Journal MeetingJournal Meeting時間時間 : AM 07:30 : AM 07:30 日期日期 : 06/29/200: 06/29/200

77地點地點 : : 胸腔外科辦公室胸腔外科辦公室

報告人報告人 : R2 : R2 許博順許博順

Pulmonary resection for metastases from hepatocellular carcinoma: Factors influencing prognosis

• The Journal of Thoracic and Cardiovascular Surgery, June 2006

• Takahito Nakagawa, MD, Toshiya Kamiyama, MD, Kazuaki Nakanishi, MD, Hideki Yokoo, MD, Hirofumi Kamachi, MD, Michiaki Matsushita, MD, Satoru Todo, MD

• Department of General Surgery, Hokkaido University, Graduate School of Medicine, Sapporo, Japan.

Introduction Introduction

• highly fatal cancer

• common in Taiwan and Japan, increasing incidence in the world

• reduced the operative morbidity and mortality

• long-term outcome: poor because high incidence of recurrence

• Recurrence: most common in the liver, extra-hepatic in the lung

Surgical resection of pulmonary metastases from HCC

• Indications??

•Prognostic factors??

•This paper analyzes the clinical factors and outcome.

Abbreviations and Acronyms

• AFP: alpha-fetoprotein• DFI: disease-free interval• HCC: hepatocellular carcinoma• TACE: trans-arterial chemoembolization• RFA: radiofrequency ablation• PEIT: percutaneous ethanol injection therapy

Methods

•From January 1987 to December 2003•544 underwent partial hepatectomy: 12

died, 532 were followed with a interval of 3 months by CxR, serum AFP and abd CT

•Chest CT was performed if AFP level increase or significant finding on CxR

Criteria for pulmonary resection

• Uncontrollable intrahepatic disease• No metastatic disease at another site• CT demonstrating that complete resection could be p

erformed regardless of the number of lesions• Bilateral pulmonary metastasis: no contraindication • Additional lung metastases after metastectomy: no co

ntraindication • Uncontrolled liver disease or unresectable multiple lu

ng metastases were offered chemotherapy• Uncontrolled liver disease: criteria ??

•wedge resection was the procedure of choice

•LN dissection was not undertaken•disease-free interval (DFI): last curative t

reatment for intrahepatic disease and the detection of pulmonary deposits

Statistics

• chi-square test was used to compare categoric variables between the 2 groups

• unpaired t test was used to compare continuous variables

• Survival was estimated by the Kaplan-Meier method

• differences between survival curves were tested by the log-rank test

• 1 patient died in the early postoperative period

Results

JustToBe

Pulmonary metastasectomyPulmonary metastasectomy

•Twenty-five patients•Wedge resection: 21•Lobectomy: 2•Lobectomy and wedge: 1•Bilateral lobectomy: 1•Second wedge: 6•Thrid wedge: 1

MortalityMortality

• One died of pyothorax 19 days after lobeOne died of pyothorax 19 days after lobectomy (mortality rate: 3.1%)ctomy (mortality rate: 3.1%)

• Ten died of HCC recurrenceTen died of HCC recurrence• One died sepsis 59 months after metastaOne died sepsis 59 months after metasta

sectomysectomy

•median follow-up: 37.3 months (range, 0.6-177.4 months)

•median survival: 51.8 months•1-year survival rate: 80% +/- 8%,•3-year survival rate: 61% +/- 10%,•5-year survival rate: 36% +/- 13%

Three survived more than 5 years

• Case 1: bilateral residual tumors after chemotherapy, underwent RUL and LLL lobectomy

Alive with no recurrence at 177 months• Case 3: wedge resection after a DFI of 22 months, and

32 months. Alive at 142 months without evidence of recurrence• Case 11: wedge resection 3 times at 27,33, and 45 mon

ths after right hepatectomy hepatic recurrence managed with TACE 2 years later an

d disease-free at 25 months after TACE

• tumor number (solitary or multiple) or tumor distribution (unilateral or bilateral lung): no significant effect

•Mean DFI: 16.3 months (range, 1-37 months).

