1. Journal Meeting 時間 : AM 07:30 日期 : 06/29/2007 地點 : 胸腔外科辦公室 報告人 : R2 許博順

2. 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.

3. 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

4. Surgical resection of pulmonary metastases from HCC Indications?? Prognostic factors?? This paper analyzes the clinical factors and outcome.

5. 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

6. 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

7. Criteria for pulmonary resection Uncontrollable intrahepatic disease No metastatic disease at another site CT demonstrating that complete resection could be performed regardless of the number of lesions Bilateral pulmonary metastasis: no contraindication Additional lung metastases after metastectomy: no contraindication Uncontrolled liver disease or unresectable multiple lung metastases were offered chemotherapy Uncontrolled liver disease: criteria ??

8. wedge resection was the procedure of choice LN dissection was not undertaken disease-free interval (DFI): last curative treatment for intrahepatic disease and the detection of pulmonary deposits

9. 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

10. Results

13. Pulmonary metastasectomy Twenty-five patients Wedge resection: 21 Lobectomy: 2 Lobectomy and wedge: 1 Bilateral lobectomy: 1 Second wedge: 6 Thrid wedge: 1

14. Mortality One died of pyothorax 19 days after lobectomy (mortality rate: 3.1%) One died of pyothorax 19 days after lobectomy (mortality rate: 3.1%) Ten died of HCC recurrence Ten died of HCC recurrence One died sepsis 59 months after metastasectomy One died sepsis 59 months after metastasectomy

15. 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%

16. 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 months after right hepatectomy hepatic recurrence managed with TACE 2 years later and disease-free at 25 months after TACE

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

18. 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. 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

20. 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 500ng/ml) 3-year survival: 42% +/- 14% 5-year survival: 21% +/- 16%

21. 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)

22. Discussion

24. 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 from 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.

25. Prognosis 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 the 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.

26. MELD Score ＝ 0.957 × Loge(creatinine mg/dL) + 0.378 Loge(bilirubin mg/dL) + 1.120 × Loge (INR) + 0.643 MELD Score ＝ 0.957 × Loge(creatinine mg/dL) + 0.378 Loge(bilirubin mg/dL) + 1.120 × Loge (INR) + 0.643

27. 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

35. RFA cirrhosis and HCC (Child-Pugh class A, 50; B, 31; C, 29), 110 patients were treated. The complication rate was 13%, with local recurrence developing in only 4% at a follow-up of 19 months, although in a large number of patients, recurrent disease developed at other sites within the liver cirrhosis and HCC (Child-Pugh class A, 50; B, 31; C, 29), 110 patients were treated. The complication rate was 13%, with local recurrence developing in only 4% at a follow-up of 19 months, although in a large number of patients, recurrent disease developed at other sites within the liver Radiofrequency ablation of hepatocellular cancer in 110 patients with cirrhosis. Ann Surg 2000; 232:381-391 Radiofrequency ablation of hepatocellular cancer in 110 patients with cirrhosis. Ann Surg 2000; 232:381-391