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Gelfoam chemoembolization for control of carcinoid syndrome symptoms and octreotide requirements
April 2000
SSATAIOS7
2275
2277
DEVASCULARIZATION-MODIFIED SUGWRA PROCEDURE. DOES IT HAVE ANY ROLE IN THE MANAGEMENT OF VARICEAL BLEEDING? A REPORT OF LONG-TERM RESULTS IN CHILE. Jorge A. Martinez, Alfonso F. Diaz, Claudia 1. Aguayo, Mario A. Caracci, Rose M. Mege, Enrique E. Waugh, Julio R. Reyes, Dept of Digest Surg Catholic Univ, Santiago, Chile; Digest Surg Service, Sotero del Rio Hosp, Santiago, Chile.
RESECTION OF HEPATIC METASTASES IN PATIENTS TRADI· TIONALLY NOT CONSIDERED RESECTION CANDIDIATES. Joseph F. Buell, Daniel M. Labow, Atsushi Yoshida, Ralph Layman, David C. Cronin, J. Michael Millis, Mitchell C. Posner, Univ of Chicago Hospitals, Chicago, IL.
Background: Variceal bleeding is still a medical challenge in patients with portal hypertension. In the last decade surgical approaches to this problem have been replaced by endoscopic sclerotherapy, band ligation and the use of transjugular intrahepatic portosystemic shunt (TIPS). Liver transplantation, which provides definitive treatment for end-stage liver disease, is not still widespread available in our country. The aim of this report is to retrospectively review the long-term results of the modified-devascularization Sugiura procedure (DSP) done electively in patients with variceal bleeding in a public hospital setting. Patients and methods: Between June 1980 and December 1986, 48 patients with portal hypertension complicated with esophageal variceal bleeding, were electively submitted to the modified-DSP. Preoperative Child-Pugh class was assessed before surgery in all but one patient. Overall mortality, morbidity, postoperative hospital stay and variceal bleeding recurrences were determined. All death reports and certification were obtained. Mean follow-up of all patients was 9 ±6 years. Bleeding recurrence and long-term cumulative survivals were analyzed using Kaplan-Meier curves. Differences in survival were determined by the log-rank test. Results: The operative 30-day mortality and overall morbidity were 8.3% and 43.8% respectively. Portal hypertension was due to liver cirrhosis in 42 patients and from extrahepatic origin in 6. The Child-Pugh class in cirrhotic patients was A: 15 patients (35.7 %); B: 21 (50 %) and C: 5 patients (11.9 %). In 19 cases (39.6%) there were endoscopic evidences of variceal recurrence; nine out of them needed further sclerotherapy. Eleven patients (22.9 %) re-bled during the followup; 3 from variceal origin. Ten-year actuarial survival was 46.7%; 27.3% and 0 % for Child-Pugh A, B, C patients respectively (p< 0.001) and 100 % in extrahepatic portal hypertension patients. Overall 10- and IS-year survival in all series was 40.4 % and 27.5 %. Conclusion: The modifiedDSP may be still a good alternative surgical option in patients with variceal bleeding with well-preserved hepatic function who will not be candidates to liver transplantation.
