use a cluster of of indices
20:51to help us make decisions,
20:53including serum bilirubin and the
20:55presence or absence of clinically
20:57significant portal hypertension.
20:58Well, what's clinically significant?
21:00Portal hypertension?
21:01Well, we look at a number of things.
21:04You look at the presence or absence
21:06of splenomegaly thrombocytopenia,
21:08and we can get a an actual
21:10quantitative measure using wedge
21:11product vein pressure gradients,
21:13and I'll talk about that more in a minute.
21:17And in some cases we turned to actual
21:21histopathologic analysis using liver biopsy.
21:25Um, you know this.
21:27In designing green clearance is
21:30one of the reasons we don't this.
21:33This graphic illustrates the challenge
21:35with it in a western population,
21:39there is a broad distribution of.
21:42Severity scores with overlapping
21:44in designing green clearance.
21:46So it it's it's less useful clinically.
21:51One of the things that we do use a
21:54lot is simple CT or MRI assessment.
21:58Patients like this with bulky big
22:01clearcut verisys in a big spleen.
22:04We know we're unlikely to
22:07be surgical candidates.
22:08Another example of significant upper
22:11abdominal variceal development.
22:13So what are my favorite measures?
22:16In another reason that we really rely
22:20on a multidisciplinary assessment is
22:22the use of Patrick Kane wedge pressure.
22:26This is a procedure that the interventional
22:30radiologists are quite expert at.
22:32It involves catheter placed
22:34through the vena cava,
22:36usually through transjugular approach,
22:38and the catheter is directed out
22:41through the paddock vein wedge.
22:44And a reading is taken and it's expressed
22:47as a gradient in reference to the SVC.
22:50Anything greater than 10 millimeters of
22:53Mercury represents what we would consider
22:56clinically significant portal hypertension.
22:58The data for that is really from a
23:02classic paper from the Barcelona group,
23:05Jordi Bruin colleagues that was
23:08published in many years ago now,
23:11but they looked at the outcome of
23:14of patients after liver surgery.
23:17And compared their preoperative
23:19paddock vein pressure gradient
23:21patients who underwent,
23:23went to surgery with a paddock vein,
23:28pressure less than 10 generally did
23:31very well without any decompensation.
23:34There were a couple who were
23:38higher but most did.
23:40Did quite well with his lower group
23:44patients who decompensated almost all.
23:46Virtually all have these higher
23:49preoperative FedEx thing wage pressures
23:52so that measurement is a is really
23:55a critical piece of information.
23:57For for us surgeons,
23:59as we think about taking these
24:01patients in the operating room.
24:03The other thing that can be done at
24:06the same time as phatic pain wedge
24:09pressures is this transjugular liver biopsy.
24:12It's minimally invasive.
24:13A biopsy instrument can be guided
24:16into the liver parenchyma through it.
24:19A transjugular approach in a small
24:21tissue sample taken that can help us
24:24grade the degree of fibrosis or cirrhosis,
24:27which will also help with decisions.
24:30So overall, as we think about our approach.
24:34Surgically are the treatment
24:35really is driven by stage?
24:38Know this early stage group of
24:40patients we consider both for
24:42liver transplant in reception.
24:44Portal pressures are key here.
24:47Patients have normal porting pressures.
24:49Early stage disease can be
24:52treated with reception.
24:53Increased pressures need to be evaluated
24:56for transplantation or ablation.
25:02So to pull it all together,
25:05the people that I'm looking for his potential
25:07candidates are patients without cirrhosis.
25:09Inhuma major hepat Ectomy can be performed
25:12without morbidity and I will even operate
25:15on patients with significant with large
25:17tumors in this group without cirrhosis.
25:19These are folks who will tolerate a major
25:22headache ectomy patients with compensated
25:24cirrhosis are much more difficult,
25:26the decision-making is more difficult.
25:28These are this is a group you have
25:31to collect all this information.
25:33In the operative,
25:34planning is more difficult.
25:35They generally will not tolerate
25:37a major help detect me.
25:38You have to be looking at a segmented
25:41happy talk to me or an ablation.
