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Yttrium-90 radioembolization versus transarterial chemoembolization for unresectable hepatocellular carcinoma: A comparative analysis
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Electronic Poster Abstracts
Conclusions: Aggressive approach with “en bloc” and extended liver resections with vascular reconstruction has an acceptable preoperative morbimortality with a good 5 years survival.
EP01B-018 RECURRENCE DETERMINED 10-YEAR SURVIVAL OF HEPATOCELLULAR CARCINOMA AFTER HEPATECTOMY T. C. Wong, T. T. Cheung, K. S. Chok, A. C. Chan, W. C. Dai, S. C. Chan, R. T. Poon, S. T. Fan and C. M. Lo University of Hong Kong, Hong Kong Introduction: The reported actual 10-year survival rate of hepatocellular carcinoma (HCC) after hepatectomy was 7.2% only. Our study was conducted to compare the characteristics of HCC patients who survived >10 years after hepatectomy. Method: This was a retrospective study in a university affiliated hospital. All patients who had hepatectomy for HCC from 1990 to 2004 were analyzed. Data was retrieved from a prospective collected database. Baseline, operative, pathological and survival data between 10-year survivors were compared to non 10-year survivors. Results: There were 727 HCC patients who had hepatectomy and 247 (34.0%) patients survived 10 years after hepatectomy. Among these 10 year survivors, 150 (60.6%) patients were disease free. 10-year survivors were younger (52 vs. 55 year old, p = 0.04), more likely to have screen detected HCC (54.3 vs. 33.5%, p < 0.001) and had better liver function (indocyanine green retention at 15 mins: 9 vs. 10.9%, p = 0.003). The use of major hepatectomy (61.1 vs. 62.1%, p = 0.80), anterior approach (20.6 vs. 20.8%, p = 0.95) and Pringle manoeuver (32.4 vs. 33.8%, p = 0.71) were not different. There was no difference in postoperative complication and hospital mortality. Non 10-year survivors were more likely to have tumors with marco- or microscopic vascular invasion, microsatellite nodule and multiple tumors (>3). In multivariable analysis, tumor recurrence was associated with inferior survival. Conclusion: We have demonstrated 34% of HCC patients can survive at least 10-years after hepatectomy. Timing and pattern of tumor recurrence predicted long-term survivals.
EP01B-020 OPERATIVE MICROWAVE ABLATION FOR HEPATOCELLULAR CARCINOMA: POSTOPERATIVE OUTCOMES, RECURRENCE AND SURVIVAL E. Baker1, K. Thompson1, I. Mckillop1, A. Cochran1, M. Russo2, D. Vrochides1, J. Martinie1, D. Iannitti1 and R. Swan1 1 Surgery, Carolinas Medical Center, and 2Internal Medicine, Carolinas Medical Center, United States Background: Microwave ablation (MWA) of hepatocellular carcinoma (HCC) offers local regional treatment that can be safely and effectively performed, even in patients with advanced liver disease. We update results from our group’s previous analysis of operative MWA for HCC. Methods: Retrospective review was performed of all patients who underwent operative MWA for HCC from 2007e2014. Patient demographics, operative
characteristics and complications were recorded. Follow up imaging was reviewed to determine rates of complete ablation, local, regional and metastatic recurrence. Results: Two hundred nineteen patients were included with a total of 340 tumors treated with operative MWA. Median tumor size was 3.2cm (1e6 cm). Cirrhosis was present in 89.5% of patients, 60.7% had hepatitis C, and 8.2% had hepatitis B. 25.9% were Child Pugh class B/C. 96.8% of MWA procedures were performed laparoscopically. Four deaths occurred within 30 days (1.8%). Clavien-Dindo grade III complications occurred in 3.2% of patients. Complete ablation was identified in 97.1% of tumors, with local recurrence rates of 8.5% at 10.9 months median follow up (0e80 months). Regional recurrence occurred in 34.8% of patients at 10.9 months median follow up and metastatic recurrence was seen in 8.1% of patients. One year overall survival was 80.0% and two year survival was 61.5%. Conclusions: We propose that laparoscopic MWA offers a low morbidity approach for treatment of HCC affording low rates of local recurrence even for patients with significant underlying liver dysfunction. This large series offers insight into outcomes of this modality as definitive treatment for patients with HCC.