Hepatic resection for metastatic disease is considered appropriate in colorectal cancer (CRC) patients with minimal tumor burden ($3 rnetastases)isolated to the liver. Metastasectomy in the presence of advanced age, bilobar disease or non-colorectal metastases is controversial. We examined the efficacy of hepatic resection in this cohort. Methods: Sevety-seven non-traditional resection candidates (NTR) were identified and compared to sixty-three traditional resection (TR)candidates composed of patients with unilobar coiorectal cancer whose age was less than 70 yrs. Statistical comparisions of demographics and survival were performed by student's t-test, actuarial survivals, and log-rank analysis. Results: The NTR group was composed of 21 CRC patients 2: 70 yrs of age, 25 patients with bilobar CRC and 31 with non-CRC metastases. Patients with bilobar disease had a significantly decreased disease-free interval from primary resection to metastatic disease when compared to the TR group (9.6±9.3 vs. 20.9±28. I mos.;p<0.006). Both the number and size of metastatic lesions were significantly greater in the NTR group compared to the TR group (2.2 ± 1.5 vs. 1.6± 1.2 lesions; p<0.02 and 5.7±3.6 vs. 3.8±2.8 cm;p<0.002), respectively. Resection margins were not different between the groups. Length of hospital stay (7.7±4.5 vs. 7.5±1.8 days),90-day mortality (2/77 vs. 0/63)and morbidity rates (12% vs.10%)were similar. Disease-free survival at 1,3 and 5 yrs was significantly different between the NTR and TR group: 81 ±4, 41 ±7,and 23±8% vs. 93±3, 6O±7,and 49±8%; p<0.008. Patients > 70 years of age with CRC demonstrated an equivalent 5-year survival compared to the TR group (42± 14% vs. 49±8%; p=NS). Patients with bilobar CRC had a decreased 5-yr survival when compared to the TR group(25± 11%; p=0.056). The non-CRC group had a significantly diminished 3-yr. survival (36± 13%; p<0.002) when compared to TR. Conclusions: Hepatic resection in NTR patients can be performed with minimal morbidity and mortality. Despite decreased survival in the NTR cohorts particularly those with bilobar disease or non-CRC metastases, when the NTR group is compared to TR patients, survival approximates those historically reported for resection of hepatic CRC metastases. These data suggest liberalizing the indications for resection of hepatic metastases may have a substantial impact.
2276
2278
SURGICAL RESULTS IN PATIENTS WITH HEPATITIS VIRUS RELATED HEPATOCELLULAR CARCINOMA IN TAIWAN. Miin-Fu Chen, Wei-Chen Lee, Long-Bin Jeng, Chang Gung Memorial Hosp, Taipei, Taiwan, ROC. To evaluate the surgical results in patients with hepatitis virus related hepatocellular carcinoma (HCC), 252 patients, 196 male and 56 female, who had undergone hepatic resection for HCC from March, 1992, to August, 1998, with complete profiles of hepatis virus markers study were reviewed. The patients were divided into 4 groups, 30 patients (11.9%) without neither hepatitis B surface antigen (HBsAg) or anti-hepatitis C antibody (Anti-HCV Ab) (N-HCC group), 133 patients (52.8%) with positivity of HBsAg only (B-HCC group), 66 patients (26.2%) with positivity of Anti-HCV Ab only (C-HCC group), and 23 patients (9.1%) with positivity of either HBsAg and anti-HCV Ab (BC-HCC group). Compared to the patients in other groups, the patients in C-HCC group were older and were associated with more severe cirrhotic change of the liver. The surgical complication rates and hospital mortalities in C-HCC and BC-HCC groups were 30.3%, 12.1% and 30.4%, 17.4%, respectively, which were higher than those of N-HCC (13.3%, 3.3%) and B-HCC (15.8%, 3.8%) groups. The mean disease-free survival for N-HCC, B-HCC, C-HCC and BC-HCC groups were 31.4 months, 25.4 months, 38.9 months and 13.8 months, respectively. The difference between these four groups was statistically significant (p < 0.05). However, the mean overall survival time, 38.3 months for N-HCC group, 37.2 months for B-HCC group, 52.1 months for C-HCC group, and 32.7 months for BC-HCC group, were not different statistically (p=0.146). In conclusion, the surgical treatment for HCC related to hepatitis C or dual hepatitis B and C were associated with higher surgical complication rate and hospital mortalities. Hepatocellular carcinoma-related to dual hepatitis B and C infection recurred earlier after hepatectomies. But, the overall survival between these four groups was not different statistically.
