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Surgical outcomes of metabolic syndrome related HCC: A comparative study with viral and alcoholic HCC
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E-AHPBA: Poster Abstracts
Aims: Associating liver partition and portal vein ligation in staged hepatectomy (ALPPS) is an alternative to conventional portal vein embolization or -ligation (PVE/PVL). In patients with technically resectable liver tumors but insufficient future liver remnant (FLR) some growth stimuli is needed. Initial experiences indicated that the complication rate and perioperative mortality following ALPPS exceeded that of PVE/PVL. The aim of this study was to assess the initial safety and feasibility of ALPPS at three Scandinavian HPB centers. Methods: Thirty-six patients (2:1 male:female), median age 67 (22e80) years were operated during a 26 month period at three Scandinavian institutions. Colorectal liver metastases was the most common diagnosis followed by cholangiocarcinoma and HCC. The number of lesions varied from 1e20. None of the patients had underlying liver disease. Results: All patients completed the 2-stage procedure at a median of 8 days (7e15) following stage 1. Majority of the patients had extended right hemi-hepatectomies, wheras the remaining few had conventional right hemi-hepatectomies and atypical ALPPS. Median hospital stay after the second procedure was 9.5 days (2e50). No perioperative mortality was observed. Although complications were observed in majority of the cases, the highest grade according to Clavien-Dindo grading was 3b, seen in 3 patients (8%). Conclusions: ALPPS is an alternative to PVE/PVL in some patients. An acceptable complication rate can be obtained in selected patient cohort and the feasibility and rate of severe complications found in this cohort compares favorably to previously published results with PVE and two-stage hepatectomy. Early recurrences have been found following ALPPS, and our short and intermediate oncological results will be presented. Randomized controlled trials to define what patients may benefit from ALPPS are lacking. A multicenter Scandinavian trial, LIGRO (www.clinicaltrials.gov NCT02215577) has therefore been initiated and has been enrolling patients since May 2014.
LIVER 0752 DIFFERENTIATION OF HEPATIC ADENOMA FROM FOCAL NODULAR HYPERPLASIA WITH PRIMOVIST MRI: VALIDATION OF DIAGNOSTIC CRITERIA M. Doyle1, J. S. Bagia2, J. Yeo1, A. Teixeira-Pinto2 and S. Tran1 1 St George Hospital; 2University of Sydney, Australia Aims: To evaluate performance of MRI with PrimovistÒ (Bayer Healthcare, germany) (pMRI) in discriminating Hepatic Adenoma (HA) from Focal Nodular Hyperplasia (FNH) by retrospectively applying assessment criteria described by Grazioli [1] to our series of pMRI images. Methods: Our hepatobiliary surgical database was retrospectively reviewed for patients with histologicallyconfirmed HA or FNH, who underwent pMRI prior to tissue sampling. 12 patients with a total of 13 lesions (7 FNH lesions, 6 HA lesions) were identified. Two independent readers performed qualitative and quantitative
analysis on all pMRI Including Signal Intensity (SI) characteristics during dynamic and delayed phases, and SI numerical quantification allowing contrast enhancement ratio (CER), liver-to-lesion contrast (LLC) and SI ratios to be calculated. Results: 12 patients with 13 lesions were included. Ther were 11 females. 5 patients had HA, 6 patients had FNH and 1 patient had 2 lesions, with one HA and one FNH. Mean size of HA lesions was 3.2cm and FNH 6.4cm. No HA demonstrated a central scar while 57e71% of FNH had SI characteristics in keeping with a central scar. All FNH lesions were iso- to hyperintense on portal venous and delayed dynamic phase imaging, while only 2 HA (33%) were iso-hyperintense during delayed dynamic phase imaging. 67e83% of HA were isointense during hepatobiliary phase imaging while only 14e29% of FNH were hypointense during similar image sequencing. The CER of HA in the arterial phase (mean 86.1% +/ 42%) was similar to FNH (mean 104% +/ 74.7%), while the LLC of HA during the hepatobiliary was more strongly negative (mean 0.70 +/ 0.69) than FNH (mean 0.08 +/ 0.85). Conclusions: pMRI continues to improve diagnostic accuracy between HA and FNH. This qualitative and quantitative assessment method is potentially reproducible, however some variability occurred as expected with small numbers and no prior experience with this type of imaging analysis.