EP01B-021 YTTRIUM-90 RADIOEMBOLIZATION VERSUS TRANSARTERIAL CHEMOEMBOLIZATION FOR UNRESECTABLE HEPATOCELLULAR CARCINOMA: A COMPARATIVE ANALYSIS M. Massani1, G. Pirozzolo1, F. Dalla Pozza2, P. Maccatrozzo3, D. Barbisan4, C. Ruffolo1 and N. Bassi1 1 IV Dpt HPB Surgery, 2Nuclear Medicine, 3Regional Clinical Hospital, and 4Radiology Department, Regional Clinical Hospital, Italy Introduction: Transhepatic Arterial Chemembolization (TACE) and Transhepatic Arterial Radioembolization (TARE) represent two therapeutic option for unresectable HCC. The effectiveness of these procedures has been compared in several retrospective series, but few of these emphasized the importance of an accurate selection of patients. Barcellona Clinic Liver Cancer (BCLC) system stratifies patients according to the outcome and offers a therapeutic indication, however TARE is not mentioned in the flow-chart among the therapeutic options for intermediate (group B) or advanced stage (group C). Aim of this single centre retrospective study is to compare the effectiveness of these treatments and to evaluate the outcomes according with BCLC stage. Methods: Forty-seven TACE (BCLCB/C 44,7%/55,3%) and twenty-six TARE (BCLCB/C 26,9%/73%) patients were included in our analysis. Survival was determined via the KaplaneMeyer method, and multivariate analysis for factors affecting survival was performed. Results: There were no substantial differences in median Overall Survival (23,33 and 23,5 for TACE and TARE respectively), in 1-year overall survival (78,7% and 76,9%) and in 2-year overall survival (46,8% and 50%). We observed an increased survival for TARE patients in BCLC B patients (2-year survival 85,7% versus 52,3%) and no differences in BCLC C patients. HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts Conclusion: Our study suggests a similar effectiveness of these procedures, but the subgroup analysis, following the BCLC stages, showed differences on survival. A more comprehensive study, with a prospective design and an adequate follow-up, could clarify further differences producing objective data on the clinical indications.
EP01B-023 LAPAROSCOPIC RESECTION OF HEPATOCELLULAR CARCINOMA IN CIRRHOTIC PATIENTS V. Molina Santos1, J. Sampson2, R. Diaz del Gobbo2, J. Ferrer2, J. Fuster2 and J. C. García-Valdecasas2 1 Digestive and General Surgery, and 2Hospital Clinic, Spain Objective: To evaluate our results since the introduction of laparoscopic approach in the treatment of hepatocellular carcinoma. Patients and methods: This study includes 54 patients (41 mena and 13 women, median 63 + 1.5 years old) who underwent laparoscopic hepatectomy for Hepatocellular carcinoma from January 2008 to December 2014. The selection criteria for a laparoscopic approach were ChildPugh class A cirrhosis, a solitary tumor accessible with a laparoscopic approach, without vascular invasion or extrahepatic spread, not presenting thrombus in the main portal vein or inferior vena cava and treatable by minor resection ( < 3 segments). Tumor diagnosis and treatment were performed according to The Barcelona Clinic Liver Cancer (BCLC) strategy, but we included eleven selected patients with portal hypertension and a well preserved hepatic function and normal bilirubin values. Results: Anatomic hepatic resections were performed in 42 (78%) of patients. The median operative time was 160 8 min. Conversion to laparotomy only occurred in 4 (7,4%) patients. No intraoperative complications occurred in the entire study cohort. None of the patients developed liver failure or encephalopathy. Overall morbidity was 27,7%. Liver related complications were present in three patients who developed transient ascites that required diuretic therapy. One patient had IIIb complication according to modified Clavien-Dindo classification, that required reoperation due to hemoperitoneum secondary to port site bleeding. There was no in-hospital death after operation. The mean postoperative hospital stay was 4 days. Conclusions: Minimally invasive techniques are safe and feasible for the treatment of HCC in well-compensated cirrhotic patients.
