Liver Cancer Surgery

Transcript

• 00:00Offered by the smile or Liver
• 00:03cancer program and we want to.
• 00:07Go in the next three months,
• 00:10go through some of the aspects that
• 00:14are more novel in the treatment of
• 00:18able to sell a carcinoma liver cancer,
• 00:22and we asked some of our faculty,
• 00:25like Doctor
• 00:26Billingslea, another Madoff
• 00:28and Doctor Stein too.
• 00:30Teach us the novelty in their respective
• 00:33field as you know about the cell
• 00:37carcinoma is on the rise is becoming
• 00:40one of the most frequent and and
• 00:43little two models on our latitudes.
• 00:46And what is important to understand
• 00:49is that treatment of hepatocellular
• 00:52carcinoma is complex is a moving target.
• 00:55And then it takes a village.
• 00:58Here you see some of the our colleagues
• 01:01working with us to go through the
• 01:05different possible approaches to this
• 01:07patient an I have to tell you that
• 01:11this picture are in defect with.
• 01:13There are many other.
• 01:15Colleagues said they work with
• 01:18us with this patient,
• 01:20but today today we have the
• 01:23pleasure of having Doctor Kevin
• 01:25Billingslea carrying as a great
• 01:28pedigree in terms of these studies,
• 01:32they went to Stanford and then
• 01:35John Hopkins enjoy in the surgery
• 01:38residency at the Oregon Health.
• 01:41And after a fellowship at NCI an MSA KCC,
• 01:46he joined the faculty at the
• 01:48University of Washington Ann and
• 01:51became Chief of Surgical Oncology.
• 01:53Focusing of effort to be Jerry surgery,
• 01:56an anchoring Carissa for almost 16 year,
• 02:00and then we were.
• 02:02Fortunate enough to be able to recruit
• 02:06him as a Chief medical officer of the
• 02:10Smiler Hospital Ann You Cancer Center.
• 02:14And he came at the beginning of the year,
• 02:19and was instrumental in all our
• 02:21transformation that we went
• 02:23through because of the covid.
• 02:26And but in a way that made
• 02:29as reminding of our patients,
• 02:31so that nobody will be left behind.
• 02:35That. In addition,
• 02:36if I have to have had a personal note,
• 02:40is a really pleasant colleague. It's it's.
• 02:43It's just a joy working with them.
• 02:47And you always participate to
• 02:49our two more boards with the
• 02:53extremely helpful insight.
• 02:55And so.
• 02:57Without further
• 02:58ado, I'll I'll, I'll leave
• 03:00the stage to Doctor Billingslea.
• 03:06Coming.
• 03:10Oreo, thank you very much for that
• 03:16really gracious introduction.
• 03:18Let me just make sure that.
• 03:23Everyone seeing my slides.
• 03:30Has that look under folks? Yep, OK.
• 03:36Well, you know, thank you again.
• 03:38It's been an absolute absolute pleasure
• 03:41being here at yell for the past year and I
• 03:44am delighted to be here in a leadership role,
• 03:48but I will say one of the highlights
• 03:50of my clinical life,
• 03:52which is very important to me,
• 03:54has been the opportunity to participate
• 03:57in this liver tumor program.
• 03:59You know, under Mario's leadership and with
• 04:01the contribution of many other people, this.
• 04:04Program really represents that what we
• 04:07are aiming to develop in all of our of
• 04:12our disease sites and disease centers,
• 04:15which is a collaborative,
• 04:17multidisciplinary team that meets regularly,
• 04:20plans treatment prospectively collects
• 04:22data and continuously examines what we're
• 04:26doing to improve and optimize treatment
• 04:29for patients and moving the field forward.
• 04:32So it's it's it really is is
• 04:35a pleasure and an honor.
• 04:36So I'm a surgical oncologist by background,
• 04:40in clinical practice,
• 04:41and is Martin shared I've spent.
• 04:44The majority of my time in the past over.
• 04:49Close to 20 years focusing on both
• 04:52liver cancer and pancreatic cancer,
• 04:54but primarily liver cancer in liver surgery,
• 04:57and I think the management of this
• 05:00group of patients with a paddle
• 05:02cellular carcinoma in some ways is
• 05:05the most complicated set of patients
• 05:07I'm involved with because not only is
• 05:10the surgery technically complicated,
• 05:12will touch on that a little bit,
• 05:15but the decision-making about who to
• 05:17operate window operate who transplants.
• 05:20And who to treat with alternative?
• 05:22You know,
• 05:23oblativa or arterial therapies
• 05:25is also extremely complicated,
• 05:27and we'll talk more as we go along.
• 05:31But it it very much involves complex
• 05:34multidisciplinary decision making.
• 05:39You know, so was Mario
• 05:42indicated in the introduction?
• 05:44Apparel Center carcinoma remains one
• 05:46of our most daunting global public
• 05:49health challenges in the cancer arena.
• 05:52And if you look at this graphic.
• 05:56The incidence of the disease is going up.
• 06:01Only in North American,
• 06:04but basically around the world.
• 06:06And like many diseases,
• 06:08there is a greater burden of disease
• 06:11in under represented minorities
• 06:13and vulnerable populations.
• 06:15Although you know the overall incidence
• 06:19is creeping up in almost across the board.
• 06:24You know this is to a large degree due to
• 06:27the the underlying burden of viral hepatitis,
• 06:31principally hepatitis C.
• 06:33Here in North America and Europe.
• 06:36hepatitis B more in Asia.
• 06:38But really,
• 06:39the looming crisis on the
• 06:41horizon is the explosion of non
• 06:44alcoholic fatty liver disease,
• 06:46or so-called knaflich from a
• 06:48variety of sources and etiologies.
• 06:51But Nah fled is on track to.
• 06:54Be the largest and most
• 06:56significant indication for liver
• 06:58transplant in the coming years,
• 07:00and it is probably going to be
• 07:03the most prominent underlying
• 07:04contributor to a parasailer carcinoma,
• 07:07particularly as our antiviral
• 07:10therapies improve.
• 07:12So my focus today is going to be
• 07:15on surgical therapy and you know.
• 07:18Where do we stand in surgical
• 07:20treatment for for HTC in 2021?
• 07:23Well,
• 07:23I think there are many things that
• 07:27we can be proud of and be excited
• 07:30about and are causes for optimism.
• 07:33Surgical treatment for HCC as well
• 07:36as other liver tumors have really
• 07:39developed in the past 2020 years.
• 07:41In a in a number of ways we've
• 07:43seen a renaissance related to the
• 07:46introduction of minimally invasive
• 07:49techniques for liver surgery.
• 07:51I'm going to talk about both laparoscopic
• 07:54and robotic approaches in some detail.
• 07:57The way we action surgically come
• 07:59through the liver and divide,
• 08:01deliver surgically has changed.
• 08:03You know,
• 08:04we used to use a lot of crush plant.