LIVER 0760 SURGICAL OUTCOMES OF METABOLIC SYNDROME RELATED HCC: A COMPARATIVE STUDY WITH VIRAL AND ALCOHOLIC HCC A. Ruzzenente, M. De Angelis, S. Conci, F. Bagante, A. Valdegamberi, F. Bertuzzo, G. Mantovani, C. Iacono and A. Guglielmi University and Hospital Trust of Verona, Italy Aims: Up to 30% of HCC are not related to usual risk factors, the majority of these HCC are associated with nonalcoholic fatty liver disease (NAFLD), hepatic manifestations of metabolic syndrome (MS). The purposes of the study were to analyse the clinical features, short-term and long-term outcomes of metabolic syndrome HCC (MSHCC) compared to alcoholic and viral HCC. Methods: One hundred twenty-four consecutive patients with available etiology data underwent liver resection for HCC from January 2006 to December 2013 in a single HPB tertiary referral center. The clinical, pathological and surgical features, overall survival and disease-free survival data were analysed. Results: Among 124 patients with HCC, 26 patients (20.9%) had MS, 35 patients (28.2%) had alcohol consumption 60 g/die (alcohol-HCC) and 63 patients (50.9%) presented a HBV and/or HCV infection (viralHCC). Patients with MS-HCC resulted oldest compare with alcohol and viral HCC with a mean age of 74.83, 70.01 and 68.35 years, respectively, p = 0.029. MS-HCC showed lower rate of underlying cirrhosis (32% vs. 68.6% in alcohol-HCC and 68.3% in viral-HCC, respectively,
HPB 2016, 18 (S2), e685ee738
E-HPBA: Poster Abstracts p = 0.004). Grade 2 or 3 steatosis was significantly more common in MS-HCC (53.9% vs. 11.6% in alcohol-HCC and 5% in viral-HCC). Postoperative mortality was not significantly different between the three groups. The rates of severe complications (Dindo 3) in MS-HCC, alcoholHCC and viral-HCC, were 7.7%, 8.6% and 19.0%, respectively, p = 0.034. 5-years overall survival rate of MSHCC, alcohol-HCC and viral-HCC was 71.7%, 41.5% and 39.2% months, respectively (p = 0.701). 5-years DFS rate was 54.7% in MS-HCC, 28.4% in alcohol-HCC and 19.4% in viral-HCC (p = 0.026). Conclusions: Patients in MS group presented frequently with no underlying liver cirrhosis but with moderate-severe steatosis. DFS was significantly higher in patients with MSHCC compared with alcohol-HCC and viral-HCC.