25:43I'm not going to spend a lot of time
25:45talking about ablation in this talk,
25:48but it's another important
25:49tool in our armamentarium.
25:52So. And our multidisciplinary formats.
25:55We're looking at all of these things,
25:57severity of liver disease through child Pugh,
26:00Mail portal, hypertension, Histology.
26:01Then we assess the extent of disease,
26:03size of lesions number, vaster invasions,
26:05as well as all these other factors that
26:08we think about surgically comorbidities.
26:10Do they have heart disease,
26:12lung disease, or kidney disease,
26:13as well as the size of the liver remnant?
26:19So. As we pull these this information
26:22together, we wind up really getting
26:24what I would describe as this multi
26:27parameter assessment for respectability,
26:29and I won't walk through this all,
26:31but you can see that really it's a pretty
26:34small group who are really low risk.
26:37These are patients who have no portal
26:40hypertension in minor have to talk to me.
26:43It's important to understand that in this
26:46low risk of group group of patients,
26:49liver resection is very safe.
26:51Liver related mortality less than 5%.
26:54As soon as you get up into intermediate risk,
26:58we're looking at, you know,
27:00pushing a 30% risk of decompensation
27:02close to 10% mortality.
27:04High risk group, greater than a
27:0730% risk of decompensation Anna.
27:09Significant risk of surgical mortality.
27:11So all of this kind of accuracy.
27:14Indecision making is really
27:17critical for safe patient outcomes.
27:21So how do we do this?
27:24Well, I probably should just use Mario
27:26slide with this surgical decision,
27:28making it is more than just the surgeons.
27:31It takes a team or in his words
27:34it takes a village.
27:36You know,
27:37and I cannot tell you over the years,
27:40how many times I say HPB surgeon
27:43have been rained in in my surgical
27:46enthusiasm by one of my colleagues
27:48who points out some other pieces
27:51of the patients history or biology
27:53that would make surgery unsafe.
27:55And, you know,
27:57that's where we all get together
27:59in our liver tumor conference.
28:01Hepatology IR pathology, medical oncology,
28:03thinking about alternative treatments
28:05are body image Ng colleagues or.
28:07Very helpful in pointing out.
28:10The extent of the disease,
28:12potentially non or extra paddock
28:14sites of disease.
28:16Other things that will be deal
28:18Breakers and then.
28:20All of the surgical.
28:22Teens need to be involved.
28:25Transplant surgeons and surgical
28:27oncologist both bring kind of
28:29interdependent overlapping
28:30expertise to the table and caring
28:32for this group of patients.
28:36So I'm going to turn for minute shift
28:39gears and talk about surgical technique.
28:42So these are the classic
28:44major hepat ectomy operations.
28:46You know, these are the classical
28:48operations that originally described
28:50his liver surgery was developed.
28:52You know this is right now
28:54protect me left at protect me.
28:57Extended right hip protect me or
28:59left lateral segment Or's left
29:01lateral section ectomy and you know
29:03these operations are really great
29:05for patients who are non cirrhotic,
29:08have larger tumors,
29:09but as you can tell many of them.
29:12Involve sacrifices of a major of
29:15volume of functioning liver and anyone
29:17any patient who has any degree of
29:19liver disease will not tolerate these
29:22things with the exception perhaps
29:24of the left lateral section ectomy.
29:27So a key for liver surgeons is
29:30understanding hepatic segmental anatomy.
29:31This was originally described by
29:33the French anatomist Cloud Kanade.
29:35There are eight segments in the liver.
29:38The caudate,
29:39you know two and three on the left
29:42lateral segment for left medial
29:44567 and eight on the right side,
29:47and it's critical to understand that
29:49we can mix and match and tailor our
29:52operations very precisely based
29:54on this segmental anatomy.
29:56So as we think about segmental
29:59liver resection for small HCC
30:00understanding those segments gives
30:02us a great ability to to do again.
30:05Taylor or Target the extent of
30:07the operation to the the size
30:09and location of the disease.
30:11This is a perfectly in the posterior
30:14sector which would be for section in
30:16segment six and seven poster sector ectomy.