EP01B-024 EXPRESSION OF TOLL-LIKE RECEPTOR 2, 4 AND RELATED CYTOKINES IN PATIENTS WITH HEPATIC CYSTIC AND ALVEOLAR ECHINOCOCCOSIS T. Tuxun1, H. Wen2, J. -M. Zhao2, S. Apaer2 and A. Aierken3 1 Department of Hepatobiliary and Pancreatic Surgery, 2 The First Affiliated Hospital of Xinjiang Medical
HPB 2016, 18 (S1), e1ee384
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University, and 3Department of Ultrasonography, The First Affiliated Hospital of Xinjiang Medical University, China Introduction: Several studies have demonstrated the important role of Toll like receptors in various parasitic infections. This study aims at to explore expression of Tolllike receptors (TLRs) and related cytokines in patients with human cystic (CE) and alveolar echinococcosis (AE). Methods: 78 subjects including AE group (N = 28), CE group (N = 22), and healthy controls (HC, N = 28) were enrolled in this study. The mRNA expression levels of TLR2, TLR4 in blood and hepatic tissue and plasma levels related cytokines were detected by using ELISA. Results: Median levels of TLR2 mRNA in AE and CE groups were significantly elevated as compared with that in healthy control group. Median levels of TLR4 expression was increased in AE and CE. Plasma concentration levels of IL-5, IL-6 and IL-10 were slightly increased in AE and CE groups than those in HC group with no statistical differences (p > 0.05). The IL-23 concentration levels was significantly higher in AE and CE groups than that in HC subjects with statistical significance. Conclusion: The Expression pattern of TLR 2 and 4 in PBMCs in patients with AE and CE might be involved in the cytokine modulation, which allowed the parasite to escape, which seems to be stronger in AE, host immunesurveillance and promoted chronic infection.
EP01B-025 THE FUNCTIONAL ROLE OF C/EBPa AND C/EBPb IN HEPATOCELLULAR CARCINOMA (HCC) X. Zhao, N. Habib and V. Reebye HPB Surgery, Surgery and Cancer, Imperial College London, United Kingdom Hepatocellular carcinoma with drastically increasing incidence and mortality, were poorly detected at the early stage leading to advanced stage, liver dysfunction. As very few patients are suitable for surgical treatment, molecular targeted therapy is becoming the primary treatment owing to huge progress to discover the role of specific transcription factor regulating tumor growth. C/EBPa, a member of the CCAAT/ enhancer binding proteins (CEBP) family of transcription factors, is liver-specific and correlated with hepatic glucose and bilirubin homeostasis. Our group has demonstrated C/EBPa activation by short-activating RNA (saRNA) can decrease tumor burden and improve liver function in vivo. This study attempts to elucidate the role and mechanism of both C/EBPa and C/EBPb in regulating cell proliferation and hepatocyte function in vitro. To understand the biological function of C/EBPa and C/EBPb in HCC cell lines, we measured the mRNA and protein levels of C/EBPa, C/EBPb and downstream factors including cyclin kinase inhibitor 1 (p21), Albumin and Alphafetoprotein (AFP) by qRT-PCR and western blot when activated and suppressed C/EBPa and C/EBPb in HepG2, Hep3B and PLC/PRF/5 cells. Cell cytotoxicity, proliferation and migration assay were also performed to study the role of C/EBPa and C/EBPb in the regulation of these functions. Enhancing C/EBPa expression upregulates the expression of C/EBPb, P21 and Albumin, and inhibits AFP expression, tumor cell growth and migration in HepG2 and
Electronic Poster Abstracts
Conclusions: Aggressive approach with “en bloc” and extended liver resections with vascular reconstruction has an acceptable preoperative morbimortality with a good 5 years survival.
