Laparoscopic Liver Resection for Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC), remains one of the most common causes of cancer-related death globally. HCC typically arises in the setting of chronic liver disease and cirrhosis and as such, treatment must be balanced between the biology of the tumor, underlying liver function and performance status of the patient. Hepatic resection is the procedure of choice in patients with high-performance status who harbor a solitary mass (regardless of size). Before the first laparoscopic hepatectomy (LH) was described as early as 1991, open hepatectomy (OH) was the only choice for surgical treatment of liver tumors. LH indications were initially based solely on tumor location, size, and type and was only used for partial resection of the anterolateral segments. Since then, LH has been shown to share the benefits of other laparoscopic procedures, such as earlier recovery and discharge, and reduced postoperative pain; these are obtained with no differences in oncologic outcomes compared to open resection. Specific to liver resection, LH can limit the volume of intraoperative blood loss, shorten portal clamp time and decrease overall and liver-specific complications. This chapter will offer an overview of standard steps are in pursuing laparoscopic liver resection, be it for a minor segmentectomy or a lobectomy

Lymphovascular and perineural invasion as selection criteria for adjuvant therapy in intrahepatic cholangiocarcinoma: a multi-institution analysis

AbstractObjectivesCriteria for the selection of patients for adjuvant chemotherapy in intrahepatic cholangiocarcinoma (IHCC) are lacking. Some authors advocate treating patients with lymph node (LN) involvement; however, nodal assessment is often inadequate or not performed. This study aimed to identify surrogate criteria based on characteristics of the primary tumour.MethodsA total of 58 patients who underwent resection for IHCC between January 2000 and January 2010 at any of three institutions were identified. Primary outcome was overall survival (OS).ResultsMedian OS was 23.0months. Median tumour size was 6.5cm and the median number of lesions was one. Overall, 16% of patients had positive margins, 38% had perineural invasion (PNI), 40% had lymphovascular invasion (LVI) and 22% had LN involvement. A median of two LNs were removed and a median of zero were positive. Lymph nodes were not sampled in 34% of patients. Lymphovascular and perineural invasion were associated with reduced OS [9.6months vs. 32.7months (P= 0.020) and 10.7months vs. 32.7months (P= 0.008), respectively]. Lymph node involvement indicated a trend towards reduced OS (10.7months vs. 30.0months; P= 0.063). The presence of either LVI or PNI in node-negative patients was associated with a reduction in OS similar to that in node-positive patients (12.1months vs. 10.7months; P= 0.541). After accounting for adverse tumour factors, only LVI and PNI remained associated with decreased OS on multivariate analysis (hazard ratio4.07, 95% confidence interval 1.60–10.40; P= 0.003).ConclusionsLymphovascular and perineural invasion are separately associated with a reduction in OS similar to that in patients with LN-positive disease. As nodal dissection is often not performed and the number of nodes retrieved is frequently inadequate, these tumour-specific factors should be considered as criteria for selection for adjuvant chemotherapy

The neutrophile to lymphocyte ratio (NLR) in the peripheral blood as a prognostic biomarker in patients with digestive cancer including adenocarcinoma and neuroendocrine tumors

The aim of this dissertation is to describe the relationship between the Neutrophile to Lymphocyte Ratio (NLR) and digestive tract cancer. We are particularly interested in the correlation of the NLR biomarker and the overall survival per stage of the disease, but also in the recurrence-free survival. Already, several variables have been described in the past that correlate with these two important disease outcome variables, such as metastasis to local lymph nodes, the ratio of positive lymph nodes to the number of total lymph nodes collected, and local invasion of the tumor to nervous or lymphatic (neural / lymphovascular invasion). Our secondary objective is to systematically look at the association of the NLR with other indicators described in the past, such as those mentioned above.Ο στόχος της παρούσας Διατριβής είναι να περιγράψει τη σχέση μεταξύ του δείκτη Neutrophile to Lymphocyte Ratio (NLR)και του καρκίνου του πεπτικού συστήματος. Μας ενδιαφέρει ιδιαίτερα η συσχέτιση του δείκτη NLR και της συνολικής επιβίωσης ανά στάδιο της νόσου, αλλά και με το διάστημα κατά το οποίο οι ασθενείς δεν εμφανίζουν υποτροπή. Ήδη, αρκετές μεταβλητές έχουν περιγραφεί στο παρελθόν που συσχετίζονται με αυτές τις δύο σημαντικές μεταβλητές έκβασης της νόσου, όπως η μετάσταση στους τοπικούς λεμφαδένες, η αναλογία των θετικών λεμφαδένων ως προς τον αριθμό συνολικών λεμφαδένων που συλλέχθηκαν και η τοπική εισβολή του όγκου στα νευρικά ή λυμφαγγειακά στοιχεία (neural/ lymphovascular invasion). Δευτερογενής στόχος μας είναι να εξετάσουμε συστηματικά τη σύσχετιση του δείκτη NLR με άλλους δείκτες που έχουν περιγραφεί στο παρελθόν, όπως αυτοί που προαναφέρθηκαν

Elevated CA 19-9 portends poor prognosis in patients undergoing resection of biliary malignancies

AbstractBackgroundBiliary tree malignancies including cholangiocarcinoma and gallbladder cancer are aggressive cancers with a high disease-specific mortality despite resection. The aim of the present study was to identify predictors of survival after resection.MethodsA retrospective review of all patients that underwent radical resection of biliary malignancies was performed. Demographics, elevated CA19-9 (>35U/ml), treatment and outcome data were collected and compared according to tumour location. Kaplan–Meier survival curves were created and compared using log-rank analysis. Multivariate analysis was undertaken using Cox proportional hazards regression.ResultsNinety-one patients with biliary malignancies underwent surgical resection between 1992 and 2007. There were 46 (50.5%) extrahepatic cholangiocarcinomas (EHC), 23 (25.2%) intrahepatic cholangiocarcinomas (IHC) and 22 (24.2%) gallbladder carcinomas (GBC). The median (range) age was 64 (24–92) years. An elevated CA19-9 was recorded in 45 (55%) patients (52% of IHC, 63% of EHC, and 41% of GBC). The overall median (range) survival was 22.5 (0.3–153.3) months. All three groups were similar in terms of age, gender, pre-operative CA 19-9 level, completeness of resection and tumour histopathological characteristics. GBC were associated with the shortest median survival (14.3 months) followed by EHC (24.8 months) and IHC (30.4 months); however, this did not meet statistical significance (P= 0.971). Only elevated pre-operative CA 19-9 level (>35U/ml) was predictive of poor median survival by univariate (P= 0.003) and multivariate analysis (15.1 months vs. 67.4, P= 0.047).ConclusionsElevated pre-operative CA 19-9 levels were found to be independent predictors of poor survival after attempted resection for biliary tree malignancies. It is recommended that CA19-9 be routinely measured prior resection