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Prognostic value of lymph node ratio after resection of intra-hepatic and peri-hilar cholangiocarcinoma
ABSTRACTS FRL has been provided. With this highly selective approach the rate of completion of the procedure is high and the results show that, despite a higher rate of complications associated with the second stage, mortality is low and similar to that reported in the literature for procedures in a single time. The two stage hepatectomy in two stages represents another treatment option for patients with CLM, although careful selection of patients is required even considering the apparently greater complexity of the second stage.
Surgical resection of hccHCC in cirrhosis: prognostic value of portal Hypertension A . Gu g l i e l m i , A . R uz z e n e nt e , S. Pa c h e r a , T. Ca m pag na ro , A. Valdegamberi, C. Iacono Division of General Surgery “A”, GB Rossi Hospital, University of Verona, Verona, Italy Background: EASL/AASLD guidelines consider the presence of clinical portal hypertension (PH) as a contraindication to liver resection for HCC in patients with liver cirrhosis. The aims of this study were to analyse the outcome of resection in patients with or without PH, and the relationship between PH, extent of hepatectomy and long-term survival. Materials and Methods: Retrospective analysis of 135 patients with HCC in cirrhosis radically resected between 1995 and 2008. Grade of cirrhosis was classified according to Child-Pugh (C-P) score; the presence of PH was defined as the presence of oesophageal varices or splenomegaly associated with platelet count <100,000/mm3. Results: One-hundred and ten patients were class C-PA and 25 were C-P B; 91 patients had single HCC and 44 had multi-nodular HCC (range 2e5). PH was present in 44 (32.5%) patients. Overall mortality and morbidity were 2.2% and 33.7% respectively; the complication rate in patients with or without PH was 37% and 32% respectively. Mean follow-up was of 38.3 months; threeand five-year survival was 58% and 46% respectively. Median survival time in patients with or without PH was 31.6 and 64.9 months respectively (p¼0.04). In the subgroup of C-P A patients, median survival was 65.1 and 60.5 months respectively. Patients undergoing wedge resection (WR) or segmentectomy, with and without PH, had a median survival of 60.5 and 64.9 months respectively. On the contrary, patients who underwent resection of 2 or more segments, with or without PH, showed a mean survival of 34.4 and 116 respectively (p¼0.03). Conclusions: PH is not an absolute contraindication to hepatectomy in cirrhotic patients. In ChildePugh A patients undergoing WR or segmentectomy long-term survival was not significantly different in patients with or without PH. On the contrary, surgical resection of 2 or more segments in patients with PH resulted in significantly shorter survival times and should not be recommended. Prognostic value of lymph node ratio after resection of intra-hepatic and peri-hilar cholangiocarcinoma A. Guglielmi, A. Ruzzenente, T. Campagnaro, S. Pachera, S. Conci, C. Iacono Division of General Surgery “A”, GB Rossi Hospital, University of Verona, Verona, Italy Background: Lymph node (LN)metastasis is a major negative prognostic factor for intra-hepatic (ICC) and peri-hilar cholangiocarcinoma (PCC). Prognostic significance of the extent of LN dissection and of the number of metastaticLNis still under debate.Moreover, the prognostic significance of lymphnode ratio (LNR) had not been investigated in ICC and PCC. The aims of this study are to evaluate the prognostic value of LN status, of the total number of LNs evaluated and of LNR in ICC and PCC. Methods: Patients with ICC and PCC undergoing surgical resection with curative intent between 1990 and 2008 were retrospectively evaluated. Number and status of harvested LN were recorded. Results: One hundred and ten patients (62 with PCC and 48 with ICC) underwent surgical resection with curative intent. Survival after a mean
1021 follow-up of 24 months was 22 months (95% CI 18e26) for PCC and 41 months (95% CI 18e63) for ICC. In 85 patients (77%) regional lymphadenectomy was performed. Median number of LNs examined was 6.7 (range 1e26). LNs were positive (N+) in 22 patients (42%) with PCC and in 7 patients (20%) with ICC (p¼0.03). Median survival in N0 patients was significantly longer compared with N+ patients: 42 and 23 months respectively (p¼0.03) in PCC, 56 and 19 months respectively (p¼0.02) in ICC. Mean survival was significantly related to the number of LN harvested: mean survival for patients with 0 LNs retrieved, between 1 and 3 and more than 3 LNs retrieved was 9, 25 and 32 months respectively for PCC (p<0.001), and 47, 33 and 87 respectively for ICC (p¼0.16). Further statistical analysis identified a LNR cut-off value of 0.25; survival analysis identified that five-year survival for patients above and below an LNR of 0.25 was 0% and 22% respectively for PCC (p¼0.03) and 0% and 37% respectively for ICC (p<0.01). Conclusion: LN metastasis is a major prognostic factor for survival after surgical resection of PCC and ICC. Number of LN harvested and LNR showed prognostic value. Like other gastrointestinal tumours, our