LIPIODOLIGELFOAM CHEMOEMBOLIZATION FOR CONTROL OF CARCINOID SYNDROME SYMPTOMS AND OCTREOTIDE REQUIREMENTS. Frank 1. Wessels, Scott R. Schell, Lisa E. Moffat, James G. Caridi, Irvin F. Hawkins, Edward M. Copeland, Univ of Florida - Dept of Surg, Gainesville, FL; Univ of Florida Sch of Medicine, Gainesville, FL; Univ of Florida - Dept of Radiology, Gainesville, FL. Background: Hepatic artery chemoembolization has shown promise for treating symptoms and slowing tumor progression for patients with advanced hepatic metastases from carcinoid tumors. Prior studies examined single or continuous hepatic artery infusions using ethiodized oil with or without other agents, and several have shown improvement in short-term quality of life and tumor progression. Our institution uses a technique of repeated selective transcatheter hepatic artery embolization using Lipiodol and Gelfoam for treatment of various primary and metastatic hepatic tumors. This report reviews our experience in fifteen patients with advanced, unresectable hepatic metastases from carcinoid tumors, examining symptom control, quality of life, dependence upon octreotide, and tumor progression. Methods: Fifteen (6 male, 9 female, mean age 61.1±5.4 yr.) patients with unresectable bilobar hepatic metastases from carcinoid tumors were treated with selective hepatic artery embolization using Lipiodol/Gelfoam from 1994-1999. Patients had carcinoid diagnoses confirmed with urinary 5-HIAA levels, and biopsy-proven neuroendocrine tumors. Before treatment, 10 patients (67%) had carcinoid syndrome. Median follow-up was 29.3 mos. We developed an analog scale for rating symptom severity, ranging from a score of I for NO SYMPTOMS to a score of 5 for symptoms that were TOTALLY DISABLING or REQUIRED HOSPITALIZATION. Nine patients required octreotide for carcinoid symptom control prior to treatment. After treatment, symptom severity, octreotide dose, and tumor response were measured. Results: Patients without carcinoid syndrome did not develop symptoms or require octreotide during treatment. After treatment, Lipiodol uptake was seen on CT scan in all patients. Hepatic metastases were stable or decreased in size in 12 patients (80%). Patients with carcinoid syndrome demonstrated symptomatic relief and required less octreotide after treatment. Mean pre-treatment symptom scores were 3.9± 0.2, decreasing to 1.6± 0.3 after treatment, with 60% of patients asymptomatic. Mean pre-treatment octreotide dosages were 472±89 mcg/d, decreasing to 106±54 mcg/d after treatment, with 56% of patients off octreotide. One patient died from rapidly progressive extrahepatic disease. Conclusions: This study demonstrates that Lipiodol/Gelfoam hepatic artery chemoembolization produces excellent control of carcinoid syndrome, allowing patients to decrease or eliminate use of octreotide.
SSATAIOS7
2275
2277
DEVASCULARIZATION-MODIFIED SUGWRA PROCEDURE. DOES IT HAVE ANY ROLE IN THE MANAGEMENT OF VARICEAL BLEEDING? A REPORT OF LONG-TERM RESULTS IN CHILE. Jorge A. Martinez, Alfonso F. Diaz, Claudia 1. Aguayo, Mario A. Caracci, Rose M. Mege, Enrique E. Waugh, Julio R. Reyes, Dept of Digest Surg Catholic Univ, Santiago, Chile; Digest Surg Service, Sotero del Rio Hosp, Santiago, Chile.
RESECTION OF HEPATIC METASTASES IN PATIENTS TRADI· TIONALLY NOT CONSIDERED RESECTION CANDIDIATES. Joseph F. Buell, Daniel M. Labow, Atsushi Yoshida, Ralph Layman, David C. Cronin, J. Michael Millis, Mitchell C. Posner, Univ of Chicago Hospitals, Chicago, IL.
Background: Variceal bleeding is still a medical challenge in patients with portal hypertension. In the last decade surgical approaches to this problem have been replaced by endoscopic sclerotherapy, band ligation and the use of transjugular intrahepatic portosystemic shunt (TIPS). Liver transplantation, which provides definitive treatment for end-stage liver disease, is not still widespread available in our country. The aim of this report is to retrospectively review the long-term results of the modified-devascularization Sugiura procedure (DSP) done electively in patients with variceal bleeding in a public hospital setting. Patients and methods: Between June 1980 and December 1986, 48 patients with portal hypertension complicated with esophageal variceal bleeding, were electively submitted to the modified-DSP. Preoperative Child-Pugh class was assessed before surgery in all but one patient. Overall mortality, morbidity, postoperative hospital stay and variceal bleeding recurrences were determined. All death reports and certification were obtained. Mean follow-up of all patients was 9 ±6 years. Bleeding recurrence and long-term cumulative survivals were analyzed using Kaplan-Meier curves. Differences in survival were determined by the log-rank test. Results: The operative 30-day mortality and overall morbidity were 8.3% and 43.8% respectively. Portal hypertension was due to liver cirrhosis in 42 patients and from extrahepatic origin in 6. The Child-Pugh class in cirrhotic patients was A: 15 patients (35.7 %); B: 21 (50 %) and C: 5 patients (11.9 %). In 19 cases (39.6%) there were endoscopic evidences of variceal recurrence; nine out of them needed further sclerotherapy. Eleven patients (22.9 %) re-bled during the followup; 3 from variceal origin. Ten-year actuarial survival was 46.7%; 27.3% and 0 % for Child-Pugh A, B, C patients respectively (p< 0.001) and 100 % in extrahepatic portal hypertension patients. Overall 10- and IS-year survival in all series was 40.4 % and 27.5 %. Conclusion: The modifiedDSP may be still a good alternative surgical option in patients with variceal bleeding with well-preserved hepatic function who will not be candidates to liver transplantation.
