Page 180 - ebook HCC

178 PROGRAMME AND ABSTRACTS GENEVA, SWITZERLAND EASL HCC SUMMIT 179
FEBRUARY 13 - 16, 2014

HISTOLOGICAL CLASSIFICATION OF HCC: RESECTION FOR HCC, CURRENT DATA
OLD-FASHIONED OR STILL HOT?
Christian Toso 1
1 Services de chirurgie viscérale et transplantation,
Michael Torbenson 1 Hôpitaux Universitaires de Genève, Geneva, Switzerland
1 Johns Hopkins Hospital, Baltimore, United States
Corresponding author’s e-mail: Christian.Toso@hcuge.ch
Corresponding author’s e-mail: MTORBEN@jhmi.edu

Liver tumors are classified into subtypes because subtypes are relevant to clinical care Outcomes after liver resection for hepatocellular carcinoma have improved over the
and to tumor biology. Historically and today, the only important liver tumor classification recent years, with expected five-year patient survival rates of 50-80% (Lim et al. BJS
systems are those based on tumor morphology revealed by light microscopy. Now and in 2012). These improvements are linked to better patient selection, improved pre-operative
liver parenchyma preparation and refined peri-operative patient management.Factors
the future, advances in science will lead to new discoveries in liver tumor biology. How do generally accepted as contra-indications for surgery include advanced liver disease (Child
we best incorporate these new discoveries into tumor classification? Some have advocated B and especially C), signs of portal hypertension (hepatic venous pressure gradient >10
that there should be no incorporation, but instead, old ways of tumor classification should mmHg) and the presence of extra-hepatic disease. In addition, recent data also brought
be discarded and new molecular classifications embraced. In this regard, “out with the attention on the risks linked to HCC liver resection in patients with NASH, with up to 18%
old, in with the new” has become an increasingly common theme in the scientific study mortality at 90 days. Such patients with metabolic disease and abnormal liver parenchyma
of liver tumors. I hope to convince you otherwise. Morphology is a direct expression of should be selected carefully and pre-surgery portal vein embolization should be used
genetics in the tumor microenvironment. Should a botanist study only DNA and ignore liberally (Cauchy et al. BJS 2013). A variety of patients with HCC can benefit from surgery.
the forest? Likewise, the molecular study of tumors without morphology is inherently They include patients with single small (≤3 cm) HCCs, although some of them would
limiting. By examining specific examples, we will see how direct observation of tumor be better treated by radio-frequency ablation. The choice between both techniques
morphology through light microscopy strengthens molecular studies and how molecular should be based on tumor location (HCC bulging at the liver surface is better resected
and HCC deep in the parenchyma is better treated by RFA). Large HCCs can be well
studies can in turn refine light microscopy classifications. Histological classifications are treated by resection. They are expected to have a good biology (slow growing without
CLINICAL SPEAKERS ABSTRACTS Future classification of liver tumors will be derived by incorporating together histology and preferred in young patients without major co-morbidities.Pre-surgery liver parenchyma CLINICAL SPEAKERS ABSTRACTS
old, but not old fashioned. Molecular classifications are hot now, but all things cool, and
metastasis) and require only minimal functional liver parenchyma resection. Patients with
their longevity in the end will depend on their relevance to clinical care and tumor biology.
oligo-nodular HCCs may also benefit from resection, although transplantation may be
molecular findings and the future lies to neither alone but to both together.
preparation has improved over the recent years. Portal vein embolization helps increasing
the volume and the quality of the expected liver remnant within four weeks, allowing more
extreme resections. This strategy is currently the best studied pro-regenerative tool, but
radiofrequency embolization has recently also gained attention. It helps both treating the
HCC and promoting the growth of the contra-lateral liver lobe, yet requiring more time
to achieve a significant effect (control CT is usually performed at three months)(Gaba et
al Ann Surg Oncol 2009).Thanks to the help of multidisciplinary teams, patients can be
better prepared for surgery. This includes promoting smoking cessation, which decreases
post-operative lung complications even after a few days without smoking. Pre-surgery
exercising (daily walking) is recommended in order to have the patients “as fit as possible”
at the time of resection. With the implementation of “enhanced recovery after surgery”
programs patients are mobilized early, with the use of epidural analgesia for the first
few days, the gastric tube is removed in the OR and the bladder catheter on day one
(Schulz et al. BJS 2013). Finally, selected patients can benefit from minimally invasive
surgery, with the potential of a faster recovery.Overall, the multi-disciplinary choice of
the HCC treatment, the liberal use of pro-regenerative liver strategies, the appropriate
patient preparation to surgery and the establishment of enhanced recovery after surgery
programs can help further improving HCC resection outcomes and cost-effectiveness.