LIVER 0761 ASSOCIATION BETWEEN PATIENT AND CHEMOTHERAPY CHARACTERISTICS WITH SHORTTERM OUTCOMES OF RESECTIONS FOR COLORECTAL CANCER LIVER METASTASES J. Urdzik, U. Haglund, F. Duraj and A. Norén Uppsala University, Sweden Aims: Increasing use of preoperative chemotherapy for colorectal cancer liver metastases (CRCLM) before resection has raised questions about its impact on postoperative complications. The aim of this study is therefore to elucidate the impact of patient comorbidities and preoperative chemotherapy treatment on short-term outcomes of liver surgery for CRCLM. Methods: A retrospective analysis of a prospective database of 471 consecutive patients who underwent 516 liver resections for CRCLM at Uppsala University Hospital between January 2000 and December 2013. Patient characteristics, comorbidity and chemotherapy treatment before liver surgery were analysed and related to post-hepatectomy haemorrhage (PHH), biliary leakage (BL), post-hepatectomy liver failure (PHLF), severe complications (Dindo-Clavien grade IIIb) and 90-day mortality (90dMOR). Results: PHH was associated with more than four oxaliplatin cycles (relative risk, RR 1.4, p = 0.047), intraoperative blood loss over 1100 ml, transfusion of erythrocytes and synchronous metastases. BL was associated with the biliary system procedures and major resections. PHLF was associated with major resections, perioperative transfusion of erythrocytes, and male gender. PHLF risk was lower in rectal cancer metastases. Severe complications were associated with major resections, blood loss over 1100 ml, and number of tumours. 90dMOR was 1.9%, increasing with grade C liver-specific complications: 50% for PHH, 20% for BL and 29% for PHLF. Further, 90dMOR was associated with underlying liver disease (RR 8.7, p = 0.015) and diabetes mellitus (RR 6.4, p = 0.007). Conclusions: PHH was associated with more than four oxaliplatin cycles, but other short-term outcomes of CRCLM resections were not influenced by preoperative chemotherapy in this series of patients. Underlying liver
HPB 2016, 18 (S2), e685ee738
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disease and diabetes mellitus were associated with 90dMOR.
LIVER 0762 ADRENAL GLAND HEPATOCELLULAR CARCINOMA METASTASES M. F. Valentini, S. Roselli, R. Lopatriello, G. Gigante and L. G. Lupo Policlinico Bari, Italy Aims: To establish the probability to develop adrenal gland metastases (AGM) in patients with hepatocellular carcinoma (HCC) and to evaluate risk factors associated. Methods: From 1997 to 2014, 847 patients were admitted at our Centre with a diagnosis of HCC: 321 were treated with hepatic resection (HR) and 526 with radiofrequency ablation (RFA). 8 patients presented AGM. Site of metastases was: AG alone (4), AG and liver (1), AG and lung or abdominal lymphonodes (2), AG and liver or lung (1). All metastases were treated with adrenalectomy. Median disease-free survival (from HCC diagnosis to AGM) was 20 months (range 2e93 months). 3 patients died of cancer. Variables considered were: gender (7 male, 1 female), liver disease (3 with HBV and 5 with HCV-related cirrhosis), Child Pugh score (7 A, 1 B), HCC number of lesions (7 with 1 nodule, 1 with more than 3 nodules) and size of HCC largest lesion (2 with nodules sized < 30 mm, 5 sized 30e 50 mm and 1 sized >50 mm) at diagnosis and number of intrahepatic recurrences (2 had 1 recurrence, 1 had 2 recurrences and 5 had no recurrence). Results: Virological status (OR 1,9, CI 95 % 0,4e8,1 p value ns), number of lesions (OR 2,6, CI 95% 0,3 22 p value ns) , size of largest HCC (OR 1,2, CI 95% 0,1 10,2 p value ns), number of intrahepatic recurrences and type of treatment were analyzed. Conclusions: No evidence of risk factors related to development of HCC AGM was observed.
LIVER 0764 TREATMENT OF RECURRENT HCC AFTER CURATIVE RESECTION IMPROVES SURVIVAL S. Conci, A. Ruzzenente, A. Valdegamberi, M. Fontana, F. Bertuzzo, M. Piccino, G. Mantovani, C. Iacono and A. Guglielmi University and Hospital Trust of Verona, Italy Aims: Recurrences after curative treatment of HCC reach a rate of 70e80% within 5 years and remain one of the major negative event influencing overall survival. The purposes of this study were to identify risk factors for the recurrence of HCC and to analyze the impact on survival of management of recurrent disease. Methods: Two hundred and sixty nine patients who have undergone curative liver resection for HCC from January 1990 to December 2012 were included in this study. Clinical and pathological variables were analyzed with a univariate and multivariate survival analysis to identify prognostic factors for early recurrence. Recurrent patients were evaluated for new treatment according to tumor stage, liver function and general condition.