Hepatic resection for metastatic disease is considered appropriate in colorectal cancer (CRC) patients with minimal tumor burden ($3 rnetastases)isolated to the liver. Metastasectomy in the presence of advanced age, bilobar disease or non-colorectal metastases is controversial. We examined the efficacy of hepatic resection in this cohort. Methods: Sevety-seven non-traditional resection candidates (NTR) were identified and compared to sixty-three traditional resection (TR)candidates composed of patients with unilobar coiorectal cancer whose age was less than 70 yrs. Statistical comparisions of demographics and survival were performed by student's t-test, actuarial survivals, and log-rank analysis. Results: The NTR group was composed of 21 CRC patients 2: 70 yrs of age, 25 patients with bilobar CRC and 31 with non-CRC metastases. Patients with bilobar disease had a significantly decreased disease-free interval from primary resection to metastatic disease when compared to the TR group (9.6±9.3 vs. 20.9±28. I mos.;p<0.006). Both the number and size of metastatic lesions were significantly greater in the NTR group compared to the TR group (2.2 ± 1.5 vs. 1.6± 1.2 lesions; p<0.02 and 5.7±3.6 vs. 3.8±2.8 cm;p<0.002), respectively. Resection margins were not different between the groups. Length of hospital stay (7.7±4.5 vs. 7.5±1.8 days),90-day mortality (2/77 vs. 0/63)and morbidity rates (12% vs.10%)were similar. Disease-free survival at 1,3 and 5 yrs was significantly different between the NTR and TR group: 81 ±4, 41 ±7,and 23±8% vs. 93±3, 6O±7,and 49±8%; p<0.008. Patients > 70 years of age with CRC demonstrated an equivalent 5-year survival compared to the TR group (42± 14% vs. 49±8%; p=NS). Patients with bilobar CRC had a decreased 5-yr survival when compared to the TR group(25± 11%; p=0.056). The non-CRC group had a significantly diminished 3-yr. survival (36± 13%; p<0.002) when compared to TR. Conclusions: Hepatic resection in NTR patients can be performed with minimal morbidity and mortality. Despite decreased survival in the NTR cohorts particularly those with bilobar disease or non-CRC metastases, when the NTR group is compared to TR patients, survival approximates those historically reported for resection of hepatic CRC metastases. These data suggest liberalizing the indications for resection of hepatic metastases may have a substantial impact.
