Management of hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is one of the most common tumors globally, with varying prevalence based on endemic risk factors. In high-risk populations, including those with hepatitis B or C or with cirrhosis, serum alpha-fetoprotein (AFP) and screening ultrasound have improved detection of resectable HCC. Treatment options, including surgical resection, for patients with HCC must be selected based on the number and size of hepatic tumors, underlying hepatic function, patient condition, and available resources. An approach, which has been summarized shows the corresponding treatment choices under given clinical circumstances. For cirrhotic patients with less than three tumor nodules of a size less than 3 cm or a solitary HCC less than 5 cm, liver transplantation offers long-term survival similar to that observed in patients transplanted for nonmalignant disease. Ablative treatment using either chemical or thermal techniques provides locally effective tumor destruction. Transcatheter arterial chemoembolization (TACE) is commonly used for palliation of unresectable tumors as well as an adjunct to surgical resection, treatment of tumors before transplant, and in conjunction with other ablative therapies in a multimodality approach. Regional approaches to chemotherapy have produced more encouraging results than systemic chemotherapy, although both remain ineffective for long-term tumor control. Several newer treatment modalities are under investigation, including gene therapy, tagged antibodies, isolated perfusion, and novel radiotherapy techniques.

Biliary reconstruction using non-penetrating, tissue everting clips versus conventional sewn biliary anastomosis in liver transplantation.

BACKGROUND: Biliary complications occur following approximately 25% of liver transplantations. Efforts to decrease biliary complications include methods designed to diminish tissue ischemia. Previously, we reported excellent short-term results and decreased biliary anastomosis time in a porcine liver transplant model using non-penetrating, tissue everting clips (NTEC), specifically VCS clips. METHODS: We examined the incidence of biliary anastomotic complications in a group of patients in whom orthotopic liver transplantation was performed with biliary reconstruction using NTEC and compared that group to a matched group treated with biliary reconstruction via conventional end-to-end sewn choledochocholedochostomy. Patients were matched in a 1:2 fashion by age at transplantation, disease etiology, Child-Turcot-Pugh scores, MELD score or UNOS status (prior to 1998), cold and warm ischemia times, organ donor age, and date of transplantation. RESULTS: Seventeen patients had clipped anastomosis and 34 comparison patients had conventional sewn anastomosis. There were no differences between groups in terms of baseline clinical or demographic data. The median time from completion of the hepatic artery anastomosis to completion of clipped versus conventional sewn biliary anastomosis was 45 (interquartile range = 20 min) versus 47 min (interquartile range = 23 min), respectively (p=0.12). Patients were followed for a mean of 29 months. Biliary anastomotic complications, including leak or anastomotic stricture, were observed in 18% of the clipped group and 24% of the conventional sewn group. CONCLUSIONS: Biliary reconstruction can be performed clinically using NTEC as an alternative to conventional sewn biliary anastomoses with good results.

Effective treatment of biliary cystadenoma.

OBJECTIVE: Evaluate experience over 15 years with treatment of this lesion. SUMMARY BACKGROUND DATA: Biliary cystadenoma, a benign hepatic tumor arising from Von Meyenberg complexes, usually present as septated intrahepatic cystic lesions. METHODS: Data were collected concurrently and retrospectively on patients identified from hospital medical records reviewed for pertinent International Classification of Diseases, Ninth Revision, Clinical Modification and CPT codes, pathology logs, and from operative case logs. Pathology specimens were rereviewed to confirm the diagnosis of biliary cystadenoma or biliary cystadenocarcinoma by 2 GI pathologists. RESULTS: From October 1989 to April 2004 at our institution, 19 (18F:1M) patients had pathologically confirmed biliary cystadenomas, including one with a biliary cystadenocarcinoma. The mean age was 48 +/- 15 years at initial evaluation. Complaints included abdominal pain in 74%, abdominal distension in 26%, and nausea/vomiting in 11%. Only 1 patient presented with an incidental finding. Symptoms had been present for 3 +/- 5 years, with 1 to 4 different surgeons and many other physicians involved in the diagnosis or treatment prior to definitive ablation. Eight patients had undergone 20 previous treatments, including multiple percutaneous aspirations in 4 and 11 operative procedures. CT or US was diagnostic in 95%, with internal septations present in the hepatic cysts. Definitive operative intervention consisted of hepatic resection in 12 patients, enucleation in 6 patients, and fenestration and complete fulguration in 1 patient. There were no perioperative deaths. No recurrences were observed after definitive therapy, with follow-up of 4 +/- 4 years. CONCLUSIONS: Biliary cystadenoma must be recognized and treated differently than most hepatic cysts. There remains a need for education about the imaging findings for biliary cystadenoma to reduce the demonstrated delay in appropriate treatment. Traditional treatment of simple cysts such as aspiration, drainage, and marsupialization results in near universal recurrence and occasional malignant degeneration. This experience demonstrates effective options include total ablation by standard hepatic resection and cyst enucleation.

Use of percutaneous drainage to treat hepatic abscess after radiofrequency ablation of metastatic pancreatic adenocarcinoma.

Radiofrequency ablation (RFA) is well described in the treatment of primary hepatic malignancies and colorectal carcinoma hepatic metastases. A known complication of RFA is the development of hepatic abscess. The management of hepatic abscesses subsequent to RFA for metastatic disease is not well described. A 49-year-old female with pancreatic adenocarcinoma underwent pancreaticoduodenectomy followed by adjuvant chemoradiation. Following 6 months' treatment, a new liver metastasis was identified. It remained stable for 6 months during additional chemotherapy and thereafter was treated with RFA. Three weeks after RFA, the patient presented with malaise and leukocytosis, and a CT scan demonstrated a large hepatic abscess at the site of the RFA. She remained febrile despite needle aspiration and intravenous antibiotics. A percutaneous drain was placed and the symptoms resolved. Contrast injection of the drain 4 weeks later demonstrated resolution of the abscess cavity but communication with the biliary tree. The drain was removed and the tract embolized with Gel-foam to prevent complications of biliary-cutaneous fistula. She remains well without evidence of abscess or disease recurrence. Thus, RFA can be used in treatment of limited isolated hepatic metastases from previously treated pancreatic adenocarcinoma. However, the incidence of hepatic abscess is increased due to bilioenteric anastomosis; extended antibiotic prophylaxis should be considered.