Primary non-functioning neuroendocrine tumor of the extrahepatic bile duct

In contrast to the primary biliary carcinoma or cholangiocarcinoma, other tumors derived from the bile duct are difficult to diagnose preoperatively, mainly because of its low incidence and difficult diagnostic process. However, since cholangiocarcinomas account for about 80% of all primary biliary tumors, it is important to think about other options despite their low frequency when a patient presents with abnormal characteristics. We present a case of a primary neuroendocrine tumor of the bile duct, and a review of the literature on this rare disease

A retrospective study of patient-tailored FOLFIRINOX as a first-line chemotherapy for patients with advanced biliary tract cancer

International audienceBackground: FOLFIRINOX is a pillar first-line regimen in the treatment of pancreatic cancer. Historically, biliary tract cancer (BTC) and pancreatic cancer have been treated similarly with gemcitabine alone or combined with a platinum compound. With growing evidence supporting the role of fluoropyrimidines in the treatment of BTC, we aimed at assessing the outcomes of patients (pts) with BTC on frontline FOLFIRINOX.Methods: We retrospectively analyzed data of all our consecutive patients with locally advanced (LA) or metastatic (M) BTC who were registered to receive FOLFIRINOX as a first-line therapy between 12/2013 and 11/2017 at Paul Brousse university hospital. The main endpoints were Overall Survival (OS), Time-to-Progression (TTP), best Objective Response Rate (ORR), Disease Control rate (DCR), secondary macroscopically-complete resection (res) and incidence of severe (grade 3-4) toxicity (tox).Results: There were 17 male (40%) and 25 female (60%) pts. aged 36 to 84 years (median: 67). They had PS of 0 (55%) or 1 (45%), and intrahepatic cholangiocarcinoma (CCA) (21 pts., 50%), gallbladder carcinoma (8 pts., 19%), perihilar CCA (7 pts., 17%), distal CCA (4 pts., 10%) and ampulloma (2 pts., 5%). BTC was LA or M in 10 (24%) and 32 pts. (76%) respectively. Biliary stent was placed in 14 pts. (33%). A median of 10 courses was given with median treatment duration of 6 months. There were no untoward toxicity issues, with no febrile neutropenia, emergency admission for toxicity or toxic death. We observed 12 partial responses (29%) and 19 disease stabilisations (45%). Six patients (14%) underwent secondary R0-R1 resection. Median TTP was 8 months [95%CL, 6-10] and median OS was 15 months [13-17]. Patients undergoing secondary resection displayed a 3-y disease-free rate of 83%.Conclusions: First-line FOLFIRINOX offers promising results in patients with LA and M-BTC. It deserves prospective evaluation to further improve outcomes for advanced BTC

"Laparoscopic Para-Aortic Lymph Node Sampling” First Approach for Pancreatic Adenocarcinoma as an Oncological Practice

International audienceBackground: In the setting of pancreatic ductal adenocarcinoma (PDAC), para-aortic lymph node (PALN) involvement is considered as a metastasis disease. To date, no morphological examination can effectively identify lymph node metastasis, and a significant number of patients undergo futile invasive laparotomy for PALN involvement. From an oncological point of view, laparoscopy represents a better approach for PALN sampling. The main aim of the study is to propose a laparoscopic PALN sampling first approach. We describe the surgical technique and demonstrate its technical feasibility as a routine approach as the first surgical step before pancreaticoduodenectomy for localized PDAC.Materials and Methods: During a first step of staging laparoscopy, PALN sampling was done for 31 patients with localized PDAC between November 2015 and February 2017. Demographic data and intraoperative, postoperative, and pathological criteria were evaluated. The surgical technique is described in detail.Results: The median operative time was 35 (range 18–65) minutes. The median number of PALN analyzed per patient was 2 (range 1–5). Four (13%) of 31 patients had positive PALN in frozen section analysis. No severe complication was reported for patients with positive PALN, receiving laparoscopic exploration and PALN sampling. The median hospital stay for patients with positive PALN was 2 (range 1–7) days.Conclusion: To avoid futile laparotomy, a staging laparoscopy is usually carried out. We report the feasibility and safety of laparoscopic PALN sampling and suggest its systematic realization during staging laparoscopy as a first step in patients with localized PDAC before pancreaticoduodenectomy