E-AHPBA: Poster Abstracts
Aims: Associating liver partition and portal vein ligation in staged hepatectomy (ALPPS) is an alternative to conventional portal vein embolization or -ligation (PVE/PVL). In patients with technically resectable liver tumors but insufficient future liver remnant (FLR) some growth stimuli is needed. Initial experiences indicated that the complication rate and perioperative mortality following ALPPS exceeded that of PVE/PVL. The aim of this study was to assess the initial safety and feasibility of ALPPS at three Scandinavian HPB centers. Methods: Thirty-six patients (2:1 male:female), median age 67 (22e80) years were operated during a 26 month period at three Scandinavian institutions. Colorectal liver metastases was the most common diagnosis followed by cholangiocarcinoma and HCC. The number of lesions varied from 1e20. None of the patients had underlying liver disease. Results: All patients completed the 2-stage procedure at a median of 8 days (7e15) following stage 1. Majority of the patients had extended right hemi-hepatectomies, wheras the remaining few had conventional right hemi-hepatectomies and atypical ALPPS. Median hospital stay after the second procedure was 9.5 days (2e50). No perioperative mortality was observed. Although complications were observed in majority of the cases, the highest grade according to Clavien-Dindo grading was 3b, seen in 3 patients (8%). Conclusions: ALPPS is an alternative to PVE/PVL in some patients. An acceptable complication rate can be obtained in selected patient cohort and the feasibility and rate of severe complications found in this cohort compares favorably to previously published results with PVE and two-stage hepatectomy. Early recurrences have been found following ALPPS, and our short and intermediate oncological results will be presented. Randomized controlled trials to define what patients may benefit from ALPPS are lacking. A multicenter Scandinavian trial, LIGRO (www.clinicaltrials.gov NCT02215577) has therefore been initiated and has been enrolling patients since May 2014.
LIVER 0752 DIFFERENTIATION OF HEPATIC ADENOMA FROM FOCAL NODULAR HYPERPLASIA WITH PRIMOVIST MRI: VALIDATION OF DIAGNOSTIC CRITERIA M. Doyle1, J. S. Bagia2, J. Yeo1, A. Teixeira-Pinto2 and S. Tran1 1 St George Hospital; 2University of Sydney, Australia Aims: To evaluate performance of MRI with PrimovistÒ (Bayer Healthcare, germany) (pMRI) in discriminating Hepatic Adenoma (HA) from Focal Nodular Hyperplasia (FNH) by retrospectively applying assessment criteria described by Grazioli [1] to our series of pMRI images. Methods: Our hepatobiliary surgical database was retrospectively reviewed for patients with histologicallyconfirmed HA or FNH, who underwent pMRI prior to tissue sampling. 12 patients with a total of 13 lesions (7 FNH lesions, 6 HA lesions) were identified. Two independent readers performed qualitative and quantitative
analysis on all pMRI Including Signal Intensity (SI) characteristics during dynamic and delayed phases, and SI numerical quantification allowing contrast enhancement ratio (CER), liver-to-lesion contrast (LLC) and SI ratios to be calculated. Results: 12 patients with 13 lesions were included. Ther were 11 females. 5 patients had HA, 6 patients had FNH and 1 patient had 2 lesions, with one HA and one FNH. Mean size of HA lesions was 3.2cm and FNH 6.4cm. No HA demonstrated a central scar while 57e71% of FNH had SI characteristics in keeping with a central scar. All FNH lesions were iso- to hyperintense on portal venous and delayed dynamic phase imaging, while only 2 HA (33%) were iso-hyperintense during delayed dynamic phase imaging. 67e83% of HA were isointense during hepatobiliary phase imaging while only 14e29% of FNH were hypointense during similar image sequencing. The CER of HA in the arterial phase (mean 86.1% +/ 42%) was similar to FNH (mean 104% +/ 74.7%), while the LLC of HA during the hepatobiliary was more strongly negative (mean 0.70 +/ 0.69) than FNH (mean 0.08 +/ 0.85). Conclusions: pMRI continues to improve diagnostic accuracy between HA and FNH. This qualitative and quantitative assessment method is potentially reproducible, however some variability occurred as expected with small numbers and no prior experience with this type of imaging analysis.