30:19These are segmental resection from
30:21the right side and the left side of
30:24liver segment through segment 2.
30:27Now,
30:27the other reason that understanding
30:31segmental anatomy is important is for.
30:34The technical element of Disease Control.
30:37These portal venous branches are a
30:40key pathway for dissemination of tumor
30:43cells and can be contaminated by tumor cells.
30:47So when we're doing parenchymal
30:49sparing receptions,
30:50how we conduct that reception is in
30:53relation to the portal venous branch serving.
30:57That segment is critical.
30:59This approach is ideal with a
31:01complete resection of the involved.
31:04A portal vein this beta be reception
31:07would encompass the tumor,
31:09but not as much portal vein and
31:12would put the patient at a higher
31:15risk for local recurrence.
31:17So patient selection is important,
31:20but technicalities are important as well.
31:24Now let's talk for a minute about
31:27the future liver remnant.
31:29What we know from liver surgery is
31:32that the size of the remnant is a
31:36critical predictor of postoperative outcome.
31:39Patients who have,
31:40in healthy patients who have a
31:43functional liver remnant of less than 20%.
31:46We have a very high incidence of
31:50postoperative complications and
31:51FL are of greater than 20%.
31:53Generally patients do very well now.
31:55This is in healthy livers.
31:57I would say that FLR is 40 to 50% in.
32:01Anyone with any underlying liver disease.
32:06Um? Portal vein Embolization is a
32:09key technique that we use David
32:12made off is a world expert in this.
32:16He is really built,
32:18his career among other things and and
32:21honing and refining this technique.
32:23So I'm not going to pretend to be the
32:27expert on this other than share that.
32:31As liver surgeons,
32:32this is our very best friend because
32:35this technique involves interruption
32:37of the portal venous flow to the
32:40affected side of the liver and allows
32:43hypertrophic growth which allows us
32:46to respect the contralateral side.
32:48You know this is a classic example
32:51of a pre operative left lateral
32:53segment which would have been a 14%
32:56small remnant froze up to 21% after
32:59preoperative Puerto venous embolization.
33:00This is data in a from an MD Anderson
33:03paper that David was involved with.
33:06I suspect he'll show Shell share
33:09more details when he gives his
33:12see me in a month or so.
33:15So, um,
33:16the French are actually have done
33:19nice work with this in cirrhotics or.
33:23PVD for patients with HCC and this is
33:26a relatively small series from one
33:28of the groups in Paris that show that
33:32although between these two groups,
33:34the volume after Pve was not
33:36that much greater,
33:37but the incidence of liver failure
33:40was significantly less and the stay
33:43in the ICU and hospital was less so.
33:45If you were going to do a major help
33:49protect me in a patient with any
33:52degree of underlying liver disease.
33:54A PV is a critical. Potential adjunct.
34:01The other thing that has come
34:04forward in recent years is the
34:07idea of radiation lobectomy.
34:09Again,
34:10this is a technique that our IR
34:13team is extraordinarily adept at.
34:16It involves treating the tumor
34:18as well as the involved side of
34:22the liver with Y-90 microspheres.
34:25This is a pre operative set of images.
34:29Actually I'm sorry preoperative
34:31up pretreatments up here post
34:34treatment down here it shrinks the
34:37liver and treats the tumor.
34:40So that as the the affected side of liver
34:43atrophy's and the disease is treated,
34:46the contralateral side of the
34:48liver hyper hypertrophy's,
34:49which eventually allows a reception
34:52of the affected side of the liver with
34:56this nice large left liver remnant.
34:58No,
34:59the the one of the things that's really
35:02exciting about radiation lobectomy
35:03is that it allows the tumor to be
35:06treated with the radiation well,
35:09the well the the atrophy is occurring,
35:11and if necessary,
35:13portal vein embolization can
35:14be added on top of it.
35:16I really like this technique in
35:18bulky tumors and in a patient
35:21where you may be concerned about
35:23occult metastatic disease.
35:25It gives us this window to watch them
35:27for awhile before committing to surgery.
35:33So I will share that I think one
35:35of the greatest steps forward in
35:37the past 15 years or so is the.
