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  • Author: Elin Sigurdson x
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Cletus A. Arciero and Elin R. Sigurdson

Hepatocellular carcinoma (HCC) is a major cause of cancer-related death worldwide. This disease can be treated through several surgical and nonsurgical approaches. Although the only curative options for patients with HCC are surgical (resection or transplantation), most patients unfortunately present with advanced neoplastic disease or experience the effects of chronic liver disease, making surgical resection implausible. Several additional options are available for treating this population. Ablative therapies such as percutaneous ethanol injection, cryotherapy, radiofrequency ablation, laser ablation, and microwave hyperthermic ablation can be used with varying degrees of success. Transarterial chemoembolization can be used in patients with advanced disease or advanced chronic liver disease that cannot be treated with resection or ablation. This article explores the various liver-directed therapies, including surgical resection, and defines morbidity, mortality, and survival for each.

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Leigh Selesner, Gabrielle Gauvin, Dorotea Mutabdzic, Eileen O’Halloran, Maxwell Kilcoyne, Kwan-Keat Ang, Jeffrey Farma, Elin Sigurdson and Sanjay Reddy

Introduction: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CS/HIPEC) has led to improved survival in select patients with peritoneal surface malignancies. Predicting the volume of disease and any unresectable disease is important for determining CS candidacy. Computed tomography (CT) scan is the preoperative assessment of choice, and diagnostic laparoscopy (DL) is also supported in the literature but has not been widely adopted. In this study, we report our experience comparing and evaluating the role of imaging and DL in the preoperative assessment of patients being considered for CS/HIPEC. Methods: Patients considered for CS/HIPEC at our tertiary cancer center between January 2012 and December 2017 were included. Diagnostic modality sensitivity and specificity were calculated by comparing findings on CT scan and DL to findings at the time of laparotomy and on final pathology. Specificity and sensitivity of the 2 modalities were compared using the McNemar Chi-square test. Results: Our analysis included 71 patients (60.5% male, mean age of 54.9) seen in consultation for CS/HIPEC. Primary cancer diagnosis was 57.7% colorectal cancer, 25.4% pseudomyxoma peritonei, 8.5% mesothelioma, and 8.5% adenocarcinoma of unknown primary. DL was done in 42.3% of patients (median time of 30 days between CT and DL) and an open procedure was done directly after CT in 39.4% (median interval time of 39 days). Findings of DL identified 70% as being unresectable and hence ineligible for HIPEC. The median interval time between 2 operations was 29 days (range, 16–42). When comparing diagnostic modalities to open surgery and final pathology, CT had a sensitivity and specificity of 48.2% and 76.4% and DL, 68.2% and 88.9%, respectively. DL was significantly more sensitive and specific than CT (χ2=5.54; P<.0186) at predicting ascites, small bowel, omental, liver, and lymph node involvement. Conclusion: Our results support the recommendation for performing DL prior to open exploration in patients considered for CS/HIPEC. In our cohort, DL was significantly more sensitive and specific than CT in predicting disease volume and distribution. While there is obviously greater risk to an invasive modality compared to non-invasive CT scan, routine performance of DL can potentially avoid laparotomy without CS/HIPEC in a large proportion of patients. These results will be used to inform the next phase of our study: a prospective clinical trial.

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Al B. Benson III, Thomas A. Abrams, Edgar Ben-Josef, P. Mark Bloomston, Jean F. Botha, Bryan M. Clary, Anne Covey, Steven A. Curley, Michael I. D'Angelica, Rene Davila, William D. Ensminger, John F. Gibbs, Daniel Laheru, Mokenge P. Malafa, Jorge Marrero, Steven G. Meranze, Sean J. Mulvihill, James O. Park, James A. Posey, Jasgit Sachdev, Riad Salem, Elin R. Sigurdson, Constantinos Sofocleous, Jean-Nicolas Vauthey, Alan P. Venook, Laura Williams Goff, Yun Yen and Andrew X. Zhu

Hepatobiliary Cancers Clinical Practice Guidelines in Oncology NCCN Categories of Evidence and Consensus Category 1: The recommendation is based on high-level evidence (e.g., randomized controlled trials) and there is uniform NCCN consensus. Category 2A: The recommendation is based on lower-level evidence and there is uniform NCCN consensus. Category 2B: The recommendation is based on lower-level evidence and there is nonuniform NCCN consensus (but no major disagreement). Category 3: The recommendation is based on any level of evidence but reflects major disagreement. All recommendations are category 2A unless otherwise noted. Clinical trials: The NCCN believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Overview Hepatobiliary cancers are highly lethal. In 2008, approximately 21,370 persons in the United States were estimated to be diagnosed with liver or intrahepatic bile duct cancer and 9520 with gallbladder cancer or other biliary tract cancer. Furthermore, approximately 18,410 deaths from liver or intrahepatic bile duct cancer and 3340 deaths from gallbladder cancer or other biliary tract cancer were estimated to occur.1 The types of hepatobiliary cancers covered in these guidelines include hepatocellular carcinoma (HCC), gallbladder cancer, intrahepatic cholangiocarcinoma, and extrahepatic cholangiocarcinoma. By definition, these guidelines cannot incorporate all possible clinical variations and are not intended to replace good clinical judgment or individualization of treatments. Although not explicitly stated at every decision point of the guidelines, patient participation in prospective clinical trials is the preferred option for treatment of hepatobiliary cancers. HCC Risk Factors and...
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Al B. Benson III, Michael I. D’Angelica, Thomas A. Abrams, Chandrakanth Are, P. Mark Bloomston, Daniel T. Chang, Bryan M. Clary, Anne M. Covey, William D. Ensminger, Renuka Iyer, R. Kate Kelley, David Linehan, Mokenge P. Malafa, Steven G. Meranze, James O. Park, Timothy Pawlik, James A. Posey, Courtney Scaife, Tracey Schefter, Elin R. Sigurdson, G. Gary Tian, Jean-Nicolas Vauthey, Alan P. Venook, Yun Yen, Andrew X. Zhu, Karin G. Hoffmann, Nicole R. McMillian and Hema Sundar

Hepatobiliary cancers include a spectrum of invasive carcinomas arising in the liver (hepatocellular carcinoma), gall bladder, and bile ducts (cholangiocarcinomas). Gallbladder cancer and cholangiocarcinomas are collectively known as biliary tract cancers. Gallbladder cancer is the most common and aggressive type of all the biliary tract cancers. Cholangiocarcinomas are diagnosed throughout the biliary tree and are typically classified as either intrahepatic or extrahepatic cholangiocarcinoma. Extrahepatic cholangiocarcinomas are more common than intrahepatic cholangiocarcinomas. This manuscript focuses on the clinical management of patients with gallbladder cancer and cholangiocarcinomas (intrahepatic and extrahepatic).