• 08:08Now we almost do everything with
• 08:10energy sources and and more refined
• 08:13techniques such as acusa or herby.
• 08:16Our understanding of the anesthesia
• 08:18anesthesiology anesthetic component of
• 08:20this patient management is improved
• 08:22and we've minimized look blood
• 08:24loss through the use of low CVP.
• 08:27Anaesthesia taken together
• 08:28these developments as well as
• 08:31improved surgical training,
• 08:32expertise of lowered overall
• 08:35surgical mortality into the range
• 08:38of 1 to 3% after liver resection.
• 08:41Experience centers.
• 08:42Unfortunately,
• 08:43due to the nature of the disease,
• 08:46relatively few patients who present
• 08:48with HTC are surgical candidates,
• 08:51and this is due to the severity
• 08:54underlying liver disease of
• 08:56any variety of etiologies,
• 08:58viral hepatitis,
• 08:59as well as the extent of disease.
• 09:02Sometimes patients have smaller
• 09:04early stage disease,
• 09:06but it is not uncommon for us to see
• 09:09extensive and infiltrating disease with.
• 09:12Portal vein invasion and other
• 09:15sites of disease in the liberal
• 09:18or extra padick disease.
• 09:20So this combination of things often limits.
• 09:24The surgical candidacy of a variety
• 09:27of of many of the patients.
• 09:30So in my talk this evening,
• 09:32I'm going to really highlight a
• 09:34couple of a number of key areas
• 09:37of our current status.
• 09:38We're going to spend some time talking
• 09:41about the fact that this really
• 09:43is a dual challenge for surgeons,
• 09:45but also for every specialty who's
• 09:48involved in the care of this group of
• 09:51patients because we have to treat the
• 09:53underlying liver disease and the cancer
• 09:56were not just on cologist, we are.
• 09:58Hepatology oncologist dealing
• 10:00with both disease entities.
• 10:02You know, very few of our patients are nuts.
• 10:05Erotics in the western world,
• 10:07only about 5% of them.
• 10:09In Asia, about 40% of patients
• 10:11with HCC or non cirrhotic,
• 10:13so it's a different kind of clinical
• 10:16picture in other parts of the world.
• 10:18But for what we deal with
• 10:21many patients or cirrhotics.
• 10:23We will spend a brief bit of time talking
• 10:25about reception versus transplant.
• 10:28I'm not a transplant surgeon and I'm not.
• 10:31I won't claim a mantle of expertise in this,
• 10:34but I think any discussion of
• 10:36surgery in this disease has to
• 10:39at least mention transplant.
• 10:40Given its great importance in the
• 10:43management of this group of patients.
• 10:46I'm going to spend a fair bit of time
• 10:48talking about the process of patient
• 10:51selection for reception because it
• 10:53is truly a complex art and science
• 10:55that requires the input of a lot of
• 10:58people and will discuss that some.
• 11:00Talk about these technical developments,
• 11:02primarily the role evolving role
• 11:04of minimally invasive techniques.
• 11:06Talk some about techniques for
• 11:08patient optimization,
• 11:09and then I'm going to spend a bit of
• 11:11time talking about a few key special
• 11:15clinical populations who actually
• 11:17are good surgical candidates and we
• 11:19need to be keeping an eye out for.
• 11:22As we look at patients with
• 11:25liver disease in HCC,
• 11:27it is important to understand how we
• 11:30as clinicians think about the severity
• 11:33of their underlying liver disease
• 11:36because that is going to be one of the
• 11:40key drivers of our decision-making.
• 11:41You know,
• 11:42the classic clinical system is the
• 11:45so-called Child Pugh classification
• 11:47of cirrhosis.
• 11:48This was this is a very clinically
• 11:51driven system that relies on.
• 11:533 lab tests, bilirubin,
• 11:55albumin,
• 11:56prothrombin time as well as
• 11:58two clinical assessments.
• 11:59The presence of in severity of
• 12:02ascites and Vatican several opathy
• 12:04the child Pugh system was originally
• 12:07developed to predict mortality
• 12:09for portosystemic shunt surgery,
• 12:11but it has evolved over years to predict
• 12:14mortality after other interventions,
• 12:17including liver resection, patients are
• 12:19assigned one up to one to three points.
• 12:23For each of these criteria.
• 12:25Adding up to a scale in their
• 12:29classified Childs AB or C.
• 12:31In more recent years,
• 12:33particularly relating the transplant arena,
• 12:36we've adopted the MELD classification so
• 12:39called model for in stage liver disease.
• 12:42The MELD score is less subjective,
• 12:45it is there's no.
• 12:48Wrote clinical assessment.
• 12:49It relies on 3 lab values,
• 12:53creatinine,
• 12:53bilirubin and INR.
• 12:55Anna calculation and is used and is
• 12:58used predominantly as a risk predictor
• 13:01in a mortality predictor for patients
• 13:05awaiting liver transplantation.
• 13:07Both of these indices.
• 13:11Provide somewhat different but very accurate.
• 13:17Guides for predicting complications
• 13:20and mortality for liver surgery in
• 13:23the setting of sarot SIS.
• 13:25So if you compare them again,
• 13:28as I indicated this, this is actually.
• 13:32Prediction outcomes based on these
• 13:35classifications after replacement of a
• 13:37tips device that transjugular prophetic
• 13:40portal systemic shunt for ascites,
• 13:43both for patients stratified for child Pugh
• 13:47score as well as meld above or less than 18.
• 13:52And you can see that you know there
• 13:56these are different cut offs,
• 13:59but they're both quite.
• 14:02Predictive of outcome.
• 14:04You actually compare them.
• 14:06At least this group did,
• 14:08and there you know they're very similar.
• 14:12The area under the receiver operator
• 14:15Curve is essentially equivalent,
• 14:17so although one is more clinical,
• 14:19one is more strictly lab based.
• 14:22They're both very useful and I find them
• 14:27somewhat overlapping ways to assess
• 14:30risk and underlying liver function.
• 14:33So let's turn for a minute
• 14:36to liver transplant,
• 14:37because this discussion would not
• 14:40be complete without mentioning the
• 14:42profound importance of evaluating
• 14:44patients for liver transplant candidacy.
• 14:47And having that in the background in
• 14:51and preparing them in moving them
• 14:54towards transplant and effective way,
• 14:57if they are candidates.
• 14:59So the the I think the key.
• 15:04Data from the literature is the so
• 15:07called Milan study that established the
• 15:10Milan criteria which was published in 1996.
• 15:13This really established transplant as
• 15:15the gold standard for patients with
• 15:18significant underlying liver disease
• 15:20related to cirrhosis and limited.
• 15:23HCC, Milan criteria include patients
• 15:25who have one tumor that is.
• 15:29Equal or lesser than 5 centimeters
• 15:32in diameter,
• 15:33or three or fewer tumors,
• 15:35all equal to or lesser
• 15:38less than 3 centimeters.
• 15:40Patients who fit within that criteria
• 15:43enjoy excellent post transplant survival,
• 15:46ranging around 70 to 75%.