EP01B-018 RECURRENCE DETERMINED 10-YEAR SURVIVAL OF HEPATOCELLULAR CARCINOMA AFTER HEPATECTOMY T. C. Wong, T. T. Cheung, K. S. Chok, A. C. Chan, W. C. Dai, S. C. Chan, R. T. Poon, S. T. Fan and C. M. Lo University of Hong Kong, Hong Kong Introduction: The reported actual 10-year survival rate of hepatocellular carcinoma (HCC) after hepatectomy was 7.2% only. Our study was conducted to compare the characteristics of HCC patients who survived >10 years after hepatectomy. Method: This was a retrospective study in a university affiliated hospital. All patients who had hepatectomy for HCC from 1990 to 2004 were analyzed. Data was retrieved from a prospective collected database. Baseline, operative, pathological and survival data between 10-year survivors were compared to non 10-year survivors. Results: There were 727 HCC patients who had hepatectomy and 247 (34.0%) patients survived 10 years after hepatectomy. Among these 10 year survivors, 150 (60.6%) patients were disease free. 10-year survivors were younger (52 vs. 55 year old, p = 0.04), more likely to have screen detected HCC (54.3 vs. 33.5%, p < 0.001) and had better liver function (indocyanine green retention at 15 mins: 9 vs. 10.9%, p = 0.003). The use of major hepatectomy (61.1 vs. 62.1%, p = 0.80), anterior approach (20.6 vs. 20.8%, p = 0.95) and Pringle manoeuver (32.4 vs. 33.8%, p = 0.71) were not different. There was no difference in postoperative complication and hospital mortality. Non 10-year survivors were more likely to have tumors with marco- or microscopic vascular invasion, microsatellite nodule and multiple tumors (>3). In multivariable analysis, tumor recurrence was associated with inferior survival. Conclusion: We have demonstrated 34% of HCC patients can survive at least 10-years after hepatectomy. Timing and pattern of tumor recurrence predicted long-term survivals.
EP01B-020 OPERATIVE MICROWAVE ABLATION FOR HEPATOCELLULAR CARCINOMA: POSTOPERATIVE OUTCOMES, RECURRENCE AND SURVIVAL E. Baker1, K. Thompson1, I. Mckillop1, A. Cochran1, M. Russo2, D. Vrochides1, J. Martinie1, D. Iannitti1 and R. Swan1 1 Surgery, Carolinas Medical Center, and 2Internal Medicine, Carolinas Medical Center, United States Background: Microwave ablation (MWA) of hepatocellular carcinoma (HCC) offers local regional treatment that can be safely and effectively performed, even in patients with advanced liver disease. We update results from our group’s previous analysis of operative MWA for HCC. Methods: Retrospective review was performed of all patients who underwent operative MWA for HCC from 2007e2014. Patient demographics, operative
characteristics and complications were recorded. Follow up imaging was reviewed to determine rates of complete ablation, local, regional and metastatic recurrence. Results: Two hundred nineteen patients were included with a total of 340 tumors treated with operative MWA. Median tumor size was 3.2cm (1e6 cm). Cirrhosis was present in 89.5% of patients, 60.7% had hepatitis C, and 8.2% had hepatitis B. 25.9% were Child Pugh class B/C. 96.8% of MWA procedures were performed laparoscopically. Four deaths occurred within 30 days (1.8%). Clavien-Dindo grade III complications occurred in 3.2% of patients. Complete ablation was identified in 97.1% of tumors, with local recurrence rates of 8.5% at 10.9 months median follow up (0e80 months). Regional recurrence occurred in 34.8% of patients at 10.9 months median follow up and metastatic recurrence was seen in 8.1% of patients. One year overall survival was 80.0% and two year survival was 61.5%. Conclusions: We propose that laparoscopic MWA offers a low morbidity approach for treatment of HCC affording low rates of local recurrence even for patients with significant underlying liver dysfunction. This large series offers insight into outcomes of this modality as definitive treatment for patients with HCC.