Predictors of unresectability after portal vein embolization for centrally located cholangiocarcinoma

International audienceBackground: The curative treatment of perihilar cholangiocarcinomas and centrally located intrahepatic cholangiocarcinomas often requires major hepatectomy preceded by portal vein embolization. This strategy, however, is associated with a high rate of dropouts before operation or failure of resection at the time of operative exploration. We aimed to identify predictors of unresectability (dropout or failure of resection) after portal vein embolization for centrally located cholangiocarcinoma, including perihilar cholangiocarcinomas and intrahepatic cholangiocarcinomas.Method: All patients undergoing portal vein embolization for a planned resection of a centrally located cholangiocarcinoma between 2000 and 2018 in our center were evaluated retrospectively. Predictors of unresectability were determined under intention-to-treat conditions, based on clinical, biologic, and radiologic data collected before portal vein embolization.Results: Eighty-eight consecutive patients scheduled for portal vein embolization before operative exploration were included, 56 of whom (64%) underwent curative resection and 32 (36%) of whom were not resected, including those who did not undergo exploration (n = 11) and those operated on but not resected (n = 21). The most common cause of unresectability was tumor progression (62%). A psoas muscle index <500 mm2/m2 (P = .04), high body mass index (P = .023), and low serum albumin level (P = .007) were associated with unresectabilty on multivariate analysis. A composite score including these variables (cutoffs determined after receiver operating characteristic curve analysis) was proposed and achieved accurate discrimination regarding unresectability (area under the curve = 0.82, P < .001).Conclusion: Predictors of unresectability after portal vein embolization for centrally located cholangiocarcinoma were identified, with sarcopenic overweight patients having a greater risk of unresectability. This preoperative score enables a fairly accurate prediction of unresectability in a given patient. These simple, objective, and inexpensive parameters should be considered in all patients with centrally located cholangiocarcinoma scheduled to undergo portal vein embolization

Resectable and transplantable hepatocellular carcinoma: Integration of liver stiffness assessment in the decision-making algorithm

International audienceBACKGROUND: Liver resection is a curative treatment for hepatocellular carcinoma (HCC) and an alternative to liver transplantation (LT). However, post-liver resection recurrence rates remain high. This study aimed to determine whether liver stiffness measurement (LSM) correlated with recurrence and to propose a method for predicting HCC recurrence exclusively using pre-liver resection criteria. METHODS: This retrospective monocentric study included patients who had undergone LR liver resection for HCC between 2015 and 2018 and who had (1) preoperative alpha-fetoprotein scores indicating initial transplant viability and (2) available preoperative LSM data. We developed a predictive score for recurrence over time using Cox univariate regression and multivariate analysis with a combination plot before selecting the optimal thresholds (receiver operating characteristic curves + Youden test). RESULTS: Sixty-six patients were included. After an average follow-up of 40 months, the recurrence rate was 45% (n = 30). Three-year overall survival was 88%. Four preoperative variables significantly impacted the time to recurrence: age ≥70 years, LSM ≥11 kPa, international normalized ratio (INR) ≥1.2, and maximum HCC diameter ≥3 cm. By assigning 1 point per positive item, patients with a score &lt;2 (n = 22) demonstrated greater mean overall survival (69.7 vs 54.8 months, P = .02) and disease-free survival (52.2 vs 34.7 months, P = .02) than those with a score ≥2. Patients experiencing early recurrence (&lt;1 year) presented a significantly higher preoperative LSM (P = .06). CONCLUSION: We identified a simple preoperative score predictive of early hepatocellular carcinoma recurrence after liver resection, highlighting the role of liver stiffness. This score could help physicians select patients and make decisions concerning perioperative medical treatment

Indocyanine green fluorescence imaging to predict graft survival after orthotopic liver transplantation: a pilot study

