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Laparoscopic staging for hepatobiliary carcinoma
Laparoscopic Staging for Hepatobiliary Carcinoma Rebekah R. White, M.D., Theodore N. Pappas, M.D. KEY WORDS: Laparoscopy, staging, liver neoplasms, biliary tract neoplasms
Hepatobiliary malignancies as a group are associated with particularly high rates of unresectability. Preoperative imaging is always improving but is relatively insensitive for small liver lesions, peritoneal disease, and major vascular invasion. The goal of staging laparoscopy is to avoid unnecessary laparotomy by identifying disease that precludes resection. Staging laparoscopy is generally associated with less morbidity, shorter hospital stays, and decreased recovery time compared with laparotomy. However, complications related to trocar placement and pneumoperitoneum have been described, and the time and equipment costs of laparoscopy are not trivial. Furthermore, port site recurrence is thought to be an uncommon but real risk of laparoscopic procedures for malignant disease. Like other staging modalities, laparoscopic staging is most effectively used in patients whose management will be affected by its outcome. Whether staging laparoscopy should be performed routinely, selectively, or not at all, depends on the disease.
had been incidentally identified after recent cholecystectomy. Following negative laparoscopy, approximately one third of patients undergoing laparotomy with intent to resect were resected, which is higher than expected on the basis of the literature. Hilar cholangiocarcinomas tend to cause symptoms earlier but have correspondingly lower rates of unresectability at the time of diagnosis. The yield of staging laparoscopy for hilar cholangiocarcinoma was 25% in this study, and over half of patients undergoing laparotomy were resected. For gallbladder and hilar cholangiocarcinoma, the yield of staging laparoscopy is high and the value of surgical palliation is low. We therefore recommend routine laparoscopy. Possible exceptions include relatively healthy patients with incidentally identified gallbladder carcinoma at recent cholecystectomy, as these patients not only are less likely to harbor occult disease but may also have local inflammation that makes staging laparoscopy more difficult and less accurate.
EXTRAHEPATIC BILIARY CARCINOMA
HEPATOCELLULAR CARCINOMA
Gallbladder carcinoma and extrahepatic cholangiocarcinoma are aggressive malignancies that usually present with unresectable disease. Despite preoperative imaging, patients are often found to have occult metastatic disease at the time of exploration. Because the median survival of patients with metastatic disease is less than 6 months, adequate palliation can usually be achieved with radiographically or endoscopically placed stents. The nontherapeutic laparotomy and its morbidity might be avoided by laparoscopy. In one recent series of patients with radiographically resectable extrahepatic biliary malignancies, the yield of laparoscopy for occult unresectable disease in gallbladder carcinoma was approximately 50%.1 As expected, the yield of laparoscopy was lower (20%) but not zero in patients whose gallbladder carcinoma
Despite the availability of numerous nonresectional therapies, surgical resection is still the mainstay of treatment for hepatocellular carcinoma (HCC). Resectability is dependent on several factors, including the size and location of the tumor, the presence and location of multifocal disease, and the quality of the remnant liver. Even after high-quality imaging, only about two thirds of patients explored with the intention to resect actually have hepatectomy. Laparotomy is unnecessary in the other third of patients, as most patients do not need surgical palliation. One important difference from most other abdominal malignancies is that peritoneal disease is rare in HCC. The value of surface laparoscopy for HCC is mainly the identification of additional visible liver lesions and the assessment of cirrhosis. Occasionally,
From the Department of Surgery, Duke University Medical Center, Durham, North Carolina. Correspondence: Theodore N. Pappas, M.D., Box 3479, Durham, NC 27710. e-mail: [email protected]
920
쑖 2004 The Society for Surgery of the Alimentary Tract Published by Elsevier Inc.
1091-255X/04/$—see front matter doi:10.1016/j.gassur.2004.09.048
Vol. 8, No. 8 2004
because patients with HCC often do not have a preoperative tissue diagnosis, laparoscopy may reveal an unsuspected primary malignancy elsewhere in the abdomen. Most studies of laparoscopy for HCC have also selectively used laparoscopic ultrasonography (LUS) for the more sensitive identification of additional liver lesions and assessment of major vascular invasion. Whether the information provided by laparoscopy renders a patient unresectable is obviously somewhat subjective and surgeon dependent. However, in two of the largest studies focusing on HCC, from Memorial Sloan-Kettering Cancer Center (MSKCC)2 and from Hong Kong,3 the use of staging laparoscopy/LUS for identifying unresectable disease avoided laparotomy in approximately 20% of patients, and almost 90% of patients undergoing laparotomy were resected.2,3 In the MSKCC study, laparoscopy/LUS was significantly more likely to identify unresectability in patients if imaging suggested they had cirrhosis or stage IVa disease, that is, major vascular invasion or bilobar tumors. The initial use of laparoscopy avoided unnecessary laparotomy in almost 29% of patients with these features but in only 5% of patients if neither factor was present preoperatively. In the Hong Kong study, laparoscopy/LUS was less accurate in patients with tumors greater than 10 cm. In both studies, the most commonly missed reasons for unresectability were major vascular and adjacent organ invasion. Laparoscopy/LUS should therefore be used more selectively in patients with HCC. Noncirrhotic patients with peripheral lesions are much less likely to benefit from laparoscopy/LUS than are patients with cirrhosis and patients with suspected major vascular invasion or bilobar disease. In patients with large tumors and possible adjacent organ invasion, determination of resectability often requires laparotomy for palpation and close dissection.