EP01B-021 YTTRIUM-90 RADIOEMBOLIZATION VERSUS TRANSARTERIAL CHEMOEMBOLIZATION FOR UNRESECTABLE HEPATOCELLULAR CARCINOMA: A COMPARATIVE ANALYSIS M. Massani1, G. Pirozzolo1, F. Dalla Pozza2, P. Maccatrozzo3, D. Barbisan4, C. Ruffolo1 and N. Bassi1 1 IV Dpt HPB Surgery, 2Nuclear Medicine, 3Regional Clinical Hospital, and 4Radiology Department, Regional Clinical Hospital, Italy Introduction: Transhepatic Arterial Chemembolization (TACE) and Transhepatic Arterial Radioembolization (TARE) represent two therapeutic option for unresectable HCC. The effectiveness of these procedures has been compared in several retrospective series, but few of these emphasized the importance of an accurate selection of patients. Barcellona Clinic Liver Cancer (BCLC) system stratifies patients according to the outcome and offers a therapeutic indication, however TARE is not mentioned in the flow-chart among the therapeutic options for intermediate (group B) or advanced stage (group C). Aim of this single centre retrospective study is to compare the effectiveness of these treatments and to evaluate the outcomes according with BCLC stage. Methods: Forty-seven TACE (BCLCB/C 44,7%/55,3%) and twenty-six TARE (BCLCB/C 26,9%/73%) patients were included in our analysis. Survival was determined via the KaplaneMeyer method, and multivariate analysis for factors affecting survival was performed. Results: There were no substantial differences in median Overall Survival (23,33 and 23,5 for TACE and TARE respectively), in 1-year overall survival (78,7% and 76,9%) and in 2-year overall survival (46,8% and 50%). We observed an increased survival for TARE patients in BCLC B patients (2-year survival 85,7% versus 52,3%) and no differences in BCLC C patients. HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts Conclusion: Our study suggests a similar effectiveness of these procedures, but the subgroup analysis, following the BCLC stages, showed differences on survival. A more comprehensive study, with a prospective design and an adequate follow-up, could clarify further differences producing objective data on the clinical indications.
EP01B-023 LAPAROSCOPIC RESECTION OF HEPATOCELLULAR CARCINOMA IN CIRRHOTIC PATIENTS V. Molina Santos1, J. Sampson2, R. Diaz del Gobbo2, J. Ferrer2, J. Fuster2 and J. C. García-Valdecasas2 1 Digestive and General Surgery, and 2Hospital Clinic, Spain Objective: To evaluate our results since the introduction of laparoscopic approach in the treatment of hepatocellular carcinoma. Patients and methods: This study includes 54 patients (41 mena and 13 women, median 63 + 1.5 years old) who underwent laparoscopic hepatectomy for Hepatocellular carcinoma from January 2008 to December 2014. The selection criteria for a laparoscopic approach were ChildPugh class A cirrhosis, a solitary tumor accessible with a laparoscopic approach, without vascular invasion or extrahepatic spread, not presenting thrombus in the main portal vein or inferior vena cava and treatable by minor resection ( < 3 segments). Tumor diagnosis and treatment were performed according to The Barcelona Clinic Liver Cancer (BCLC) strategy, but we included eleven selected patients with portal hypertension and a well preserved hepatic function and normal bilirubin values. Results: Anatomic hepatic resections were performed in 42 (78%) of patients. The median operative time was 160 8 min. Conversion to laparotomy only occurred in 4 (7,4%) patients. No intraoperative complications occurred in the entire study cohort. None of the patients developed liver failure or encephalopathy. Overall morbidity was 27,7%. Liver related complications were present in three patients who developed transient ascites that required diuretic therapy. One patient had IIIb complication according to modified Clavien-Dindo classification, that required reoperation due to hemoperitoneum secondary to port site bleeding. There was no in-hospital death after operation. The mean postoperative hospital stay was 4 days. Conclusions: Minimally invasive techniques are safe and feasible for the treatment of HCC in well-compensated cirrhotic patients.