• 15:51So even though the focus of this
• 15:53topic is is reception specifically,
• 15:56it is important to understand that
• 15:58transplant in many ways remains
• 16:00the optimal treatment for patients
• 16:02with limited HCC and cirrhosis.
• 16:04For all these reasons,
• 16:06patients have an excellent survival.
• 16:08Of course, there's nothing like
• 16:10a transplant to treat their
• 16:12underlying liver failure and.
• 16:14One of the shining lights here is that
• 16:18living donation does hold future promise
• 16:22for increasing organ availability.
• 16:24Challenges of course.
• 16:26Our organ availability is limited.
• 16:29Transplant post transplant care with
• 16:32person intensive fault and support.
• 16:35And we do have.
• 16:37We have learned that extended criteria
• 16:39are possible and may allow selective
• 16:43increase in eligibility for patients
• 16:46who downstage During the course of
• 16:49aggressive pre transplant therapies.
• 16:53Before we switch to the kind of
• 16:56evaluation of patients for reception,
• 16:58I think one of the things that
• 17:00is unique about HTC that is
• 17:03really important to understand,
• 17:05and I spend a lot of time talking
• 17:07to my residence about this,
• 17:10is that these tumors love to invade
• 17:12the portal venous system and that.
• 17:15You can see that radiographically
• 17:17as expensive,
• 17:18bulky thrombus is probably in acute thrombus.
• 17:21This is a more chronic thrombus and.
• 17:25The thrombus maybe tumor itself,
• 17:27or a mixture to Marie plot.
• 17:31It is in some ways the cynic Winona,
• 17:35this disease.
• 17:36Acute thrombosis may cause abrupt liver
• 17:39decompensation more chronic thrombosis
• 17:41like this patient often results in
• 17:43liver atrophy in the affected lobar
• 17:46segment with compens atory hypertrophy,
• 17:49and you're seeing that in the
• 17:51left liver in this patient who
• 17:54has a right portal vein thrombus.
• 17:58This is clearly a marker of
• 18:00high risk disease.
• 18:02Often these patients you need
• 18:04to look for lung lesions.
• 18:06That's going to be the next sighted disease,
• 18:10but in some ways we as surgeons can
• 18:12exploit this atrophy and hypertrophy
• 18:15for reception in selected candidates.
• 18:21So as we start to think about how do we
• 18:25choose patience for potential reception?
• 18:30We need to talk about the Barcelona
• 18:33Clinic liver Cancer staging system.
• 18:35The BCLC, as we often call it, there are
• 18:39a variety of of other staging systems.
• 18:43But I think most of us who do
• 18:46this work on a weekly basis,
• 18:49relying on the Barcelona system,
• 18:51kind of as our principle go to
• 18:54in the decision-making process.
• 18:56It's not perfect,
• 18:57but I think it's clinically very useful,
• 19:00so stage A patients or patients with
• 19:04early HCC, relatively small lesions,
• 19:06or a few single lesions.
• 19:09And these A1 patients are.
• 19:10This is really the group we want to operate.
• 19:13No portal hypertension.
• 19:14Normal billirubin, essentially no sarot sis.
• 19:17As we go up and stage,
• 19:19the patients tend to get some
• 19:22degree of liver disease.
• 19:24They may have portal hypertension
• 19:26or may they maybe have mild.
• 19:29Disease according to Child
• 19:31Pugh classifications,
• 19:32as we get into stage B2 mercies
• 19:36or larger tumors,
• 19:38but this stage B classification
• 19:41includes a variety of severity
• 19:44in the liver disease stage,
• 19:46sees advanced cancer and state Steve.
• 19:49This is, of course in stage disease.
• 19:56So. Is HPB surgeons.
• 20:00We are trying to extract as much
• 20:03information as we can to make
• 20:06safe decisions about reception.
• 20:09And there is a real kind of diversity
• 20:12of approaches between the Western
• 20:15western surgeons in in the Asians.
• 20:18Surgeons in China and Japan
• 20:20often rely on in design,
• 20:22and green retention is a kind of a
• 20:26biologic measure of liver function.
• 20:29Signing in green clearance seems to be
• 20:31less useful in our Western patients,
• 20:34although she centers use it,
• 20:36it seems to be more effective in this
• 20:39group of patients with hep B related disease.
• 20:43So there's a disparity in the usage.
• 20:46We in the western world tend
• 20:48to use a cluster of of indices
• 20:51to help us make decisions,
• 20:53including serum bilirubin and the
• 20:55presence or absence of clinically
• 20:57significant portal hypertension.
• 20:58Well, what's clinically significant?
• 21:00Portal hypertension?
• 21:01Well, we look at a number of things.
• 21:04You look at the presence or absence
• 21:06of splenomegaly thrombocytopenia,
• 21:08and we can get a an actual
• 21:10quantitative measure using wedge
• 21:11product vein pressure gradients,
• 21:13and I'll talk about that more in a minute.
• 21:17And in some cases we turned to actual
• 21:21histopathologic analysis using liver biopsy.
• 21:25Um, you know this.
• 21:27In designing green clearance is
• 21:30one of the reasons we don't this.
• 21:33This graphic illustrates the challenge
• 21:35with it in a western population,
• 21:39there is a broad distribution of.
• 21:42Severity scores with overlapping
• 21:44in designing green clearance.
• 21:46So it it's it's less useful clinically.
• 21:51One of the things that we do use a
• 21:54lot is simple CT or MRI assessment.
• 21:58Patients like this with bulky big
• 22:01clearcut verisys in a big spleen.
• 22:04We know we're unlikely to
• 22:07be surgical candidates.
• 22:08Another example of significant upper
• 22:11abdominal variceal development.
• 22:13So what are my favorite measures?
• 22:16In another reason that we really rely
• 22:20on a multidisciplinary assessment is
• 22:22the use of Patrick Kane wedge pressure.
• 22:26This is a procedure that the interventional
• 22:30radiologists are quite expert at.
• 22:32It involves catheter placed
• 22:34through the vena cava,
• 22:36usually through transjugular approach,
• 22:38and the catheter is directed out
• 22:41through the paddock vein wedge.
• 22:44And a reading is taken and it's expressed
• 22:47as a gradient in reference to the SVC.
• 22:50Anything greater than 10 millimeters of
• 22:53Mercury represents what we would consider
• 22:56clinically significant portal hypertension.
• 22:58The data for that is really from a
• 23:02classic paper from the Barcelona group,
• 23:05Jordi Bruin colleagues that was
• 23:08published in many years ago now,
• 23:11but they looked at the outcome of
• 23:14of patients after liver surgery.
• 23:17And compared their preoperative
• 23:19paddock vein pressure gradient
• 23:21patients who underwent,
• 23:23went to surgery with a paddock vein,
• 23:28pressure less than 10 generally did
• 23:31very well without any decompensation.
• 23:34There were a couple who were
• 23:38higher but most did.