study also identifies the prognostic role of LNR in PCC and ICC and identifies patients suitable for adjuvant therapies. Treatment of recurrent colorectal liver metastases: is repeat surgery safe and effective? A single centre experience F. Ratti, F. Cipriani, M. Catena, M. Paganelli, L. Aldrighetti, G. Ferla Dipartimento di Chirurgia Generale e Specialistica e Liver Unit. IRCCS H SanRaffaele,Universita´ Vita-Salute SanRaffaele,ViaOlgettina, Milano, Italy Background: Liver resection is the best potentially curative treatment for colorectal liver metastases (CLM). Sixty to seventy percent of patients undergoing surgical treatment develop recurrent disease and about 30% of recurrences are in the liver. In this study, we analysed intra- and postoperative outcome, survival and recurrence after primary (PR) and repeated RR) resection to determine the actual value of this approach in patients with recurrence. In addition, we aim to identify factors predictive of long-term survival after repeat liver resections with curative intent. Materials and Methods: From January 2000 to January 2006, 298 liver resections for CLMwere carried out in 245 patients at the Department of General Surgery e Liver Unit HSR. Of these 245, 53 patients underwent repeat resection and are the object of our study. PR and RR were compared in terms of extent of hepatic resection, intraoperative blood loss, complications, postoperative hospital stay and mortality, and finally overall survival (OS), disease-free survival (DFS) and recurrence rate were evaluated. Results: There was no statistically significant difference in terms of intra and postoperative outcome between PR and RR. Therewere no deaths reported within 30 days. Overall operative morbidity was also similar following FR 19.1%) compared with second resection (23.2%). Minor resections were performed more frequently: 169 in the PR group and 37 in the RR group. The OS at one, three and five years was 92%, 62% and 53% in the PR and 86%, 51% and 34%in RR group (p not significant). The recurrence rate at one, three and five yearswas respectively 40.5%, 56%and 61.2%in the PRgroup and 44.6%, 60.5% and 64%in the RR group. On univariate analyses, only the presence of extra-hepatic disease (p¼0.004) and synchronous presentation (p¼0.029) were significantly associated with a worse long-term prognosis. Conclusions: Our study confirms, as documented in previous reports, the effectiveness of repeated hepatic resection in the treatment of recurrent liver metastases from colorectal cancer. The mortality, morbidity and survival rates after repeated liver surgery are comparable with the results after the first liver resection, and these data further underscore how new technological frontiers in surgery, radiology and oncology allow a progressive improvement in the longterm outcome of patients whose life expectancy, in the past, was calculated to be a few months, with no additional cost in terms of short-term outcome.
Surgical resection of hccHCC in cirrhosis: prognostic value of portal Hypertension A . Gu g l i e l m i , A . R uz z e n e nt e , S. Pa c h e r a , T. Ca m pag na ro , A. Valdegamberi, C. Iacono Division of General Surgery “A”, GB Rossi Hospital, University of Verona, Verona, Italy Background: EASL/AASLD guidelines consider the presence of clinical portal hypertension (PH) as a contraindication to liver resection for HCC in patients with liver cirrhosis. The aims of this study were to analyse the outcome of resection in patients with or without PH, and the relationship between PH, extent of hepatectomy and long-term survival. Materials and Methods: Retrospective analysis of 135 patients with HCC in cirrhosis radically resected between 1995 and 2008. Grade of cirrhosis was classified according to Child-Pugh (C-P) score; the presence of PH was defined as the presence of oesophageal varices or splenomegaly associated with platelet count <100,000/mm3. Results: One-hundred and ten patients were class C-PA and 25 were C-P B; 91 patients had single HCC and 44 had multi-nodular HCC (range 2e5). PH was present in 44 (32.5%) patients. Overall mortality and morbidity were 2.2% and 33.7% respectively; the complication rate in patients with or without PH was 37% and 32% respectively. Mean follow-up was of 38.3 months; threeand five-year survival was 58% and 46% respectively. Median survival time in patients with or without PH was 31.6 and 64.9 months respectively (p¼0.04). In the subgroup of C-P A patients, median survival was 65.1 and 60.5 months respectively. Patients undergoing wedge resection (WR) or segmentectomy, with and without PH, had a median survival of 60.5 and 64.9 months respectively. On the contrary, patients who underwent resection of 2 or more segments, with or without PH, showed a mean survival of 34.4 and 116 respectively (p¼0.03). Conclusions: PH is not an absolute contraindication to hepatectomy in cirrhotic patients. In ChildePugh A patients undergoing WR or segmentectomy long-term survival was not significantly different in patients with or without PH. On the contrary, surgical resection of 2 or more segments in patients with PH resulted in significantly shorter survival times and should not be recommended. Prognostic value of lymph