2013. 2. 2 대한간암연구학회 7차 심포지움 및 학술대회 Indication and Clinical Outcomes of Metachronous HCC Metastasectomy Shin Hwang Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Se oul, Korea
HCC cells can go anywhere.
Extra- vs. intrahepatic HCC recurrence Overall survival Disease-free survival
Pulmonary Metastasectomy (PMT)
Published survival rates after PMT for HCC reported for studies in Korea and Japan
Indications of PMT-HCC Primary tumor control + Feasibility of complete PMT Sufficient pulmonary function after PMT Up to three isolated PM-HCC lesions, regardless of bilaterality Isolated recurrent PM-HCC
- Duration : June 1995 and September 2006 - Operation : 69 metastasectomy in 49 patients - Sex ratio : male : female = 40 : 9 - Mean age : 51.3 ± 9.4 years - Median follow-up duration: 16.4 months Primary HCC treatment AMC data Treatments of primary HCC TACE 5 Lobectomy 20 Segmentectomy 12 Liver transplantation 12 Patient No.
Number of pulmonary metastasectomy Number of Metastasectomy Number of patients Once 36 Twice 10 Three times 3 Four times 1
Patients characteristics Location of pulmonary metastasis Right 31 Left 28 Bilateral 10 Number of pulmonary metastasis Solitary 36 Multiple 33 Pre-PMT AFP level Approach 500 59 > 500 10 Open thoracotomy / sternotomy 47 VATS 22 Mode of PMT Wedge resection 62 Segmentectomy 3 Lobectomy 4 HCC lymphovascular invasion Pulmonary metastasectomy (PMT) Positive 12 Negative 37 Number Patients chracteristics Size of metastatic nodule 2 53 > 2 16 Hilar/mediastinal lymph node metastasis Negative 16 Positive 5 Mean hospital stay (day) Number VATS 4.2 ± 3.0 Thoracotomy / sternotomy 8.5 ± 4.7 Postoperative complication No complication 64 Chemical pleurodesis 1 Pneumothorax after chest tube removal Others 1 Post-PMT adjuvant therapy Chemotherapy 18 No chemotherapy 31 Post-PMT recurrence Intrathoracic recurrence 43 Other distant organ 18 3
Survival Outcomes Overall survival Recurrence-free survival 1-YSR: 78.7% 2-YSR : 55.1% 3-YSR : 41.0% 1-YSR: 72.8% 2-YSR : 41.8% 3-YSR : 31.1% months months
Open vs. Video-assisted Surgery VATS Open thoracotomy / sternotomy P-value Number of patients 22 47 Hospital stay (days) 4.2 ± 3.0 8.5 ± 4.7 < 0.05 Number of resection 1.8 ±1.2 2.1 ± 2.1 NS Postop. complication 1 4 NS Intrathoracic recurrence 12 30 0.60
Adverse risk factors for PMT
Suggestions 폐전이시 절제적 치료가 가장 양호한 예후를 보이고 폐수술에 따른 부담이 적다. 원발병소의 치료가 가능하고 폐전이가 절제가능하게 보이면 가능한 절제한다 (대개 폐전이 병소 3개 이하) 재발성 폐전이의 경우 단독 재발이면 재절제를 시도한다.
HCC adrenal metastasis 8.4% of autopsy cases, 1-2% of clinical practice
Laparoscopic adrenalectomy
M/83, NBNC, HCC Adrenal metastasis 7 mos later, solitary adrenal meta 4 mos later -> Liver metastasis Ahn et al. Korean J Gastroenterol, 2012
M/81, NBNC, HCC Adrenal metastasis 24 mos later, solitary adrenal meta No recurrence for 14 mos Ahn et al. Korean J Gastroenterol, 2012
HCC adrenal metastasis Resection Resection is beneficial for only selected cases.
HCC adrenal metastasis Radiation therapy Jpn J Clin Oncol 2005;35: 61
Suggestions 타 부위재발의 가능성, 수술 위험도, 내시경적 수술 등을 고려하여 절제치료 여부를 결정한다. 부신 절제시의 예후는 예측하기가 어렵기 때문에 대개 타부위 재발 위험이 낮은 경우에 우선적으로 고려한다. 절제술 vs. 방사선 치료
HCC resection for synchronous LN meta Overall survival Disease-free survival N0 N1 N0 N1 Metachronous intraabdominal LN meta
F/74, HCV, HCC Portacaval LN metastasis 19 mos later, PC LN meta No recurrence for 5 yrs Anticancer researche 2011;31:33991
Paraaortic LN metastasis F/65, HCV, HCC 6 mos later, paraaortic LN meta No recurrence for 6 mos World J Gastroenterol 2012;18: 3027-3031
HCC lymph node metastasis Resection Acta Med Okayama 2012;66:177-182
Suggestions 위치와 크기에 따른 절제 가능성을 우선적으로 따진 다. 단발성 병변에서는 예상외의 양호한 예후를 보이는 경우가 있다.
Extraperitoneal solitary metastasis
Cervical LN metastasis M/73, HBV, HCC Right hepatectomy 47 mos later, PIVKA-2 rise: Cervical LN level 5 meta -> No recurrence for 18 mos after resection
Intercostal muscle metastasis M/65, HBV, HCC TACE + RFA 1 yr later Resection of 7 th & 8 th ribs -> No recurrence for 20 mos
Suggestions 위치와 크기에 따른 절제 가능성을 우선적으로 따진 다. 완전 절제시 예상외의 양호한 예후를 보이는 경우가 흔하다.
Other intraperitoneal metastasis
HCC peritoneal metastasis Often after HCC rupture
Peritoneal metastasis
Overall survival Resection
Overall survival
Peritoneal recurrence resection cases
HCC ovarian metastasis Resection Gut and Liver 2011;5:543-547
HCC ovarian metastasis Gut and Liver 2011;5:543-547
Summary 간외 재발시에는 재발위치, 절제 가능성, 환자의 전신 상태, 간기능, 종양특성 등을 면밀히 고려하여 절제가능성을 판단해야 한다. 절제 후에는 대개 전신적 항암요법(sorafenib)을 병행한다. 간외재발의 절제는 수술의 위험도를 고려하여 근치적 절제가 가능하게 보이는 환자에 대해서 장기적인 예후 향상을 위해 적극적인 치료의 일환으로 적용된다.
Summary It is anticipated that for surgery to be considered in patients with extrahepatic metastasis from HCC, a variety of factors including the site of metastasis, resectability, overall fitness of the patient, functional status of the liver and tumor biology needs to be carefully examined. When surgery is performed, it should be combined with the current most effective systemic therapy, sorafenib. It is hoped that this will better define the role of resection and selection of patients that are best suited for this aggressive approach to achieve long-term survival.