• 23:40Did quite well with his lower group
• 23:44patients who decompensated almost all.
• 23:46Virtually all have these higher
• 23:49preoperative FedEx thing wage pressures
• 23:52so that measurement is a is really
• 23:55a critical piece of information.
• 23:57For for us surgeons,
• 23:59as we think about taking these
• 24:01patients in the operating room.
• 24:03The other thing that can be done at
• 24:06the same time as phatic pain wedge
• 24:09pressures is this transjugular liver biopsy.
• 24:12It's minimally invasive.
• 24:13A biopsy instrument can be guided
• 24:16into the liver parenchyma through it.
• 24:19A transjugular approach in a small
• 24:21tissue sample taken that can help us
• 24:24grade the degree of fibrosis or cirrhosis,
• 24:27which will also help with decisions.
• 24:30So overall, as we think about our approach.
• 24:34Surgically are the treatment
• 24:35really is driven by stage?
• 24:38Know this early stage group of
• 24:40patients we consider both for
• 24:42liver transplant in reception.
• 24:44Portal pressures are key here.
• 24:47Patients have normal porting pressures.
• 24:49Early stage disease can be
• 24:52treated with reception.
• 24:53Increased pressures need to be evaluated
• 24:56for transplantation or ablation.
• 25:02So to pull it all together,
• 25:05the people that I'm looking for his potential
• 25:07candidates are patients without cirrhosis.
• 25:09Inhuma major hepat Ectomy can be performed
• 25:12without morbidity and I will even operate
• 25:15on patients with significant with large
• 25:17tumors in this group without cirrhosis.
• 25:19These are folks who will tolerate a major
• 25:22headache ectomy patients with compensated
• 25:24cirrhosis are much more difficult,
• 25:26the decision-making is more difficult.
• 25:28These are this is a group you have
• 25:31to collect all this information.
• 25:33In the operative,
• 25:34planning is more difficult.
• 25:35They generally will not tolerate
• 25:37a major help detect me.
• 25:38You have to be looking at a segmented
• 25:41happy talk to me or an ablation.
• 25:43I'm not going to spend a lot of time
• 25:45talking about ablation in this talk,
• 25:48but it's another important
• 25:49tool in our armamentarium.
• 25:52So. And our multidisciplinary formats.
• 25:55We're looking at all of these things,
• 25:57severity of liver disease through child Pugh,
• 26:00Mail portal, hypertension, Histology.
• 26:01Then we assess the extent of disease,
• 26:03size of lesions number, vaster invasions,
• 26:05as well as all these other factors that
• 26:08we think about surgically comorbidities.
• 26:10Do they have heart disease,
• 26:12lung disease, or kidney disease,
• 26:13as well as the size of the liver remnant?
• 26:19So. As we pull these this information
• 26:22together, we wind up really getting
• 26:24what I would describe as this multi
• 26:27parameter assessment for respectability,
• 26:29and I won't walk through this all,
• 26:31but you can see that really it's a pretty
• 26:34small group who are really low risk.
• 26:37These are patients who have no portal
• 26:40hypertension in minor have to talk to me.
• 26:43It's important to understand that in this
• 26:46low risk of group group of patients,
• 26:49liver resection is very safe.
• 26:51Liver related mortality less than 5%.
• 26:54As soon as you get up into intermediate risk,
• 26:58we're looking at, you know,
• 27:00pushing a 30% risk of decompensation
• 27:02close to 10% mortality.
• 27:04High risk group, greater than a
• 27:0730% risk of decompensation Anna.
• 27:09Significant risk of surgical mortality.
• 27:11So all of this kind of accuracy.
• 27:14Indecision making is really
• 27:17critical for safe patient outcomes.
• 27:21So how do we do this?
• 27:24Well, I probably should just use Mario
• 27:26slide with this surgical decision,
• 27:28making it is more than just the surgeons.
• 27:31It takes a team or in his words
• 27:34it takes a village.
• 27:36You know,
• 27:37and I cannot tell you over the years,
• 27:40how many times I say HPB surgeon
• 27:43have been rained in in my surgical
• 27:46enthusiasm by one of my colleagues
• 27:48who points out some other pieces
• 27:51of the patients history or biology
• 27:53that would make surgery unsafe.
• 27:55And, you know,
• 27:57that's where we all get together
• 27:59in our liver tumor conference.
• 28:01Hepatology IR pathology, medical oncology,
• 28:03thinking about alternative treatments
• 28:05are body image Ng colleagues or.
• 28:07Very helpful in pointing out.
• 28:10The extent of the disease,
• 28:12potentially non or extra paddock
• 28:14sites of disease.
• 28:16Other things that will be deal
• 28:18Breakers and then.
• 28:20All of the surgical.
• 28:22Teens need to be involved.
• 28:25Transplant surgeons and surgical
• 28:27oncologist both bring kind of
• 28:29interdependent overlapping
• 28:30expertise to the table and caring
• 28:32for this group of patients.
• 28:36So I'm going to turn for minute shift
• 28:39gears and talk about surgical technique.
• 28:42So these are the classic
• 28:44major hepat ectomy operations.
• 28:46You know, these are the classical
• 28:48operations that originally described
• 28:50his liver surgery was developed.
• 28:52You know this is right now
• 28:54protect me left at protect me.
• 28:57Extended right hip protect me or
• 28:59left lateral segment Or's left
• 29:01lateral section ectomy and you know
• 29:03these operations are really great
• 29:05for patients who are non cirrhotic,
• 29:08have larger tumors,
• 29:09but as you can tell many of them.
• 29:12Involve sacrifices of a major of
• 29:15volume of functioning liver and anyone
• 29:17any patient who has any degree of
• 29:19liver disease will not tolerate these
• 29:22things with the exception perhaps
• 29:24of the left lateral section ectomy.
• 29:27So a key for liver surgeons is
• 29:30understanding hepatic segmental anatomy.
• 29:31This was originally described by
• 29:33the French anatomist Cloud Kanade.
• 29:35There are eight segments in the liver.
• 29:38The caudate,
• 29:39you know two and three on the left
• 29:42lateral segment for left medial
• 29:44567 and eight on the right side,
• 29:47and it's critical to understand that
• 29:49we can mix and match and tailor our
• 29:52operations very precisely based
• 29:54on this segmental anatomy.
• 29:56So as we think about segmental
• 29:59liver resection for small HCC
• 30:00understanding those segments gives
• 30:02us a great ability to to do again.
• 30:05Taylor or Target the extent of
• 30:07the operation to the the size
• 30:09and location of the disease.
• 30:11This is a perfectly in the posterior
• 30:14sector which would be for section in
• 30:16segment six and seven poster sector ectomy.
• 30:19These are segmental resection from
• 30:21the right side and the left side of
• 30:24liver segment through segment 2.
• 30:27Now,
• 30:27the other reason that understanding
• 30:31segmental anatomy is important is for.
• 30:34The technical element of Disease Control.