•10 patients had a DFI of 1 to 11 months

mean survival was 30.6 months

•14 patients had a DFI > 12 months mean survival was 35.4 months

•P=.117

•19 patients: AFP levels < 500 ng/mL•Mean survival: 39.2 months.•5 patients: AFP levels > 500 ng/mL •Mean survival: 15.9 months•P=.225

• Group 1: low-risk (DFI>12 months and AFP<500ng/ml) 3-year survival: 89% +/- 11% 5-year survival: 74% +/- 16%

• Group 2: high-risk (DFI<12 months or AFP>500ng/ml) 3-year survival: 42% +/- 14% 5-year survival: 21% +/- 16%

• Incidences of intrahepatic recurrence and pulmonary re-recurrence did not differ between the low- and high-risk groups

• Incidence of metastases to other organs was significantly higher in the high-risk group than in the low-risk group (P .003,chi-square test)

Discussion

Prognosis Predictor Prognosis Predictor

•DFI was an important prognostic factor• Long-term follow-up of operative treatment for pulmonary metastases.

Eur J Cardiothorac Surg. 1989;3:292-6.• Analysis of prognostic factors in patients undergoing resection of pulmonary metastases fro

m soft tissue sarcomas. J Thorac Cardiovasc Surg. 1984;87:260-8.

•DFI > 36 months is a good prognostic factor in colorectal cancer or breast cancer.

• Pulmonary resection for metastases from colorectal cancer: factors influencing prognosis. Twenty-year experience. Eur J Cardiothorac Surg. 2002;21:906-12.

• Results of lung metastasectomy from breast cancer: prognostic criteria on the basis of 467 cases of the international registry of lung metastases. Eur J Cardiothorac Surg. 2002;22:335-44.

Prognosis PredictorPrognosis Predictor

• CEA level is a significant predictor factor in pulmonary metastases from colorectal cancer.

• Pulmonary resection for metastases from colorectal cancer: factors influencing prognosis. Twenty-year experience. Eur J Cardiothorac Surg. 2002;21:906-12

• AFP level is significant prognostic factor• Cutoff points: 400 ng/dl• A new prognostic system for hepatocellular carcinoma: a retrospective study of 435 patients: The Cancer of t

he Liver Italian Program (CLIP) investigators. Hepatology. 1998;28:751-5

• Cutoff points: 1000 ng/dl• Prognostic factors after hepatic resection for hepatocellular carcinoma with hepatitis C viral infection: univariate and multivariate

analysis. Am J Gastroenterol. 2001;96:1243-50.

• AFP level showed close correlation with multiple tumor, larger size, macroscopic invasion, poor differentiation and 3-year recurrence

rates• Living donor liver transplantation for adult patients with hepatocellular carcinoma: experience in Japan.

Ann Surg. 2004;240:451-9.

• MELD ScoreMELD Score ＝＝ 0.957 × Loge(creatinine mg/dL) + 0.378 Loge(bilirubin mg/dL) + 1.0.957 × Loge(creatinine mg/dL) + 0.378 Loge(bilirubin mg/dL) + 1.120 × Loge (INR) + 0.643120 × Loge (INR) + 0.643

Conclusion Conclusion

•DFI of more than 1 year and a serum AFP < 500 ng/mL together predict a better outcome after pulmonary metastasectomy of HCC

•Bilateral or unilateral is no contraindication

•Single or multiple is no contraindication

RFARFA

• cirrhosis and HCC (Child-Pugh class A, 50; B, 31;cirrhosis and HCC (Child-Pugh class A, 50; B, 31; C, 29), 110 patients were treated. The complic C, 29), 110 patients were treated. The complication rate was 13%, with local recurrence deveation rate was 13%, with local recurrence developing in only 4% at a follow-up of 19 months, loping in only 4% at a follow-up of 19 months, although in a large number of patients, recurrealthough in a large number of patients, recurrent disease developed at other sites within the lnt disease developed at other sites within the liver iver

• Radiofrequency ablation of hepatocellular cancer in 110 patients with cirrhosis. Radiofrequency ablation of hepatocellular cancer in 110 patients with cirrhosis. Ann SurgAnn Surg 2000; 232:381-39 2000; 232:381-39

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