35:40Application of minimally invasive
35:42surgical techniques deliver surgery,
35:45and this has been a continuous
35:48evolution in the early 90s.
35:51Surgeons first Gabaldon small wedge.
35:54Resections of the first major hit
35:57Ectomy was reported in the mid 90s,
36:00and this was a pretty crude operation
36:03that relied a lot on surgical
36:06staplers and over the years,
36:09the our approach to laughter
36:11scopic attacked me is improved.
36:13We've adapted many of the open techniques,
36:17including Pringle maneuver techniques
36:19of dividing liver pouring command.
36:21So that.
36:22We've developed standards standards
36:24of practice and increasingly
36:27sophisticated anterolateral receptions
36:29and subsegmental receptions,
36:31and even in some centres,
36:34laparoscopic live donor operations.
36:39So this actually gives a pretty good
36:43picture of what's happened over
36:45the years since the turn of the.
36:49Millennium with a kind of a slow
36:51and this is this is data from some
36:55European centres but I think this is
36:58quite reflective of what's gone on
37:01in large centers around the world.
37:03Kind of as a decrease,
37:06steady decrease in open liver surgery
37:08and slow but progressive increase in
37:11and minimally invasive procedures.
37:13Now I don't think any.
37:15I I'm certainly not,
37:17and I don't think any experience
37:20HPB surgeon would say that open
37:23liver surgery should go away.
37:25There are too many complex.
37:28Situations that I think patients
37:30are best served with open surgery,
37:32but clearly this has been developed
37:35and embraced around the world.
37:37And over this time,
37:39many of the early operations
37:41were small wedges.
37:43Those of kind of drop down,
37:45and it's a steady increase in major
37:48protect knees and an resections in
37:51the posterior superior segments which
37:53are much more technically complicated
37:56because of their location and deliver.
37:59So laparoscopic appendectomy 20 and 2021.
38:02I think we can say is safe.
38:06Um, you know,
38:07like everything,
38:07it has to be patient enough to
38:10be selected carefully.
38:11I have not gone through all the
38:14data in this for the sake of time,
38:18but it's Uncle logically appears to be
38:20equivalent to open operations again.
38:23Selected cases there are better fits
38:25in hospital stay and recovery cost
38:27benefit analysis suggests significant
38:29value for appropriately selected patients.
38:32There are limitations with
38:34non anatomical sections,
38:35parenchymal, scarring sections,
38:36bleeding control,
38:37and biliary reconstruction
38:38is can be difficult with the
38:41laparoscopic instrumentation.
38:43So what next?
38:44Many of us are quite excited in doing
38:47robotic surgery of I think this is
38:51a rapidly developing technology.
38:54The Davinci System was introduced
38:56around 2000.
38:57Appear to Julia Naughty first
38:59did the first protect me with
39:02the robotic platform in 2003.
39:04This has expanded internationally.
39:06Now the major focus of robotic
39:08surgery really has been urology
39:11gynecology and a liver surgery
39:13is relatively late in this,
39:15but many of us are embracing it
39:17and are excited about it and
39:20feels that it brings real value.
39:23The the unique elements of the robotic
39:26platform are the 3D stereoscopic.
39:28Vision and the end of risk
39:31functionality of the instrumentation
39:33provides a degree of of dexterity and
39:37flexibility with surgical maneuvers
39:39inside the body that is just.
39:42At least for me,
39:43most of us very difficult to
39:45duplicate using straight stick
39:47laparoscopic instruments do precise
39:50suturing difficult locations.
39:52The dual console that you're seeing
39:54here is great for instruction
39:56and the economic.
39:58The ergonomics tend to be more favorable.
40:03Let's see, these are pictures I took in our
40:06own operating room a couple of weeks ago.
40:09This is actually a patient who have
40:11robotic left lateral segment resection.
40:13This is kind of the setup
40:15we've got the for robotic arms.
40:18We still have one of the
40:20instruments in place.
40:21This is an assist port that allows us to
40:24pass additional instruments and sutures
40:26in the abdomen and this is kind of just
40:30as we're closing all of the incisions.
40:32These are for small incisions across the
40:35abdomen and this is about a 3 centimeter
40:38extraction port right below the umbilicus.