• 30:37These portal venous branches are a
• 30:40key pathway for dissemination of tumor
• 30:43cells and can be contaminated by tumor cells.
• 30:47So when we're doing parenchymal
• 30:49sparing receptions,
• 30:50how we conduct that reception is in
• 30:53relation to the portal venous branch serving.
• 30:57That segment is critical.
• 30:59This approach is ideal with a
• 31:01complete resection of the involved.
• 31:04A portal vein this beta be reception
• 31:07would encompass the tumor,
• 31:09but not as much portal vein and
• 31:12would put the patient at a higher
• 31:15risk for local recurrence.
• 31:17So patient selection is important,
• 31:20but technicalities are important as well.
• 31:24Now let's talk for a minute about
• 31:27the future liver remnant.
• 31:29What we know from liver surgery is
• 31:32that the size of the remnant is a
• 31:36critical predictor of postoperative outcome.
• 31:39Patients who have,
• 31:40in healthy patients who have a
• 31:43functional liver remnant of less than 20%.
• 31:46We have a very high incidence of
• 31:50postoperative complications and
• 31:51FL are of greater than 20%.
• 31:53Generally patients do very well now.
• 31:55This is in healthy livers.
• 31:57I would say that FLR is 40 to 50% in.
• 32:01Anyone with any underlying liver disease.
• 32:06Um? Portal vein Embolization is a
• 32:09key technique that we use David
• 32:12made off is a world expert in this.
• 32:16He is really built,
• 32:18his career among other things and and
• 32:21honing and refining this technique.
• 32:23So I'm not going to pretend to be the
• 32:27expert on this other than share that.
• 32:31As liver surgeons,
• 32:32this is our very best friend because
• 32:35this technique involves interruption
• 32:37of the portal venous flow to the
• 32:40affected side of the liver and allows
• 32:43hypertrophic growth which allows us
• 32:46to respect the contralateral side.
• 32:48You know this is a classic example
• 32:51of a pre operative left lateral
• 32:53segment which would have been a 14%
• 32:56small remnant froze up to 21% after
• 32:59preoperative Puerto venous embolization.
• 33:00This is data in a from an MD Anderson
• 33:03paper that David was involved with.
• 33:06I suspect he'll show Shell share
• 33:09more details when he gives his
• 33:12see me in a month or so.
• 33:15So, um,
• 33:16the French are actually have done
• 33:19nice work with this in cirrhotics or.
• 33:23PVD for patients with HCC and this is
• 33:26a relatively small series from one
• 33:28of the groups in Paris that show that
• 33:32although between these two groups,
• 33:34the volume after Pve was not
• 33:36that much greater,
• 33:37but the incidence of liver failure
• 33:40was significantly less and the stay
• 33:43in the ICU and hospital was less so.
• 33:45If you were going to do a major help
• 33:49protect me in a patient with any
• 33:52degree of underlying liver disease.
• 33:54A PV is a critical. Potential adjunct.
• 34:01The other thing that has come
• 34:04forward in recent years is the
• 34:07idea of radiation lobectomy.
• 34:09Again,
• 34:10this is a technique that our IR
• 34:13team is extraordinarily adept at.
• 34:16It involves treating the tumor
• 34:18as well as the involved side of
• 34:22the liver with Y-90 microspheres.
• 34:25This is a pre operative set of images.
• 34:29Actually I'm sorry preoperative
• 34:31up pretreatments up here post
• 34:34treatment down here it shrinks the
• 34:37liver and treats the tumor.
• 34:40So that as the the affected side of liver
• 34:43atrophy's and the disease is treated,
• 34:46the contralateral side of the
• 34:48liver hyper hypertrophy's,
• 34:49which eventually allows a reception
• 34:52of the affected side of the liver with
• 34:56this nice large left liver remnant.
• 34:58No,
• 34:59the the one of the things that's really
• 35:02exciting about radiation lobectomy
• 35:03is that it allows the tumor to be
• 35:06treated with the radiation well,
• 35:09the well the the atrophy is occurring,
• 35:11and if necessary,
• 35:13portal vein embolization can
• 35:14be added on top of it.
• 35:16I really like this technique in
• 35:18bulky tumors and in a patient
• 35:21where you may be concerned about
• 35:23occult metastatic disease.
• 35:25It gives us this window to watch them
• 35:27for awhile before committing to surgery.
• 35:33So I will share that I think one
• 35:35of the greatest steps forward in
• 35:37the past 15 years or so is the.
• 35:40Application of minimally invasive
• 35:42surgical techniques deliver surgery,
• 35:45and this has been a continuous
• 35:48evolution in the early 90s.
• 35:51Surgeons first Gabaldon small wedge.
• 35:54Resections of the first major hit
• 35:57Ectomy was reported in the mid 90s,
• 36:00and this was a pretty crude operation
• 36:03that relied a lot on surgical
• 36:06staplers and over the years,
• 36:09the our approach to laughter
• 36:11scopic attacked me is improved.
• 36:13We've adapted many of the open techniques,
• 36:17including Pringle maneuver techniques
• 36:19of dividing liver pouring command.
• 36:21So that.
• 36:22We've developed standards standards
• 36:24of practice and increasingly
• 36:27sophisticated anterolateral receptions
• 36:29and subsegmental receptions,
• 36:31and even in some centres,
• 36:34laparoscopic live donor operations.
• 36:39So this actually gives a pretty good
• 36:43picture of what's happened over
• 36:45the years since the turn of the.
• 36:49Millennium with a kind of a slow
• 36:51and this is this is data from some
• 36:55European centres but I think this is
• 36:58quite reflective of what's gone on
• 37:01in large centers around the world.
• 37:03Kind of as a decrease,
• 37:06steady decrease in open liver surgery
• 37:08and slow but progressive increase in
• 37:11and minimally invasive procedures.
• 37:13Now I don't think any.
• 37:15I I'm certainly not,
• 37:17and I don't think any experience
• 37:20HPB surgeon would say that open
• 37:23liver surgery should go away.
• 37:25There are too many complex.
• 37:28Situations that I think patients
• 37:30are best served with open surgery,
• 37:32but clearly this has been developed
• 37:35and embraced around the world.
• 37:37And over this time,
• 37:39many of the early operations
• 37:41were small wedges.
• 37:43Those of kind of drop down,
• 37:45and it's a steady increase in major
• 37:48protect knees and an resections in
• 37:51the posterior superior segments which
• 37:53are much more technically complicated
• 37:56because of their location and deliver.
• 37:59So laparoscopic appendectomy 20 and 2021.
• 38:02I think we can say is safe.
• 38:06Um, you know,
• 38:07like everything,
• 38:07it has to be patient enough to
• 38:10be selected carefully.
• 38:11I have not gone through all the
• 38:14data in this for the sake of time,
• 38:18but it's Uncle logically appears to be
• 38:20equivalent to open operations again.