METASTATIC COLORECTAL CANCER Complete resection of colorectal metastases to the liver offers the potential for long-term survival. Despite preoperative imaging, up to 40% of patients are found to be unresectable at exploration. Two important differences between HCC and metastatic colorectal cancer are that, for the latter, cirrhosis is uncommon and extrahepatic disease—including local recurrence, nodal metastases, and peritoneal implants—is common. In one of the largest studies focusing on colorectal metastases, 103 patients at MSKCC 4 were prospectively evaluated with staging laparoscopy/LUS. Only
Laparoscopic Staging for Hepatobiliary Carcinoma
921
14% of patients overall had unresectable disease identified by laparoscopy/LUS, and only 10% were spared laparotomy. An additional 8% of patients had unresectable disease missed by laparoscopy. In particular, laparoscopy was not helpful in identifying regional lymph node metastases. Patients were stratified by a previously described clinical risk score that assigned points for node-positive primary disease, disease-free interval less than 1 year, number of hepatic lesions greater than one, largest hepatic tumor greater than 5 cm, and CEA greater than 200 ng/ml. Only 4% of patients with a score of 2 or less were found to have unresectable disease at laparoscopy, whereas 27% of patients with a score of greater than 2 had unresectable disease identified at laparoscopy. As for HCC, staging laparoscopy/LUS should be used selectively for colorectal metastases. Patients at higher risk for having unresectable disease, based on the clinical risk factors listed here, are more likely to benefit from staging laparoscopy/LUS. LAPAROSCOPIC ULTRASONOGRAPHY Open intraoperative ultrasonography is considered the gold standard for the determination of resectability of liver tumors, allowing the visualization of lesions as small as 3⫺5 mm and the identification of vascular invasion with high sensitivity. The introduction of LUS probes in the early 1980s allowed the addition of this valuable modality to staging laparoscopy. The chief limitations of LUS are that it is very operator dependent and that, even with the most experienced operator, it is difficult to obtain a biopsy sample of small, deep lesions. Most studies of LUS have included a mix of primary and metastatic tumors. In a Cleveland Clinic study5 comparing LUS with triphasic spiral CT, LUS identified all tumors seen on preoperative CT plus at least one additional tumor in 20% of patients. Although CT did not miss any lesions larger than 3 cm, 28% of lesions smaller than 1 cm were missed. Most of the missed lesions were in segments III and IV near the falciform ligament. SUMMARY For gallbladder carcinoma and extrahepatic cholangiocarcinoma, staging laparoscopy is high yield and should be performed routinely. For HCC and metastatic colon cancer, a more selective approach is warranted, reserving staging laparoscopy for patients in whom unresectable disease is more likely to be identified. The exact role of LUS in these patients is not yet determined but likely extends the advantages of
922
White and Pappas
staging laparoscopy. Staging laparoscopy spares patients with unresectable disease from nontherapeutic laparotomy, decreasing their recovery time and, it is hoped, allowing earlier initiation of nonsurgical therapy.
REFERENCES 1. Weber SM, DeMatteo RP, Fong Y, Blumgart LH, Jarnagin WR. Staging laparoscopy in patients with extrahepatic biliary carcinoma. Analysis of 100 patients. Ann Surg 2002;235: 392–399.
Journal of Gastrointestinal Surgery
2. Weitz J, D’Angelica M, Jarnagin W, et al. Selective use of diagnostic laparoscopy prior to planned hepatectomy for patients with hepatocellular carcinoma. Surgery 2004;135:273– 281. 3. Lo CM, Lai EC, Liu CL, Fan ST, Wong J. Laparoscopy and laparoscopic ultrasonography avoid exploratory laparotomy in patients with hepatocellular carcinoma. Ann Surg 1998;227: 527–532. 4. Jarnagin WR, Conlon K, Bodniewicz J, et al. A clinical scoring system predicts the yield of diagnostic laparoscopy in patients with potentially resectable hepatic colorectal metastases. Cancer 2001;91:1121–1128. 5. Foroutani A, Garland AM, Berber E, et al. Laparoscopic ultrasound vs triphasic computed tomography for detecting liver tumors. Arch Surg 2000;135:933–938.