International audienceThe incidence of primary nonfunction (PNF) after liver transplantation (LT) remains a major concern with the increasing use of marginal grafts. Indocyanine green (ICG) fluorescence is an imaging technique used in hepatobiliary surgery and LT. Because few early predictors are available, we aimed to quantify in real time the fluorescence of grafts during LT to predict 3-month survival. After graft revascularization, ICG was intravenously injected, and then the fluorescence of the graft was captured with a near infrared camera and postoperatively quantified. A multiparametric modeling of the parenchymal fluorescence intensity (FI) curve was proposed, and a predictive model of graft survival was tested. Between July 2017 and May 2019, 76 LTs were performed, among which 6 recipients underwent retransplantation. No adverse effects of ICG injection were observed. The parameter a (temporal course of FI) was significantly higher in the re-LT group (0.022 seconds (0.0011-0.059) versus 0.012 seconds (0.0001-0.054); P = 0.01). This parameter was the only independent predictive factor of graft survival at 3 months (OR, 2.4; 95% CI, 1.05-5.50; P = 0.04). The best cutoff for the parameter a (0.0155 seconds ) predicted the graft survival at 3 months with a sensitivity (Se) of 83.3% and a specificity (Spe) of 78.6% (area under the curve, 0.82; 95% CI, 0.67-0.98; P = 0.01). Quantitative assessment of intraoperative ICG fluorescence on the graft was feasible to predict graft survival at 3 months with a good Se and Spe. Further prospective studies should be undertaken to validate these results over larger cohorts and evaluate the clinical impact of this tool

Comparative analysis of outcomes after liver resection and liver transplantation for early stages hepatocellular carcinoma in HIV-infected patients. An intention-to-treat analysis

International audienceBackground: To address the results of resection for hepatocellular carcinoma (HCC) in human immunodeficiency virus (HIV)-carriers, and to compare them against survival after liver transplantation (LT).Methods: All patients with HIV and HCC listed for LT (candidates = LTc+) or resection (LR+) between 2000 and 2017 in our centre were analysed and compared for overall survival (OS) and disease-free survival (DFS).Results: The LTc + group (n = 43) presented with higher MELD scores and more advanced portal hypertension and HCC stages than LR + group (n = 15). One-, 3- and 5-year intention-to-treat survival rates were: 81%, 60% and 44%, versus 86%, 58% and 58% in the LTc+ and LR + groups, respectively (p = 0.746). Eleven LTc + patients dropped out. After LT, OS was 81%, 68% and 59% (no difference with LR + group; p = 0.844). There tended to be better DFS after LT, reaching 78%, 68% and 56% versus 53%, 33% and 33% in the LR + group (p = 0.062).Conclusion: This was the largest series of resections for HCC in HIV + patients and the first intention-to-treat analysis. Although LT and resection do not always concern the same population, they enable equivalent survival. At the price of higher recurrence rate, resection could be integrated in the global armoury of liver surgeons

R1 Vascular or Parenchymal Margins: What Is the Impact after Resection of Intrahepatic Cholangiocarcinoma?

Background: to date, long-term outcomes of R1 vascular (R1vasc) and R1 parenchymal (R1par) resections in the setting of intrahepatic cholangiocarcinoma (iCCA) have been examined in only one study which did not find significant difference. Patients and Methods: we analyzed consecutive patients who underwent iCCA resection between 2000 and 2019 in two tertiary French medical centers. We report overall survival (OS) and disease-free-survival (DFS). Univariate and multivariate analyses were performed to determine associated factors. Results: 195 patients were analyzed. The number of R0, R1par and R1vasc patients was 128 (65.7%), 57 (29.2%) and 10 (5.1%), respectively. The 1- and 2-year OS rates in the R0, R1par and R1vasc groups were 83%, 87%, 57% and 69%, 75%, 45%, respectively (p = 0.30). The 1- and 2-year DFS rates in the R0, R1par and R1vasc groups were 58%, 50%, 30% and 43%, 28%, 10%, respectively (p = 0.019). Resection classification (HR 1.56; p = 0.003) was one of the independent predictors of DFS in multivariate analysis. Conclusions: the survival outcomes after R1par resection are intermediate to those after R0 or R1vasc resection. R1vasc resection should be avoided in patients with iCCA as it does not provide satisfactory oncological outcomes