40:40Through which we removed the specimen.
40:43Patient went home in two days.
40:47So lots of discussion around the
40:49country robotic laparoscopic,
40:50you know, like everything in surgery,
40:53this is a point of surgeons
40:56love to debate back and forth.
40:58There are relatively few comparisons.
41:00This comparison study was done
41:03at the University of Pittsburgh
41:05a number of years ago,
41:07and I think what it shows is that.
41:10The robotic cases in this study
41:15were took longer.
41:17Application rates bloodloss
41:19outcomes were essentially the same,
41:21but more cases were completed completely.
41:24Minimally invasive, Lee,
41:26using the robotic platform.
41:28Many of these laparoscopic cases required
41:32a utility incision or hand port so.
41:35I think there are merits to both approaches.
41:39Um, I have found in my own practice.
41:43As this author points out,
41:45the robotic approach may facilitate
41:47parenchymal sparing receptions,
41:48particularly in these upper
41:50posterior segments,
41:51posters appear segments that you can
41:54get to it to operate on with the robot,
41:58which is hard.
41:59Lapre Scopic Lee in this series.
42:02Over half the cases the robotic series
42:04work in those difficult segments.
42:09The other area where I find the robotic
42:12helpful is anatomically complicated
42:14procedures that require a lot of careful
42:18enteropathic dissection and control the
42:21paddock veins and precise stapling.
42:23This paper was a nice report of
42:26outcomes in complex cases of left
42:29lateral section ectomy where the
42:31disease is approaching him from the
42:34veins and they compared robotic left
42:37lateral segment with left lateral
42:40laparoscopic left lateral segment.
42:42Um, you know these?
42:44This group does.
42:46Note that the robotic cases
42:48were more expensive,
42:50but when the procedures got complicated,
42:53the robot really seemed to provide
42:56benefit with reduced blood
42:58loss and better length of stay.
43:03So as you think about the
43:05cost of the value proposition,
43:08the way the cost of these procedures is
43:10allocated and understood is really critical.
43:13And if you know this is one of
43:15those situations where the robotic
43:17instrumentation is more expensive,
43:19but if you can save anything on
43:22length of stay like this series
43:25did it more than pays for itself.
43:28So I'm going to switch gears and
43:30talk about a few key kind of subsets
43:33of patients that I think we really
43:36need to understand as we think
43:39about surgical candidates for HTC.
43:41One critical group is this group
43:43of patients with so called fibro
43:46lamellar parasailer carcinoma.
43:48This is is a disease that has a
43:51bimodal age distribution distribution,
43:53but it's predominantly young adults,
43:56although there's a smaller peak
43:58later in life.
43:59In the 60s has a male predominant's.
44:02Most of these patients have
44:04non cirrhotic livers.
44:05They often proves in his large bulky tumors
44:09and surgery is the primary treatment.
44:12It's easy to mistake these
44:14tumors for benign liver lesion,
44:16such as bulky FNH or adenoma.
44:18They are malignant,
44:20they're aggressive.
44:20They need to be respected,
44:23and they can have an excellent outcome
44:25with five year survival with reception,
44:28but they need to be appropriately
44:31diagnose and manage.
44:35So this actually is great story.
44:37This was like a young man who fell off
44:40a ladder who came to see me after he
44:44was seen in the emergency Department
44:47with some bruises and sprains.
44:50And they had an abdominal CT
44:53that showed this lesion and.
44:55You know, had no underlying liver disease.
44:59And this lesion, which is best
45:02seen in the venous phase, he went,
45:06not only was it seen in that phase, but.
45:10The other thing that was ominous
45:12about it is that the lower part
45:14lesion had this extra pet extension.
45:17So he went to the operating room and had a.
45:21Right have attacked me with a kind of a
45:24liberal reception of his retroperitoneal
45:26tissues to clear that extra pack extension.
45:30Big bulky specimen.
45:31He's a healthy guy.
45:33He did great post operatively.
45:35I followed him for about five years
45:38when I was in Portland and he did well.
