hepatectomie en 2 temps - pr rené adam
TRANSCRIPT
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Two-Stage Hepatectomy vs ALPPS for
Unresectable Metastases
R Adam, K Imai, C Castro, MA Allard,
E Vibert, A Sa Cunha, D Cherqui, H Baba, D Castaing
Hôpital Paul Brousse, Villejuif, FranceUniversité Paris-Sud, France
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Multi Unilobar Multi Bilobar Multi Bilobar
Remnant Liver <30%≤3 nod. ≤30 mm >3 nod. >30 mm
Hepatectomy +Local Ablation
2-Stage HepatectomyPortal Vein
Embolization
Two-Stage Hepatectomy: Patient Selection
Standard 2-Stage ALPPS
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Portal vein ligation
Tumorectomy of liver remnant
Hypertrophy of liver remnant
Stage 1 Stage 2
>30% of total liver
4-8 weeks
Removal of the deportalized lobe
Portal vein embolization
Clavien et al. Strategies for safer liver surgery. NEJM, 2017
The Selective Staged method…Two-stage Hepatectomy
Exclusion Pts in progression
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Portal vein ligation
Tumorectomy of liver remnant
Hypertrophy of liver remnant
Stage 1 Stage 2
>30% of total liver
9 days
Removal of the deportalized lobe
Portal vein embolization
Clavien et al. Strategies for safer liver surgery. NEJM, 2017
The fast-surgery method…: ALPPS
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Present status
• Higher feasibility of complete resection with ALPPS • Faster hypertrophy rate of liver remnant
Are the oncological results better than conventional 2-stage ?
Pending question
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Results: flow chart
January 2000 – June 2014248 Pts Resected of CLM at Paul Brousse Hospital
56 Two stage hepatectomy (23%)
TSH (N = 41)
15 Failure(36%)
26 Complete (64%)
ALPPS (N = 17)
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Patient Selection
• Two-stage hepatectomy and ALPPS : indicated in patients with bilobar colorectal liver metastases not resectable by a single-stage hepatectomy with or without portal vein embolization or local ablation therapy.
• ALPPS was favoured in patients with an estimated smaller liver remnant volume irrespective of other tumour or patient characteristics
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Male 65 yrsSynchronous Bilateral Irresectable LMCCRFOLFOX AVASTIN 6 CoursesACE 228 --- 83FLR: 313cc ( < 0.5% ratio to Body weight)
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Methods
• Between January 2010 and June 2014, • 58 consecutive patients who underwent either
ALPPS (n=17) or two-stage hepatectomy (n=41) for colorectal liver metastases were enrolled in the study.
• Short-term and oncological outcomes were compared.
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Methods: ALPPS or TSH? Bilobar multiple CLM
Unresectable with a single hepatectomy even with portal vein embolization
Estimated small remnant liver
(requiring right hepatetomy
extended to segment IV)
ALPPS or Two stage hepatectomy?
Possibility to spare
segment IV
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Methods: Techniques for ALPPS
• Clairance of future remnant liver • Portal vein embolization • Parenchymal transection
12 days later….Right hepatectomy extended to segment IV
1st stage
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Methods: End points
Oncological outcomes on intention to treat• Overall survival• Disease-free survival
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Two stage vs ALPPS: baseline characteristics
Study group (n=58)
ALPPS (n=17)
TSH (n=41) P value
Sex (M/F) 12/5 23/18 0.30Age 58 (23-75) 58 (32-75) 0.90T-stage CR tumour (1-2/3-4) 15 (88) 30 (73) 0.53Site of primary tumour (colon/rectum) 13 (76) 27 (66) 0.42
Liver metastases: synchronous 15 (88) 38 (93) 0.59
No of liver lesions at diagnosis 10 (3-20) 10 (2-35) 0.37Largest size at diagnosis (mm) 40 (13-145) 50 (10-150) 0.39No of liver lesions at hepatectomy 8 (3-32) 10 (3-30) 0.39
Largest size at hepatectomy (mm) 38 (8-140) 43 (10-140) 0.26
CEA at hepatectomy (ng/mL) 8 (1-1195) 7.9 (0.5-940) 0.90Preoperative chemotherapy 17 (100) 41 (100) 1
Progression at last line 0 0 1
Concomitant extra-hepatic disease 6 (35.3%) 12 (29.3%) 0.65
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Two stage vs ALPPS: operative data
Study group (n=58)
ALPPS (n=17) TSH (n=41) P value
Percentage of estimated FLR before first-stage (%) 24 (11-38) 30 (19-53) 0.056
Percentage of estimated FLR before 2nd-stage (%) 36 (26-49) 40 (25-55) 0.12
Portal vein embolization 17 38 0.14First-stage
Radiofrequency ablation 1 6 0.32Red blood cell transfusion 4 2 0.044No. of treated tumours* 2 (0-7) 4 (1-18) 0.04
Interval chemotherapy (days) 0 35 <0.0001
Time interval between the stages (day) 12 (9-39) 103 (19-450) <0.0001
Second-stageRadiofrequency ablation 0 1 0.31Red blood cell transfusion 4 8 0.60No. of treated nodules* 8 (1-25) 6 (2-15) 0.53
Total (completed) No. of treated nodules* 9 (2-32) 8 (1-30) 0.36
Resection margin (R0/R1/ Rrfa†) 2/14/1 5/18/3 0.61
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Two stage vs ALPPS: operative data
Study group (n=58)
ALPPS (n=17) TSH (n=41) P value
Percentage of estimated FLR before first-stage (%) 24 (11-38) 30 (19-53) 0.056
Portal vein embolization 17 38 0.14First-stage
Radiofrequency ablation 1 6 0.32Red blood cell transfusion 4 2 0.044No. of treated tumours* 2 (0-7) 4 (1-18) 0.04
Interval chemotherapy (days) 0 35 <0.0001
Time interval between the stages (day) 12 (9-39) 103 (19-450) <0.0001
Second-stageRadiofrequency ablation 0 1 0.31Red blood cell transfusion 4 8 0.60No. of treated nodules* 8 (1-25) 6 (2-15) 0.53
Total (completed) No. of treated nodules* 9 (2-32) 8 (1-30) 0.36
Resection margin (R0/R1/ Rrfa†) 2/14/1 5/18/3 0.61
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ALPPS vs Two stage Hep: early outcome
ALPPS (N = 17) TSH (N = 41) P value
90-day mortality 0 (0) 1 (2.4) 0.91
Dindo-Clavien ≥ III 7 (41) 16 (39) 0.88
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Overall Survival after ALPPS vs TSHin ITT after hepatectomy
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Overall Survival after ALPPS vs TSHin ITT after the diagnosis of liver metastases
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Overall Survival after Matching for ALPPS vs TSHin ITT after the diagnosis of liver metastases
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Patient Outcome after ALPPS procedure
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Cohort updated to 24 pts:
Months
OS
pro
babi
lity
0 12 24 36 48
0.0
0.2
0.4
0.6
0.8
1.0
41 35 18 9 3 Two stage
24 13 3 ALPPS
P = 0.005MS : 28.9 mo
MS : Not reached
Two stageALPPS
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Conclusions
• Despite a higher feasibility (100% vs 63%)• …the absence of 90 day-mortality and a
comparable morbidity • Survival of ALPPS group was lower than TSH, in
intention to treat (42 vs 77 % at 2 years)• DFS was similar with however a higher
proportion of liver recurrences (100 vs 53%) and a lower use of repeat surgery .
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Summary
The higher feasibility rate of ALPPS did not seem to translate into a better oncological outcome
compared to two-stage hepatectomy.