• 38:23Selected cases there are better fits
• 38:25in hospital stay and recovery cost
• 38:27benefit analysis suggests significant
• 38:29value for appropriately selected patients.
• 38:32There are limitations with
• 38:34non anatomical sections,
• 38:35parenchymal, scarring sections,
• 38:36bleeding control,
• 38:37and biliary reconstruction
• 38:38is can be difficult with the
• 38:41laparoscopic instrumentation.
• 38:43So what next?
• 38:44Many of us are quite excited in doing
• 38:47robotic surgery of I think this is
• 38:51a rapidly developing technology.
• 38:54The Davinci System was introduced
• 38:56around 2000.
• 38:57Appear to Julia Naughty first
• 38:59did the first protect me with
• 39:02the robotic platform in 2003.
• 39:04This has expanded internationally.
• 39:06Now the major focus of robotic
• 39:08surgery really has been urology
• 39:11gynecology and a liver surgery
• 39:13is relatively late in this,
• 39:15but many of us are embracing it
• 39:17and are excited about it and
• 39:20feels that it brings real value.
• 39:23The the unique elements of the robotic
• 39:26platform are the 3D stereoscopic.
• 39:28Vision and the end of risk
• 39:31functionality of the instrumentation
• 39:33provides a degree of of dexterity and
• 39:37flexibility with surgical maneuvers
• 39:39inside the body that is just.
• 39:42At least for me,
• 39:43most of us very difficult to
• 39:45duplicate using straight stick
• 39:47laparoscopic instruments do precise
• 39:50suturing difficult locations.
• 39:52The dual console that you're seeing
• 39:54here is great for instruction
• 39:56and the economic.
• 39:58The ergonomics tend to be more favorable.
• 40:03Let's see, these are pictures I took in our
• 40:06own operating room a couple of weeks ago.
• 40:09This is actually a patient who have
• 40:11robotic left lateral segment resection.
• 40:13This is kind of the setup
• 40:15we've got the for robotic arms.
• 40:18We still have one of the
• 40:20instruments in place.
• 40:21This is an assist port that allows us to
• 40:24pass additional instruments and sutures
• 40:26in the abdomen and this is kind of just
• 40:30as we're closing all of the incisions.
• 40:32These are for small incisions across the
• 40:35abdomen and this is about a 3 centimeter
• 40:38extraction port right below the umbilicus.
• 40:40Through which we removed the specimen.
• 40:43Patient went home in two days.
• 40:47So lots of discussion around the
• 40:49country robotic laparoscopic,
• 40:50you know, like everything in surgery,
• 40:53this is a point of surgeons
• 40:56love to debate back and forth.
• 40:58There are relatively few comparisons.
• 41:00This comparison study was done
• 41:03at the University of Pittsburgh
• 41:05a number of years ago,
• 41:07and I think what it shows is that.
• 41:10The robotic cases in this study
• 41:15were took longer.
• 41:17Application rates bloodloss
• 41:19outcomes were essentially the same,
• 41:21but more cases were completed completely.
• 41:24Minimally invasive, Lee,
• 41:26using the robotic platform.
• 41:28Many of these laparoscopic cases required
• 41:32a utility incision or hand port so.
• 41:35I think there are merits to both approaches.
• 41:39Um, I have found in my own practice.
• 41:43As this author points out,
• 41:45the robotic approach may facilitate
• 41:47parenchymal sparing receptions,
• 41:48particularly in these upper
• 41:50posterior segments,
• 41:51posters appear segments that you can
• 41:54get to it to operate on with the robot,
• 41:58which is hard.
• 41:59Lapre Scopic Lee in this series.
• 42:02Over half the cases the robotic series
• 42:04work in those difficult segments.
• 42:09The other area where I find the robotic
• 42:12helpful is anatomically complicated
• 42:14procedures that require a lot of careful
• 42:18enteropathic dissection and control the
• 42:21paddock veins and precise stapling.
• 42:23This paper was a nice report of
• 42:26outcomes in complex cases of left
• 42:29lateral section ectomy where the
• 42:31disease is approaching him from the
• 42:34veins and they compared robotic left
• 42:37lateral segment with left lateral
• 42:40laparoscopic left lateral segment.
• 42:42Um, you know these?
• 42:44This group does.
• 42:46Note that the robotic cases
• 42:48were more expensive,
• 42:50but when the procedures got complicated,
• 42:53the robot really seemed to provide
• 42:56benefit with reduced blood
• 42:58loss and better length of stay.
• 43:03So as you think about the
• 43:05cost of the value proposition,
• 43:08the way the cost of these procedures is
• 43:10allocated and understood is really critical.
• 43:13And if you know this is one of
• 43:15those situations where the robotic
• 43:17instrumentation is more expensive,
• 43:19but if you can save anything on
• 43:22length of stay like this series
• 43:25did it more than pays for itself.
• 43:28So I'm going to switch gears and
• 43:30talk about a few key kind of subsets
• 43:33of patients that I think we really
• 43:36need to understand as we think
• 43:39about surgical candidates for HTC.
• 43:41One critical group is this group
• 43:43of patients with so called fibro
• 43:46lamellar parasailer carcinoma.
• 43:48This is is a disease that has a
• 43:51bimodal age distribution distribution,
• 43:53but it's predominantly young adults,
• 43:56although there's a smaller peak
• 43:58later in life.
• 43:59In the 60s has a male predominant's.
• 44:02Most of these patients have
• 44:04non cirrhotic livers.
• 44:05They often proves in his large bulky tumors
• 44:09and surgery is the primary treatment.
• 44:12It's easy to mistake these
• 44:14tumors for benign liver lesion,
• 44:16such as bulky FNH or adenoma.
• 44:18They are malignant,
• 44:20they're aggressive.
• 44:20They need to be respected,
• 44:23and they can have an excellent outcome
• 44:25with five year survival with reception,
• 44:28but they need to be appropriately
• 44:31diagnose and manage.
• 44:35So this actually is great story.
• 44:37This was like a young man who fell off
• 44:40a ladder who came to see me after he
• 44:44was seen in the emergency Department
• 44:47with some bruises and sprains.
• 44:50And they had an abdominal CT
• 44:53that showed this lesion and.
• 44:55You know, had no underlying liver disease.
• 44:59And this lesion, which is best
• 45:02seen in the venous phase, he went,
• 45:06not only was it seen in that phase, but.
• 45:10The other thing that was ominous
• 45:12about it is that the lower part
• 45:14lesion had this extra pet extension.
• 45:17So he went to the operating room and had a.
• 45:21Right have attacked me with a kind of a
• 45:24liberal reception of his retroperitoneal
• 45:26tissues to clear that extra pack extension.
• 45:30Big bulky specimen.
• 45:31He's a healthy guy.
• 45:33He did great post operatively.
• 45:35I followed him for about five years
• 45:38when I was in Portland and he did well.
• 45:41Never had a recurrence and then I
• 45:44kind of glossed him to follow up,
• 45:47but I think this is a perfect example of.