45:41Never had a recurrence and then I
45:44kind of glossed him to follow up,
45:47but I think this is a perfect example of.
45:51Many of these patients can do well
45:53or even be cured with surgery.
45:55If you look for the disease.
45:58The other group of patients is agents
46:01of what I call our our our elders,
46:04HTC in the elderly.
46:06I think it needs to be reviewed
46:09is almost a different disease.
46:12This lady was sent to me about a month ago.
46:17Sweet Lady retired nurse.
46:19Spent most of her career at Saint Raves.
46:23She has a history of breast cancer
46:26and she was undergoing evaluation
46:28and was found to have a left
46:32lateral segment liver lesion.
46:34Had an MRI which showed the least
46:37that you see and there was concerned
46:40that this is metastatic breast cancer.
46:43It was biopsied and proved to be
46:46well differentiated HCC and she has
46:48undergone a robotic left lateral segment.
46:51Resection has done great.
46:53So this was a group of patients
46:56that I noticed in my prior work.
46:59And you know you're after.
47:01Euro would keep seeing these older
47:03folks from all over the Pacific
47:05Northwest showing up with his
47:06liver tumors without cirrhosis.
47:08Most of them were actually quite healthy,
47:11so I had one of our residents write
47:13this up with one of my partners.
47:16Doctor Mahlon are transplant
47:18group in Portland.
47:19And of our series,
47:21about 50 patients median
47:23age was 75 years old.
47:25Only 13% of them had
47:27underlying liver disease.
47:29And of that group,
47:30most of them had some
47:32alcoholic liver disease.
47:34Most of them were not viral.
47:36Hepatitis over 50% were treated
47:38with the major HEPA type to me,
47:41and they all enjoyed excellent
47:43five years survival.
47:44I think the interesting thing is,
47:46you know this is a group that's already
47:49selected themselves as being older
47:51without having a life limiting comorbidity.
47:54They get a liver tumor in.
47:56You know,
47:57I would contend they merit
47:59aggressive treatment.
48:00So just to summarize him wrap up.
48:05You know surgery is the predominant topic,
48:08but I'm really need to underscore
48:10the fact that transplant
48:11remains a central treatment.
48:13It is the ideal treatment for
48:16cirrhotic patients with disease
48:17within the Milan criteria.
48:19Reception is an excellent treatment
48:21for patients with limited disease
48:23and well preserved liver function.
48:25We talked a lot about multidisciplinary
48:28assessment and the importance of
48:30the absence of portal hypertension.
48:32We talked about Portal vein embolization,
48:34and radio ablation to augment
48:36the plan remnant.
48:37A discussion of minimally invasive
48:40surgical techniques and you know,
48:42I'll share that my bias has been
48:45moved to move my own practice
48:48towards the robotic platform.
48:50Although laparoscopic approaches or
48:52equally valid we talked about fibro
48:55lamellar disease and elderly HCC,
48:58so I'm going to wrap up there
49:01and say thank you to my partners
49:05in the liver tumor program.
49:07And Mario,
49:08for his leadership and Renee
49:10for helping us put this on and
49:12ask if there any questions.
49:15You thank you, Kevin.
49:17This was a fantastic talk.
49:20Just if if there are questions,
49:23please write them in the chat.
49:27I read them and.
49:30And coming will respond.
49:34I just, I mean, well,
49:37I want to thank you Kevin,
49:40not only for this is cool shows
49:42in the master sophisticated
49:44and newer surgical technology,
49:47but most of all,
49:49for your accent on how match that
49:52she's Young's how many decisions
49:55are into a surgical indication,
49:58how many eyes look at the same slide,
50:02the same data, and how much discussion.
50:05I would dare to say that this
50:09is as important as the scale
50:12of the of the surgeon.
50:18Well, what I will say is surgical
50:22technique and precision is very important.
50:25These are operations that really need.
50:28You need to be extremely meticulous,
50:31but the the patient selection of the
50:35decision-making is absolutely central,
50:37and that's where I could not agree more.
50:41You need a thoughtful team and.
50:45You need all these valuation techniques,
50:49particularly really good image Ng assessment
50:52of liver function clinical assessment
50:54by hepatologist wedge vein pressures.