EP01B-024 EXPRESSION OF TOLL-LIKE RECEPTOR 2, 4 AND RELATED CYTOKINES IN PATIENTS WITH HEPATIC CYSTIC AND ALVEOLAR ECHINOCOCCOSIS T. Tuxun1, H. Wen2, J. -M. Zhao2, S. Apaer2 and A. Aierken3 1 Department of Hepatobiliary and Pancreatic Surgery, 2 The First Affiliated Hospital of Xinjiang Medical
HPB 2016, 18 (S1), e1ee384
e201
University, and 3Department of Ultrasonography, The First Affiliated Hospital of Xinjiang Medical University, China Introduction: Several studies have demonstrated the important role of Toll like receptors in various parasitic infections. This study aims at to explore expression of Tolllike receptors (TLRs) and related cytokines in patients with human cystic (CE) and alveolar echinococcosis (AE). Methods: 78 subjects including AE group (N = 28), CE group (N = 22), and healthy controls (HC, N = 28) were enrolled in this study. The mRNA expression levels of TLR2, TLR4 in blood and hepatic tissue and plasma levels related cytokines were detected by using ELISA. Results: Median levels of TLR2 mRNA in AE and CE groups were significantly elevated as compared with that in healthy control group. Median levels of TLR4 expression was increased in AE and CE. Plasma concentration levels of IL-5, IL-6 and IL-10 were slightly increased in AE and CE groups than those in HC group with no statistical differences (p > 0.05). The IL-23 concentration levels was significantly higher in AE and CE groups than that in HC subjects with statistical significance. Conclusion: The Expression pattern of TLR 2 and 4 in PBMCs in patients with AE and CE might be involved in the cytokine modulation, which allowed the parasite to escape, which seems to be stronger in AE, host immunesurveillance and promoted chronic infection.
EP01B-025 THE FUNCTIONAL ROLE OF C/EBPa AND C/EBPb IN HEPATOCELLULAR CARCINOMA (HCC) X. Zhao, N. Habib and V. Reebye HPB Surgery, Surgery and Cancer, Imperial College London, United Kingdom Hepatocellular carcinoma with drastically increasing incidence and mortality, were poorly detected at the early stage leading to advanced stage, liver dysfunction. As very few patients are suitable for surgical treatment, molecular targeted therapy is becoming the primary treatment owing to huge progress to discover the role of specific transcription factor regulating tumor growth. C/EBPa, a member of the CCAAT/ enhancer binding proteins (CEBP) family of transcription factors, is liver-specific and correlated with hepatic glucose and bilirubin homeostasis. Our group has demonstrated C/EBPa activation by short-activating RNA (saRNA) can decrease tumor burden and improve liver function in vivo. This study attempts to elucidate the role and mechanism of both C/EBPa and C/EBPb in regulating cell proliferation and hepatocyte function in vitro. To understand the biological function of C/EBPa and C/EBPb in HCC cell lines, we measured the mRNA and protein levels of C/EBPa, C/EBPb and downstream factors including cyclin kinase inhibitor 1 (p21), Albumin and Alphafetoprotein (AFP) by qRT-PCR and western blot when activated and suppressed C/EBPa and C/EBPb in HepG2, Hep3B and PLC/PRF/5 cells. Cell cytotoxicity, proliferation and migration assay were also performed to study the role of C/EBPa and C/EBPb in the regulation of these functions. Enhancing C/EBPa expression upregulates the expression of C/EBPb, P21 and Albumin, and inhibits AFP expression, tumor cell growth and migration in HepG2 and