LIVER 0760 SURGICAL OUTCOMES OF METABOLIC SYNDROME RELATED HCC: A COMPARATIVE STUDY WITH VIRAL AND ALCOHOLIC HCC A. Ruzzenente, M. De Angelis, S. Conci, F. Bagante, A. Valdegamberi, F. Bertuzzo, G. Mantovani, C. Iacono and A. Guglielmi University and Hospital Trust of Verona, Italy Aims: Up to 30% of HCC are not related to usual risk factors, the majority of these HCC are associated with nonalcoholic fatty liver disease (NAFLD), hepatic manifestations of metabolic syndrome (MS). The purposes of the study were to analyse the clinical features, short-term and long-term outcomes of metabolic syndrome HCC (MSHCC) compared to alcoholic and viral HCC. Methods: One hundred twenty-four consecutive patients with available etiology data underwent liver resection for HCC from January 2006 to December 2013 in a single HPB tertiary referral center. The clinical, pathological and surgical features, overall survival and disease-free survival data were analysed. Results: Among 124 patients with HCC, 26 patients (20.9%) had MS, 35 patients (28.2%) had alcohol consumption 60 g/die (alcohol-HCC) and 63 patients (50.9%) presented a HBV and/or HCV infection (viralHCC). Patients with MS-HCC resulted oldest compare with alcohol and viral HCC with a mean age of 74.83, 70.01 and 68.35 years, respectively, p = 0.029. MS-HCC showed lower rate of underlying cirrhosis (32% vs. 68.6% in alcohol-HCC and 68.3% in viral-HCC, respectively,
HPB 2016, 18 (S2), e685ee738
E-HPBA: Poster Abstracts p = 0.004). Grade 2 or 3 steatosis was significantly more common in MS-HCC (53.9% vs. 11.6% in alcohol-HCC and 5% in viral-HCC). Postoperative mortality was not significantly different between the three groups. The rates of severe complications (Dindo 3) in MS-HCC, alcoholHCC and viral-HCC, were 7.7%, 8.6% and 19.0%, respectively, p = 0.034. 5-years overall survival rate of MSHCC, alcohol-HCC and viral-HCC was 71.7%, 41.5% and 39.2% months, respectively (p = 0.701). 5-years DFS rate was 54.7% in MS-HCC, 28.4% in alcohol-HCC and 19.4% in viral-HCC (p = 0.026). Conclusions: Patients in MS group presented frequently with no underlying liver cirrhosis but with moderate-severe steatosis. DFS was significantly higher in patients with MSHCC compared with alcohol-HCC and viral-HCC.