2276
2278
SURGICAL RESULTS IN PATIENTS WITH HEPATITIS VIRUS RELATED HEPATOCELLULAR CARCINOMA IN TAIWAN. Miin-Fu Chen, Wei-Chen Lee, Long-Bin Jeng, Chang Gung Memorial Hosp, Taipei, Taiwan, ROC. To evaluate the surgical results in patients with hepatitis virus related hepatocellular carcinoma (HCC), 252 patients, 196 male and 56 female, who had undergone hepatic resection for HCC from March, 1992, to August, 1998, with complete profiles of hepatis virus markers study were reviewed. The patients were divided into 4 groups, 30 patients (11.9%) without neither hepatitis B surface antigen (HBsAg) or anti-hepatitis C antibody (Anti-HCV Ab) (N-HCC group), 133 patients (52.8%) with positivity of HBsAg only (B-HCC group), 66 patients (26.2%) with positivity of Anti-HCV Ab only (C-HCC group), and 23 patients (9.1%) with positivity of either HBsAg and anti-HCV Ab (BC-HCC group). Compared to the patients in other groups, the patients in C-HCC group were older and were associated with more severe cirrhotic change of the liver. The surgical complication rates and hospital mortalities in C-HCC and BC-HCC groups were 30.3%, 12.1% and 30.4%, 17.4%, respectively, which were higher than those of N-HCC (13.3%, 3.3%) and B-HCC (15.8%, 3.8%) groups. The mean disease-free survival for N-HCC, B-HCC, C-HCC and BC-HCC groups were 31.4 months, 25.4 months, 38.9 months and 13.8 months, respectively. The difference between these four groups was statistically significant (p < 0.05). However, the mean overall survival time, 38.3 months for N-HCC group, 37.2 months for B-HCC group, 52.1 months for C-HCC group, and 32.7 months for BC-HCC group, were not different statistically (p=0.146). In conclusion, the surgical treatment for HCC related to hepatitis C or dual hepatitis B and C were associated with higher surgical complication rate and hospital mortalities. Hepatocellular carcinoma-related to dual hepatitis B and C infection recurred earlier after hepatectomies. But, the overall survival between these four groups was not different statistically.
LIPIODOLIGELFOAM CHEMOEMBOLIZATION FOR CONTROL OF CARCINOID SYNDROME SYMPTOMS AND OCTREOTIDE REQUIREMENTS. Frank 1. Wessels, Scott R. Schell, Lisa E. Moffat, James G. Caridi, Irvin F. Hawkins, Edward M. Copeland, Univ of Florida - Dept of Surg, Gainesville, FL; Univ of Florida Sch of Medicine, Gainesville, FL; Univ of Florida - Dept of Radiology, Gainesville, FL. Background: Hepatic artery chemoembolization has shown promise for treating symptoms and slowing tumor progression for patients with advanced hepatic metastases from carcinoid tumors. Prior studies examined single or continuous hepatic artery infusions using ethiodized oil with or without other agents, and several have shown improvement in short-term quality of life and tumor progression. Our institution uses a technique of repeated selective transcatheter hepatic artery embolization using Lipiodol and Gelfoam for treatment of various primary and metastatic hepatic tumors. This report reviews our experience in fifteen patients with advanced, unresectable hepatic metastases from carcinoid tumors, examining symptom control, quality of life, dependence upon octreotide, and tumor progression. Methods: Fifteen (6 male, 9 female, mean age 61.1±5.4 yr.) patients with unresectable bilobar hepatic metastases from carcinoid tumors were treated with selective hepatic artery embolization using Lipiodol/Gelfoam from 1994-1999. Patients had carcinoid diagnoses confirmed with urinary 5-HIAA levels, and biopsy-proven neuroendocrine tumors. Before treatment, 10 patients (67%) had carcinoid syndrome. Median follow-up was 29.3 mos. We developed an analog scale for rating symptom severity, ranging from a score of I for NO SYMPTOMS to a score of 5 for symptoms that were TOTALLY DISABLING or REQUIRED HOSPITALIZATION. Nine patients required octreotide for carcinoid symptom control prior to treatment. After treatment, symptom severity, octreotide dose, and tumor response were measured. Results: Patients without carcinoid syndrome did not develop symptoms or require octreotide during treatment. After treatment, Lipiodol uptake was seen on CT scan in all patients. Hepatic metastases were stable or decreased in size in 12 patients (80%). Patients with carcinoid syndrome demonstrated symptomatic relief and required less octreotide after treatment. Mean pre-treatment symptom scores were 3.9± 0.2, decreasing to 1.6± 0.3 after treatment, with 60% of patients asymptomatic. Mean pre-treatment octreotide dosages were 472±89 mcg/d, decreasing to 106±54 mcg/d after treatment, with 56% of patients off octreotide. One patient died from rapidly progressive extrahepatic disease. Conclusions: This study demonstrates that Lipiodol/Gelfoam hepatic artery chemoembolization produces excellent control of carcinoid syndrome, allowing patients to decrease or eliminate use of octreotide.