50:57All all of that makes a difference.
51:01And that's why.
51:03Am centers such as ours are.
51:07We get good outcomes.
51:11A few questions, I'm gonna read it so.
51:18Doctor Chi is nice talk.
51:20Why not fold the results in ATC?
51:24How to treat it and?
51:28This is if I can answer
51:30that question for you.
51:32We wish to know that we
51:35are heavily investigating.
51:36And if you want to add something on this,
51:41but then is that there's another question
51:44here for satisfied can rate told Kevin
51:47in addition to radiation lobectomy.
51:49Any thoughts on using ethereal embolization?
51:53On bridge to protect me for ATC in large,
51:57bulky tumors.
52:00No such thanks for the question.
52:05You know I, I will say, I think it. It is.
52:10It's probably a very reasonable approach.
52:13In these large bulky tumors.
52:17I guess I will share that my experiences
52:21been more towards a Y-90 approach
52:25to radiation lobectomy approach.
52:28And maybe that was the bias of the IR group
52:32that I worked with closely in Portland.
52:36I do think there's some merit to it,
52:40because with the search or why 90,
52:43you're not going to get an acute necrosis
52:47or ischemic effect in a large tumor.
52:50It's a. It's a more gradual
52:53cytotoxic tumor killing effect.
52:55I think the patients tolerate
52:57it pretty well and then.
52:59Then you get this benefit of
53:02of liver atrophy as well,
53:04probably in a way that you don't
53:06get in the Saint to the same
53:09degree with with tastes you know.
53:12And I'll I will share.
53:14I've operated on at least
53:16two or three patients,
53:17six or eight months after radio ablation and.
53:21At least in one patient I can remember,
53:24there's no viable tumor left, so.
53:25I'm not sure they all
53:27eventually need surgery,
53:28but it's it's kind of.
53:31Hard to know till you've done it.
53:33Well, a couple more of a very
53:36sophisticated questions here.
53:37One is from Stacy.
53:39What do you think about the
53:41use of systemic therapy?
53:44They specifically immune therapy as
53:46a neoadjuvant therapy or argument
53:48therapy to prevent recurrence.
53:51Well, you know, I think.
53:55If you look at the history of.
53:59Multidisciplinary therapy in GI cancers.
54:01We're all moving in every disease,
54:04more twords neoadjuvant,
54:05and I think as we see the efficacy
54:09of treatment in HTC improving,
54:12we probably will get to that.
54:15I don't think we're there yet.
54:19Um? You know,
54:21so wrapping it just was not active enough.
54:25A tease. Oh Bev, maybe.
54:28And then I think,
54:29you know we'll probably get there with
54:31the postoperative adamant as well.
54:33I, I'll be honest,
54:35ACI's inspector trials underway
54:36that you are probably more
54:38acquainted with than I am.
54:41I just just. So remember that we
54:45do have atrial here that Stacy
54:48is the PII in to understand
54:52the answer to this question.
54:55So patient after surgery.
54:57Weather immunotherapy can can
54:59help preventing the recurrence.
55:02Because this is the problem with this
55:05cancer that recurs so Thomas Daddy.
55:08Is ask is congratulating for your talk,
55:10but interesting how many people with
55:13hepatitis C have been treated and
55:15there she knows is well compensated.
55:17They remain at risk.
55:19Do you favor surgery over
55:22ablation for smoke humor?
55:25You know, I think there are
55:28a couple of pieces in that.
55:31Question and my own.
55:36I think in this group of patients who are
55:39treated for hepatitis C at their risk.
55:42For developing, HTC does go down and
55:45I suspect that the hepatologist know
55:48those numbers much better than I do.
55:51What I can tell you is.
55:55Having operated on many patients over
55:57the years have had in a sustained
56:01virologic response to hep C treatment.
56:04They are much better surgical
56:06candidates or livers, or healthier.
56:09They tolerate surgery much more
56:12readily than either non treated
56:15patients or or patients who did
56:17not have some adequate response.
56:20I do think they remain at
56:23risk regarding ablation.