node ratio after resection of intra-hepatic and peri-hilar cholangiocarcinoma A. Guglielmi, A. Ruzzenente, T. Campagnaro, S. Pachera, S. Conci, C. Iacono Division of General Surgery “A”, GB Rossi Hospital, University of Verona, Verona, Italy Background: Lymph node (LN)metastasis is a major negative prognostic factor for intra-hepatic (ICC) and peri-hilar cholangiocarcinoma (PCC). Prognostic significance of the extent of LN dissection and of the number of metastaticLNis still under debate.Moreover, the prognostic significance of lymphnode ratio (LNR) had not been investigated in ICC and PCC. The aims of this study are to evaluate the prognostic value of LN status, of the total number of LNs evaluated and of LNR in ICC and PCC. Methods: Patients with ICC and PCC undergoing surgical resection with curative intent between 1990 and 2008 were retrospectively evaluated. Number and status of harvested LN were recorded. Results: One hundred and ten patients (62 with PCC and 48 with ICC) underwent surgical resection with curative intent. Survival after a mean
1021 follow-up of 24 months was 22 months (95% CI 18e26) for PCC and 41 months (95% CI 18e63) for ICC. In 85 patients (77%) regional lymphadenectomy was performed. Median number of LNs examined was 6.7 (range 1e26). LNs were positive (N+) in 22 patients (42%) with PCC and in 7 patients (20%) with ICC (p¼0.03). Median survival in N0 patients was significantly longer compared with N+ patients: 42 and 23 months respectively (p¼0.03) in PCC, 56 and 19 months respectively (p¼0.02) in ICC. Mean survival was significantly related to the number of LN harvested: mean survival for patients with 0 LNs retrieved, between 1 and 3 and more than 3 LNs retrieved was 9, 25 and 32 months respectively for PCC (p<0.001), and 47, 33 and 87 respectively for ICC (p¼0.16). Further statistical analysis identified a LNR cut-off value of 0.25; survival analysis identified that five-year survival for patients above and below an LNR of 0.25 was 0% and 22% respectively for PCC (p¼0.03) and 0% and 37% respectively for ICC (p<0.01). Conclusion: LN metastasis is a major prognostic factor for survival after surgical resection of PCC and ICC. Number of LN harvested and LNR showed prognostic value. Like other gastrointestinal tumours, our study also identifies the prognostic role of LNR in PCC and ICC and identifies patients suitable for adjuvant therapies. Treatment of recurrent colorectal liver metastases: is repeat surgery safe and effective? A single centre experience F. Ratti, F. Cipriani, M. Catena, M. Paganelli, L. Aldrighetti, G. Ferla Dipartimento di Chirurgia Generale e Specialistica e Liver Unit. IRCCS H SanRaffaele,Universita´ Vita-Salute SanRaffaele,ViaOlgettina, Milano, Italy Background: Liver resection is the best potentially curative treatment for colorectal liver metastases (CLM). Sixty to seventy percent of patients undergoing surgical treatment develop recurrent disease and about 30% of recurrences are in the liver. In this study, we analysed intra- and postoperative outcome, survival and recurrence after primary (PR) and repeated RR) resection to determine the actual value of this approach in patients with recurrence. In addition, we aim to identify factors predictive of long-term survival after repeat liver resections with curative intent. Materials and Methods: From January 2000 to January 2006, 298 liver resections for CLMwere carried out in 245 patients at the Department of General Surgery e Liver Unit HSR. Of these 245, 53 patients underwent repeat resection and are the object of our study. PR and RR were compared in terms of extent of hepatic resection, intraoperative blood loss, complications, postoperative hospital stay and mortality, and finally overall survival (OS), disease-free survival (DFS) and recurrence rate were evaluated. Results: There was no statistically significant difference in terms of intra and postoperative outcome between PR and RR. Therewere no deaths reported within 30 days. Overall operative morbidity was also similar following FR 19.1%) compared with second resection (23.2%). Minor resections were performed more frequently: 169 in the PR group and 37 in the RR group. The OS at one, three and five years was 92%, 62% and 53% in the PR and 86%, 51% and 34%in RR group (p not significant). The recurrence rate at one, three and five yearswas respectively 40.5%, 56%and 61.2%in the PRgroup and 44.6%, 60.5% and 64%in the RR group. On univariate analyses, only the presence of extra-hepatic disease (p¼0.004) and synchronous presentation (p¼0.029) were significantly associated with a worse long-term prognosis. Conclusions: Our study confirms, as documented in previous reports, the effectiveness of repeated hepatic resection in the treatment of recurrent liver metastases from colorectal cancer. The mortality, morbidity and survival rates after repeated liver surgery are comparable with the results after the first liver resection, and these data further underscore how new technological frontiers in surgery, radiology and oncology allow a progressive improvement in the longterm outcome of patients whose life expectancy, in the past, was calculated to be a few months, with no additional cost in terms of short-term outcome.