Hepatobiliary malignancies as a group are associated with particularly high rates of unresectability. Preoperative imaging is always improving but is relatively insensitive for small liver lesions, peritoneal disease, and major vascular invasion. The goal of staging laparoscopy is to avoid unnecessary laparotomy by identifying disease that precludes resection. Staging laparoscopy is generally associated with less morbidity, shorter hospital stays, and decreased recovery time compared with laparotomy. However, complications related to trocar placement and pneumoperitoneum have been described, and the time and equipment costs of laparoscopy are not trivial. Furthermore, port site recurrence is thought to be an uncommon but real risk of laparoscopic procedures for malignant disease. Like other staging modalities, laparoscopic staging is most effectively used in patients whose management will be affected by its outcome. Whether staging laparoscopy should be performed routinely, selectively, or not at all, depends on the disease.
had been incidentally identified after recent cholecystectomy. Following negative laparoscopy, approximately one third of patients undergoing laparotomy with intent to resect were resected, which is higher than expected on the basis of the literature. Hilar cholangiocarcinomas tend to cause symptoms earlier but have correspondingly lower rates of unresectability at the time of diagnosis. The yield of staging laparoscopy for hilar cholangiocarcinoma was 25% in this study, and over half of patients undergoing laparotomy were resected. For gallbladder and hilar cholangiocarcinoma, the yield of staging laparoscopy is high and the value of surgical palliation is low. We therefore recommend routine laparoscopy. Possible exceptions include relatively healthy patients with incidentally identified gallbladder carcinoma at recent cholecystectomy, as these patients not only are less likely to harbor occult disease but may also have local inflammation that makes staging laparoscopy more difficult and less accurate.
EXTRAHEPATIC BILIARY CARCINOMA
HEPATOCELLULAR CARCINOMA
Gallbladder carcinoma and extrahepatic cholangiocarcinoma are aggressive malignancies that usually present with unresectable disease. Despite preoperative imaging, patients are often found to have occult metastatic disease at the time of exploration. Because the median survival of patients with metastatic disease is less than 6 months, adequate palliation can usually be achieved with radiographically or endoscopically placed stents. The nontherapeutic laparotomy and its morbidity might be avoided by laparoscopy. In one recent series of patients with radiographically resectable extrahepatic biliary malignancies, the yield of laparoscopy for occult unresectable disease in gallbladder carcinoma was approximately 50%.1 As expected, the yield of laparoscopy was lower (20%) but not zero in patients whose gallbladder carcinoma
Despite the availability of numerous nonresectional therapies, surgical resection is still the mainstay of treatment for hepatocellular carcinoma (HCC). Resectability is dependent on several factors, including the size and location of the tumor, the presence and location of multifocal disease, and the quality of the remnant liver. Even after high-quality imaging, only about two thirds of patients explored with the intention to resect actually have hepatectomy. Laparotomy is unnecessary in the other third of patients, as most patients do not need surgical palliation. One important difference from most other abdominal malignancies is that peritoneal disease is rare in HCC. The value of surface laparoscopy for HCC is mainly the identification of additional visible liver lesions and the assessment of cirrhosis. Occasionally,
From the Department of Surgery, Duke University Medical Center, Durham, North Carolina. Correspondence: Theodore N. Pappas, M.D., Box 3479, Durham, NC 27710. e-mail: [email protected]
920
쑖 2004 The Society for Surgery of the Alimentary Tract Published by Elsevier Inc.
1091-255X/04/$—see front matter doi:10.1016/j.gassur.2004.09.048
Vol. 8, No. 8 2004
because patients with HCC often do not have a preoperative tissue diagnosis, laparoscopy may reveal an unsuspected primary malignancy elsewhere in the abdomen. Most studies of laparoscopy for HCC have also selectively used laparoscopic ultrasonography (LUS) for the more sensitive identification of additional liver lesions and assessment of major vascular invasion. Whether the information provided by laparoscopy renders a patient unresectable is obviously somewhat subjective and surgeon dependent. However, in two of the largest studies focusing on HCC, from Memorial Sloan-Kettering Cancer Center (MSKCC)2 and from Hong Kong,3 the use of staging laparoscopy/LUS for identifying unresectable disease avoided laparotomy in approximately 20% of patients, and almost 90% of patients undergoing laparotomy were resected.2,3 In the MSKCC study, laparoscopy/LUS was significantly more likely to identify unresectability in patients if imaging suggested they had cirrhosis or stage IVa disease, that is, major vascular invasion or bilobar tumors. The initial use of laparoscopy avoided unnecessary laparotomy in almost 29% of patients with these features but in only 5% of patients if neither factor was present preoperatively. In the Hong Kong study, laparoscopy/LUS was less accurate in patients with tumors greater than 10 cm. In both studies, the most commonly missed reasons for unresectability were major vascular and adjacent organ invasion. Laparoscopy/LUS should therefore be used more selectively in patients with HCC. Noncirrhotic patients with peripheral lesions are much less likely to benefit from laparoscopy/LUS than are patients with cirrhosis and patients with suspected major vascular invasion or bilobar disease. In patients with large tumors and possible adjacent organ invasion, determination of resectability often requires laparotomy for palpation and close dissection.