• 45:51Many of these patients can do well
• 45:53or even be cured with surgery.
• 45:55If you look for the disease.
• 45:58The other group of patients is agents
• 46:01of what I call our our our elders,
• 46:04HTC in the elderly.
• 46:06I think it needs to be reviewed
• 46:09is almost a different disease.
• 46:12This lady was sent to me about a month ago.
• 46:17Sweet Lady retired nurse.
• 46:19Spent most of her career at Saint Raves.
• 46:23She has a history of breast cancer
• 46:26and she was undergoing evaluation
• 46:28and was found to have a left
• 46:32lateral segment liver lesion.
• 46:34Had an MRI which showed the least
• 46:37that you see and there was concerned
• 46:40that this is metastatic breast cancer.
• 46:43It was biopsied and proved to be
• 46:46well differentiated HCC and she has
• 46:48undergone a robotic left lateral segment.
• 46:51Resection has done great.
• 46:53So this was a group of patients
• 46:56that I noticed in my prior work.
• 46:59And you know you're after.
• 47:01Euro would keep seeing these older
• 47:03folks from all over the Pacific
• 47:05Northwest showing up with his
• 47:06liver tumors without cirrhosis.
• 47:08Most of them were actually quite healthy,
• 47:11so I had one of our residents write
• 47:13this up with one of my partners.
• 47:16Doctor Mahlon are transplant
• 47:18group in Portland.
• 47:19And of our series,
• 47:21about 50 patients median
• 47:23age was 75 years old.
• 47:25Only 13% of them had
• 47:27underlying liver disease.
• 47:29And of that group,
• 47:30most of them had some
• 47:32alcoholic liver disease.
• 47:34Most of them were not viral.
• 47:36Hepatitis over 50% were treated
• 47:38with the major HEPA type to me,
• 47:41and they all enjoyed excellent
• 47:43five years survival.
• 47:44I think the interesting thing is,
• 47:46you know this is a group that's already
• 47:49selected themselves as being older
• 47:51without having a life limiting comorbidity.
• 47:54They get a liver tumor in.
• 47:56You know,
• 47:57I would contend they merit
• 47:59aggressive treatment.
• 48:00So just to summarize him wrap up.
• 48:05You know surgery is the predominant topic,
• 48:08but I'm really need to underscore
• 48:10the fact that transplant
• 48:11remains a central treatment.
• 48:13It is the ideal treatment for
• 48:16cirrhotic patients with disease
• 48:17within the Milan criteria.
• 48:19Reception is an excellent treatment
• 48:21for patients with limited disease
• 48:23and well preserved liver function.
• 48:25We talked a lot about multidisciplinary
• 48:28assessment and the importance of
• 48:30the absence of portal hypertension.
• 48:32We talked about Portal vein embolization,
• 48:34and radio ablation to augment
• 48:36the plan remnant.
• 48:37A discussion of minimally invasive
• 48:40surgical techniques and you know,
• 48:42I'll share that my bias has been
• 48:45moved to move my own practice
• 48:48towards the robotic platform.
• 48:50Although laparoscopic approaches or
• 48:52equally valid we talked about fibro
• 48:55lamellar disease and elderly HCC,
• 48:58so I'm going to wrap up there
• 49:01and say thank you to my partners
• 49:05in the liver tumor program.
• 49:07And Mario,
• 49:08for his leadership and Renee
• 49:10for helping us put this on and
• 49:12ask if there any questions.
• 49:15You thank you, Kevin.
• 49:17This was a fantastic talk.
• 49:20Just if if there are questions,
• 49:23please write them in the chat.
• 49:27I read them and.
• 49:30And coming will respond.
• 49:34I just, I mean, well,
• 49:37I want to thank you Kevin,
• 49:40not only for this is cool shows
• 49:42in the master sophisticated
• 49:44and newer surgical technology,
• 49:47but most of all,
• 49:49for your accent on how match that
• 49:52she's Young's how many decisions
• 49:55are into a surgical indication,
• 49:58how many eyes look at the same slide,
• 50:02the same data, and how much discussion.
• 50:05I would dare to say that this
• 50:09is as important as the scale
• 50:12of the of the surgeon.
• 50:18Well, what I will say is surgical
• 50:22technique and precision is very important.
• 50:25These are operations that really need.
• 50:28You need to be extremely meticulous,
• 50:31but the the patient selection of the
• 50:35decision-making is absolutely central,
• 50:37and that's where I could not agree more.
• 50:41You need a thoughtful team and.
• 50:45You need all these valuation techniques,
• 50:49particularly really good image Ng assessment
• 50:52of liver function clinical assessment
• 50:54by hepatologist wedge vein pressures.
• 50:57All all of that makes a difference.
• 51:01And that's why.
• 51:03Am centers such as ours are.
• 51:07We get good outcomes.
• 51:11A few questions, I'm gonna read it so.
• 51:18Doctor Chi is nice talk.
• 51:20Why not fold the results in ATC?
• 51:24How to treat it and?
• 51:28This is if I can answer
• 51:30that question for you.
• 51:32We wish to know that we
• 51:35are heavily investigating.
• 51:36And if you want to add something on this,
• 51:41but then is that there's another question
• 51:44here for satisfied can rate told Kevin
• 51:47in addition to radiation lobectomy.
• 51:49Any thoughts on using ethereal embolization?
• 51:53On bridge to protect me for ATC in large,
• 51:57bulky tumors.
• 52:00No such thanks for the question.
• 52:05You know I, I will say, I think it. It is.
• 52:10It's probably a very reasonable approach.
• 52:13In these large bulky tumors.
• 52:17I guess I will share that my experiences
• 52:21been more towards a Y-90 approach
• 52:25to radiation lobectomy approach.
• 52:28And maybe that was the bias of the IR group
• 52:32that I worked with closely in Portland.
• 52:36I do think there's some merit to it,
• 52:40because with the search or why 90,
• 52:43you're not going to get an acute necrosis
• 52:47or ischemic effect in a large tumor.
• 52:50It's a. It's a more gradual
• 52:53cytotoxic tumor killing effect.
• 52:55I think the patients tolerate
• 52:57it pretty well and then.
• 52:59Then you get this benefit of
• 53:02of liver atrophy as well,
• 53:04probably in a way that you don't
• 53:06get in the Saint to the same
• 53:09degree with with tastes you know.
• 53:12And I'll I will share.
• 53:14I've operated on at least
• 53:16two or three patients,
• 53:17six or eight months after radio ablation and.
• 53:21At least in one patient I can remember,
• 53:24there's no viable tumor left, so.
• 53:25I'm not sure they all
• 53:27eventually need surgery,
• 53:28but it's it's kind of.
• 53:31Hard to know till you've done it.
• 53:33Well, a couple more of a very
• 53:36sophisticated questions here.
• 53:37One is from Stacy.
• 53:39What do you think about the
• 53:41use of systemic therapy?