LIVER 0761 ASSOCIATION BETWEEN PATIENT AND CHEMOTHERAPY CHARACTERISTICS WITH SHORTTERM OUTCOMES OF RESECTIONS FOR COLORECTAL CANCER LIVER METASTASES J. Urdzik, U. Haglund, F. Duraj and A. Norén Uppsala University, Sweden Aims: Increasing use of preoperative chemotherapy for colorectal cancer liver metastases (CRCLM) before resection has raised questions about its impact on postoperative complications. The aim of this study is therefore to elucidate the impact of patient comorbidities and preoperative chemotherapy treatment on short-term outcomes of liver surgery for CRCLM. Methods: A retrospective analysis of a prospective database of 471 consecutive patients who underwent 516 liver resections for CRCLM at Uppsala University Hospital between January 2000 and December 2013. Patient characteristics, comorbidity and chemotherapy treatment before liver surgery were analysed and related to post-hepatectomy haemorrhage (PHH), biliary leakage (BL), post-hepatectomy liver failure (PHLF), severe complications (Dindo-Clavien grade IIIb) and 90-day mortality (90dMOR). Results: PHH was associated with more than four oxaliplatin cycles (relative risk, RR 1.4, p = 0.047), intraoperative blood loss over 1100 ml, transfusion of erythrocytes and synchronous metastases. BL was associated with the biliary system procedures and major resections. PHLF was associated with major resections, perioperative transfusion of erythrocytes, and male gender. PHLF risk was lower in rectal cancer metastases. Severe complications were associated with major resections, blood loss over 1100 ml, and number of tumours. 90dMOR was 1.9%, increasing with grade C liver-specific complications: 50% for PHH, 20% for BL and 29% for PHLF. Further, 90dMOR was associated with underlying liver disease (RR 8.7, p = 0.015) and diabetes mellitus (RR 6.4, p = 0.007). Conclusions: PHH was associated with more than four oxaliplatin cycles, but other short-term outcomes of CRCLM resections were not influenced by preoperative chemotherapy in this series of patients. Underlying liver
HPB 2016, 18 (S2), e685ee738
e731
disease and diabetes mellitus were associated with 90dMOR.
LIVER 0762 ADRENAL GLAND HEPATOCELLULAR CARCINOMA METASTASES M. F. Valentini, S. Roselli, R. Lopatriello, G. Gigante and L. G. Lupo Policlinico Bari, Italy Aims: To establish the probability to develop adrenal gland metastases (AGM) in patients with hepatocellular carcinoma (HCC) and to evaluate risk factors associated. Methods: From 1997 to 2014, 847 patients were admitted at our Centre with a diagnosis of HCC: 321 were treated with hepatic resection (HR) and 526 with radiofrequency ablation (RFA). 8 patients presented AGM. Site of metastases was: AG alone (4), AG and liver (1), AG and lung or abdominal lymphonodes (2), AG and liver or lung (1). All metastases were treated with adrenalectomy. Median disease-free survival (from HCC diagnosis to AGM) was 20 months (range 2e93 months). 3 patients died of cancer. Variables considered were: gender (7 male, 1 female), liver disease (3 with HBV and 5 with HCV-related cirrhosis), Child Pugh score (7 A, 1 B), HCC number of lesions (7 with 1 nodule, 1 with more than 3 nodules) and size of HCC largest lesion (2 with nodules sized < 30 mm, 5 sized 30e 50 mm and 1 sized >50 mm) at diagnosis and number of intrahepatic recurrences (2 had 1 recurrence, 1 had 2 recurrences and 5 had no recurrence). Results: Virological status (OR 1,9, CI 95 % 0,4e8,1 p value ns), number of lesions (OR 2,6, CI 95% 0,3 22 p value ns) , size of largest HCC (OR 1,2, CI 95% 0,1 10,2 p value ns), number of intrahepatic recurrences and type of treatment were analyzed. Conclusions: No evidence of risk factors related to development of HCC AGM was observed.
LIVER 0764 TREATMENT OF RECURRENT HCC AFTER CURATIVE RESECTION IMPROVES SURVIVAL S. Conci, A. Ruzzenente, A. Valdegamberi, M. Fontana, F. Bertuzzo, M. Piccino, G. Mantovani, C. Iacono and A. Guglielmi University and Hospital Trust of Verona, Italy Aims: Recurrences after curative treatment of HCC reach a rate of 70e80% within 5 years and remain one of the major negative event influencing overall survival. The purposes of this study were to identify risk factors for the recurrence of HCC and to analyze the impact on survival of management of recurrent disease. Methods: Two hundred and sixty nine patients who have undergone curative liver resection for HCC from January 1990 to December 2012 were included in this study. Clinical and pathological variables were analyzed with a univariate and multivariate survival analysis to identify prognostic factors for early recurrence. Recurrent patients were evaluated for new treatment according to tumor stage, liver function and general condition.