METASTATIC COLORECTAL CANCER Complete resection of colorectal metastases to the liver offers the potential for long-term survival. Despite preoperative imaging, up to 40% of patients are found to be unresectable at exploration. Two important differences between HCC and metastatic colorectal cancer are that, for the latter, cirrhosis is uncommon and extrahepatic disease—including local recurrence, nodal metastases, and peritoneal implants—is common. In one of the largest studies focusing on colorectal metastases, 103 patients at MSKCC 4 were prospectively evaluated with staging laparoscopy/LUS. Only
Laparoscopic Staging for Hepatobiliary Carcinoma
921
14% of patients overall had unresectable disease identified by laparoscopy/LUS, and only 10% were spared laparotomy. An additional 8% of patients had unresectable disease missed by laparoscopy. In particular, laparoscopy was not helpful in identifying regional lymph node metastases. Patients were stratified by a previously described clinical risk score that assigned points for node-positive primary disease, disease-free interval less than 1 year, number of hepatic lesions greater than one, largest hepatic tumor greater than 5 cm, and CEA greater than 200 ng/ml. Only 4% of patients with a score of 2 or less were found to have unresectable disease at laparoscopy, whereas 27% of patients with a score of greater than 2 had unresectable disease identified at laparoscopy. As for HCC, staging laparoscopy/LUS should be used selectively for colorectal metastases. Patients at higher risk for having unresectable disease, based on the clinical risk factors listed here, are more likely to benefit from staging laparoscopy/LUS. LAPAROSCOPIC ULTRASONOGRAPHY Open intraoperative ultrasonography is considered the gold standard for the determination of resectability of liver tumors, allowing the visualization of lesions as small as 3⫺5 mm and the identification of vascular invasion with high sensitivity. The introduction of LUS probes in the early 1980s allowed the addition of this valuable modality to staging laparoscopy. The chief limitations of LUS are that it is very operator dependent and that, even with the most experienced operator, it is difficult to obtain a biopsy sample of small, deep lesions. Most studies of LUS have included a mix of primary and metastatic tumors. In a Cleveland Clinic study5 comparing LUS with triphasic spiral CT, LUS identified all tumors seen on preoperative CT plus at least one additional tumor in 20% of patients. Although CT did not miss any lesions larger than 3 cm, 28% of lesions smaller than 1 cm were missed. Most of the missed lesions were in segments III and IV near the falciform ligament. SUMMARY For gallbladder carcinoma and extrahepatic cholangiocarcinoma, staging laparoscopy is high yield and should be performed routinely. For HCC and metastatic colon cancer, a more selective approach is warranted, reserving staging laparoscopy for patients in whom unresectable disease is more likely to be identified. The exact role of LUS in these patients is not yet determined but likely extends the advantages of
922
White and Pappas
staging laparoscopy. Staging laparoscopy spares patients with unresectable disease from nontherapeutic laparotomy, decreasing their recovery time and, it is hoped, allowing earlier initiation of nonsurgical therapy.
REFERENCES 1. Weber SM, DeMatteo RP, Fong Y, Blumgart LH, Jarnagin WR. Staging laparoscopy in patients with extrahepatic biliary carcinoma. Analysis of 100 patients. Ann Surg 2002;235: 392–399.
Journal of Gastrointestinal Surgery
2. Weitz J, D’Angelica M, Jarnagin W, et al. Selective use of diagnostic laparoscopy prior to planned hepatectomy for patients with hepatocellular carcinoma. Surgery 2004;135:273– 281. 3. Lo CM, Lai EC, Liu CL, Fan ST, Wong J. Laparoscopy and laparoscopic ultrasonography avoid exploratory laparotomy in patients with hepatocellular carcinoma. Ann Surg 1998;227: 527–532. 4. Jarnagin WR, Conlon K, Bodniewicz J, et al. A clinical scoring system predicts the yield of diagnostic laparoscopy in patients with potentially resectable hepatic colorectal metastases. Cancer 2001;91:1121–1128. 5. Foroutani A, Garland AM, Berber E, et al. Laparoscopic ultrasound vs triphasic computed tomography for detecting liver tumors. Arch Surg 2000;135:933–938.