56:25You know I didn't spend a lot
56:27of time talking about ablation,
56:30but I think it is a very useful modality,
56:34either by the interventional radiologists
56:36or in some cases by surgeons,
56:39in difficult locations.
56:41And I think for small tumors it's a very.
56:45It's a very reasonable approach,
56:48and I think there's really abundant
56:50data that indicates that for,
56:53you know, for a 2 centimeter tumor,
56:56the outcome is going to be
56:58a essentially equivalent.
57:00So I I think it's a very
57:03reasonable alternative.
57:04Yeah,
57:05there's no patience is safe Surgical
57:07candidate and they have minimal disease.
57:09Name would like a reception.
57:11Sometimes there is satisfaction to
57:13having the disease out of their body,
57:16and I think it's reasonable.
57:18But then there's the fact of
57:20comorbidities too, so locks goes good,
57:23goes into the
57:24decision. We have three more questions to go,
57:27one from David Madoff.
57:30Only the only issue with additional
57:32back to me is that we do not know
57:34that kinetic growth rate of deliver.
57:37There is literature on PBE, an sequential
57:41days combined with PVA, hopefully.
57:43We have this figure out the sample and
57:47that's more common than thank you bye.
57:51And Sue Chan.
57:53From our pathology Department
57:54has to do this action matching.
57:57What is the minimum distance in
57:59millimeters of tumor to resection
58:01margin you prefer to call
58:03negative any data for that.
58:07Yeah. Yeah. There, I guess the way
58:14I would answer that question is
58:17that what I try to aim for is a.
58:20Is a centimeter margin.
58:23Often you know, depending on
58:27the location of the disease,
58:29in the proximity to other structures,
58:32that is not achievable.
58:34I think for most HCC and narrow
58:38margin of even a couple of
58:41minutes millimeters is adequate.
58:44Certainly a positive margin is a marker
58:48is associated with poor outcomes.
58:52But it is. I will say,
58:54it's difficult to know in
58:55some of these situations.
58:57Is is it the margin that's the driver,
59:00the outcome or the biology of the disease.
59:05So I I don't think that answers
59:08the question completely,
59:09but what I would say is like I,
59:12I tried to get a centimeter
59:14of margin and finally we have
59:16a question from John Kuntzman.
59:18Another of our surgical oncologist.
59:20I generally consider a section to be
59:23contraindicated in multifocal agency,
59:25even in non cirrhotic.
59:27Would you agree with that?
59:33Um?
59:38In general. Yes. Um? Although.
59:45John, you know as well as I do.
59:50There are no absolutes in surgical oncology.
59:53You know, I think some of that
59:56depends on the size, the location,
59:59the health of the patient, their age,
01:00:03the technicalities of the operation,
01:00:05kind of all those other intangibles that
01:00:09would that would go into the decision.
01:00:14Domino's rephrased
01:00:17It doesn't give you quarter here, So what are
01:00:21your exceptions?
01:00:22Oh, you know I would say in
01:00:25in someone who has two regions
01:00:28that are resectable safely with.
01:00:30Even a right hepat ectomy.
01:00:34You know, I would probably send the
01:00:36patient to Stacy and maybe have them have
01:00:38her treat them with systemic therapy.
01:00:41Kind of in an ad hoc way for you know,
01:00:44the question came up about neoadjuvant.
01:00:46Well, this is the case where yeah,
01:00:48I'd figure out a way to do some new agents.
01:00:51So you were watching the
01:00:53patient for a few months.
01:00:54Make sure that they don't have lung
01:00:57lesions or bone lesions, and if there
01:00:59was no new disease or progression.
01:01:01Yeah, it operate.
01:01:02I bet you would too.
01:01:05Alright, well
01:01:06thank you very much Kevin for
01:01:09taking time out of your very busy
01:01:13day to give and deliver this.
01:01:16This lessons about novelty and
01:01:18what is establishing in surgery.
01:01:21Ann and thank you to the audience
01:01:24and thank you to Renee for another
01:01:28outstanding organization of this.
01:01:30We will meet again in a month to here.
01:01:35David Mouth, yes I thank you again everybody.
01:01:39Thank you alright have a good one.