• 53:44They specifically immune therapy as
• 53:46a neoadjuvant therapy or argument
• 53:48therapy to prevent recurrence.
• 53:51Well, you know, I think.
• 53:55If you look at the history of.
• 53:59Multidisciplinary therapy in GI cancers.
• 54:01We're all moving in every disease,
• 54:04more twords neoadjuvant,
• 54:05and I think as we see the efficacy
• 54:09of treatment in HTC improving,
• 54:12we probably will get to that.
• 54:15I don't think we're there yet.
• 54:19Um? You know,
• 54:21so wrapping it just was not active enough.
• 54:25A tease. Oh Bev, maybe.
• 54:28And then I think,
• 54:29you know we'll probably get there with
• 54:31the postoperative adamant as well.
• 54:33I, I'll be honest,
• 54:35ACI's inspector trials underway
• 54:36that you are probably more
• 54:38acquainted with than I am.
• 54:41I just just. So remember that we
• 54:45do have atrial here that Stacy
• 54:48is the PII in to understand
• 54:52the answer to this question.
• 54:55So patient after surgery.
• 54:57Weather immunotherapy can can
• 54:59help preventing the recurrence.
• 55:02Because this is the problem with this
• 55:05cancer that recurs so Thomas Daddy.
• 55:08Is ask is congratulating for your talk,
• 55:10but interesting how many people with
• 55:13hepatitis C have been treated and
• 55:15there she knows is well compensated.
• 55:17They remain at risk.
• 55:19Do you favor surgery over
• 55:22ablation for smoke humor?
• 55:25You know, I think there are
• 55:28a couple of pieces in that.
• 55:31Question and my own.
• 55:36I think in this group of patients who are
• 55:39treated for hepatitis C at their risk.
• 55:42For developing, HTC does go down and
• 55:45I suspect that the hepatologist know
• 55:48those numbers much better than I do.
• 55:51What I can tell you is.
• 55:55Having operated on many patients over
• 55:57the years have had in a sustained
• 56:01virologic response to hep C treatment.
• 56:04They are much better surgical
• 56:06candidates or livers, or healthier.
• 56:09They tolerate surgery much more
• 56:12readily than either non treated
• 56:15patients or or patients who did
• 56:17not have some adequate response.
• 56:20I do think they remain at
• 56:23risk regarding ablation.
• 56:25You know I didn't spend a lot
• 56:27of time talking about ablation,
• 56:30but I think it is a very useful modality,
• 56:34either by the interventional radiologists
• 56:36or in some cases by surgeons,
• 56:39in difficult locations.
• 56:41And I think for small tumors it's a very.
• 56:45It's a very reasonable approach,
• 56:48and I think there's really abundant
• 56:50data that indicates that for,
• 56:53you know, for a 2 centimeter tumor,
• 56:56the outcome is going to be
• 56:58a essentially equivalent.
• 57:00So I I think it's a very
• 57:03reasonable alternative.
• 57:04Yeah,
• 57:05there's no patience is safe Surgical
• 57:07candidate and they have minimal disease.
• 57:09Name would like a reception.
• 57:11Sometimes there is satisfaction to
• 57:13having the disease out of their body,
• 57:16and I think it's reasonable.
• 57:18But then there's the fact of
• 57:20comorbidities too, so locks goes good,
• 57:23goes into the
• 57:24decision. We have three more questions to go,
• 57:27one from David Madoff.
• 57:30Only the only issue with additional
• 57:32back to me is that we do not know
• 57:34that kinetic growth rate of deliver.
• 57:37There is literature on PBE, an sequential
• 57:41days combined with PVA, hopefully.
• 57:43We have this figure out the sample and
• 57:47that's more common than thank you bye.
• 57:51And Sue Chan.
• 57:53From our pathology Department
• 57:54has to do this action matching.
• 57:57What is the minimum distance in
• 57:59millimeters of tumor to resection
• 58:01margin you prefer to call
• 58:03negative any data for that.
• 58:07Yeah. Yeah. There, I guess the way
• 58:14I would answer that question is
• 58:17that what I try to aim for is a.
• 58:20Is a centimeter margin.
• 58:23Often you know, depending on
• 58:27the location of the disease,
• 58:29in the proximity to other structures,
• 58:32that is not achievable.
• 58:34I think for most HCC and narrow
• 58:38margin of even a couple of
• 58:41minutes millimeters is adequate.
• 58:44Certainly a positive margin is a marker
• 58:48is associated with poor outcomes.
• 58:52But it is. I will say,
• 58:54it's difficult to know in
• 58:55some of these situations.
• 58:57Is is it the margin that's the driver,
• 59:00the outcome or the biology of the disease.
• 59:05So I I don't think that answers
• 59:08the question completely,
• 59:09but what I would say is like I,
• 59:12I tried to get a centimeter
• 59:14of margin and finally we have
• 59:16a question from John Kuntzman.
• 59:18Another of our surgical oncologist.
• 59:20I generally consider a section to be
• 59:23contraindicated in multifocal agency,
• 59:25even in non cirrhotic.
• 59:27Would you agree with that?
• 59:33Um?
• 59:38In general. Yes. Um? Although.
• 59:45John, you know as well as I do.
• 59:50There are no absolutes in surgical oncology.
• 59:53You know, I think some of that
• 59:56depends on the size, the location,
• 59:59the health of the patient, their age,
• 01:00:03the technicalities of the operation,
• 01:00:05kind of all those other intangibles that
• 01:00:09would that would go into the decision.
• 01:00:14Domino's rephrased
• 01:00:17It doesn't give you quarter here, So what are
• 01:00:21your exceptions?
• 01:00:22Oh, you know I would say in
• 01:00:25in someone who has two regions
• 01:00:28that are resectable safely with.
• 01:00:30Even a right hepat ectomy.
• 01:00:34You know, I would probably send the
• 01:00:36patient to Stacy and maybe have them have
• 01:00:38her treat them with systemic therapy.
• 01:00:41Kind of in an ad hoc way for you know,
• 01:00:44the question came up about neoadjuvant.
• 01:00:46Well, this is the case where yeah,
• 01:00:48I'd figure out a way to do some new agents.
• 01:00:51So you were watching the
• 01:00:53patient for a few months.
• 01:00:54Make sure that they don't have lung
• 01:00:57lesions or bone lesions, and if there
• 01:00:59was no new disease or progression.
• 01:01:01Yeah, it operate.
• 01:01:02I bet you would too.
• 01:01:05Alright, well
• 01:01:06thank you very much Kevin for
• 01:01:09taking time out of your very busy
• 01:01:13day to give and deliver this.
• 01:01:16This lessons about novelty and
• 01:01:18what is establishing in surgery.
• 01:01:21Ann and thank you to the audience
• 01:01:24and thank you to Renee for another
• 01:01:28outstanding organization of this.
• 01:01:30We will meet again in a month to here.
• 01:01:35David Mouth, yes I thank you again everybody.
• 01:01:39Thank you alright have a good one.