EASL-EORTC clinical practice guidelines : management of hepatocellular carcinoma

Background and objective The Atlanta classification of acute pancreatitis enabled standardised reporting of research and aided communication between clinicians. Deficiencies identified and improved understanding of the disease make a revision necessary. Methods A web-based consultation was undertaken in 2007 to ensure wide participation of pancreatologists. After an initial meeting, the Working Group sent a draft document to 11 national and international pancreatic associations. This working draft was forwarded to all members. Revisions were made in response to comments, and the web-based consultation was repeated three times. The final consensus was reviewed, and only statements based on published evidence were retained. Results The revised classification of acute pancreatitis identified two phases of the disease: early and late. Severity is classified as mild, moderate or severe. Mild acute pancreatitis, the most common form, has no organ failure, local or systemic complications and usually resolves in the first week. Moderately severe acute pancreatitis is defined by the presence of transient organ failure, local complications or exacerbation of co-morbid disease. Severe acute pancreatitis is defined by persistent organ failure, that is, organ failure >48 h. Local complications are peripancreatic fluid collections, pancreatic and peripancreatic necrosis (sterile or infected), pseudocyst and walled-off necrosis (sterile or infected). We present a standardised template for reporting CT images. Conclusions This international, web-based consensus provides clear definitions to classify acute pancreatitis using easily identified clinical and radiologic criteria. The wide consultation among pancreatologists to reach this consensus should encourage widespread adoption.

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Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus

background The effect of adjuvant treatment on survival in pancreatic cancer is unclear. We report the final results of the European Study Group for Pancreatic Cancer 1 Trial and update the interim results. methods In a multicenter trial using a two-by-two factorial design, we randomly assigned 73 patients with resected pancreatic ductal adenocarcinoma to treatment with chemoradiotherapy alone (20 Gy over a two-week period plus fluorouracil), 75 patients to chemotherapy alone (fluorouracil), 72 patients to both chemoradiotherapy and chemotherapy, and 69 patients to observation. results The analysis was based on 237 deaths among the 289 patients (82 percent) and a median follow-up of 47 months (interquartile range, 33 to 62). The estimated five-year survival rate was 10 percent among patients assigned to receive chemoradiotherapy and 20 percent among patients who did not receive chemoradiotherapy (P=0.05). The five-year survival rate was 21 percent among patients who received chemotherapy and 8 percent among patients who did not receive chemotherapy (P=0.009). The benefit of chemotherapy persisted after adjustment for major prognostic factors. conclusions Adjuvant chemotherapy has a significant survival benefit in patients with resected pancreatic cancer, whereas adjuvant chemoradiotherapy has a deleterious effect on survival.

https://pancreaticcanceraction.org/wp-content/uploads/2010/09/ESPAC1.pdf

A Randomized Trial of Chemoradiotherapy and Chemotherapy after Resection of Pancreatic Cancer

https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1002/hep.29913

Diagnosis, Staging, and Management of Hepatocellular Carcinoma: 2018 Practice Guidance by the American Association for the Study of Liver Diseases

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NCCN clinical practice guidelines in oncology: hepatobiliary cancers.

Background/aims There is a diversity of mucin-producing tumors of the pancreas, including benign adenoma, malignant intraductal papillary carcinoma and invasive papillary carcinoma. However, there has been little discussion of appropriate techniques for surgically treating these tumors. Methodology From August 1981 to December 1997, surgery was performed on 24 patients with mucin-producing pancreatic tumors (18 cases were malignant and 6 were benign). The surgical techniques which were used, the results of surgery, and the post-operative course of the patients are discussed. Results Surgical resection was possible in 23 patients and included: 4 cases of total pancreatectomy; 1 case of pancreaticoduodenectomy (Whipple's procedure); 1 case of Whipple's procedure with a transverse colectomy; 13 cases of pylorus-preserving pancreaticoduodenectomy (PPPD); 2 cases of duodenum-preserving pancreatic head resection (DPPHR); 1 case of resection of the posterior segment of the pancreas (posterior segmentectomy); and, 1 case of resection of the medial segment of the pancreas (medial segmentectomy). Surgical resection was also used for 17 (94.4%) of the 18 patients with malignant tumor. There were no fatalities during or immediately following surgery. One patient developed transient duodenal stenosis after DPPHR. The 5-year survival rate after surgical resection was 68.4% for the 17 patients with malignant tumor. Mucus leaked from the pancreatic duct into the operating field of 1 patient during pancreatectomy. This patient died 7 months after surgery from a tumor metastasis of the thoracic mediastinal lymph nodes and peritoneal seeding. This episode illustrates the high risk associated with leakage of pancreatic duct mucus into the operating field. The longest surviving patient, 13 years and 11 months after total pancreatectomy, has good health and shows no signs of recurrence. Conclusions The prognosis for surgically resectable mucin-producing pancreatic tumors is better than that for invasive pancreatic duct carcinoma. When treating mucin-producing pancreatic tumors surgically, techniques which allow preservation of pancreatic and gastroenteric functions should be selected when possible. These techniques include PPPD, DPPHR and pancreatic segmentectomy. A total pancreatectomy should only be selected in cases where cancer has invaded the entire pancreas (especially when cancer has invaded the duct within the pancreatic head, through the tail). It may also be used when residual cancer cells have been detected by intra-operative pathological examination at the distal stump of the pancreas. During surgery with any technique, leakage of pancreatic duct mucus into the operating field must be avoided.

Surgery for mucin-producing pancreatic tumor.

Background/purpose

The aim of this study is to evaluate a new scoring system, called the chronic liver dysfunction (CLD) score, for prediction of the surgical risk of partial hepatectomy in patients with chronic liver damage. Morbidity and mortality rates after gastroenterological surgery are high in patients with hepatic cirrhosis. Accordingly, it is very important to assess the surgical risk in such patients before surgery. Although the Child classification (or Child-Pugh score) has been a standard system, it did not always accurately predict patients at the risk of mortality after gastroenterological surgery, especially partial hepatectomy.



Methods

In 1985, we established a new system called the CLD score, reviewing the patients undergoing gastroenterological operations at one hospital. In the present study, we prospectively used the CLD score in 256 consecutive patients with chronic liver dysfunction who were treated surgically by partial hepatectomy, and investigated the usefulness of the CLD score concerning mortality. The results were compared with those of the Child-Pugh score (C-P score).



Results

After major hepatectomy, all the patients with CLD score exceeding 1.5 died of hepatic failure. After minor hepatectomy, all the patients with CLD score exceeding 2.5 died of hepatic failure. On the other hand, C-P score did not predict the outcome in these patients.



Conclusions

Compared with the C-P score, which was considered the gold standard scoring system for assessing surgical risk for patients with chronic liver dysfunction, our CLD score provides a more reliable assessment of the risk of partial hepatectomy.

https://onlinelibrary.wiley.com/doi/pdf/10.1007/s00534-004-0953-0

A scoring system for the assessment of the risk of mortality after partial hepatectomy in patients with chronic liver dysfunction.

Background/purpose
The origin of cholangiolocellular carcinoma (CoCC) is still controversial. To solve this problem, morphometric and immunohistochemical features of CoCC were examined.

/pdf/morphometric-and-immunohistochemical-study-of-49xpct2h72.pdf

Morphometric and immunohistochemical study of cholangiolocellular carcinoma: comparison with non-neoplastic cholangiole, interlobular duct and septal duct

Background Surgical results of patients with resected distal cholangiocarcinoma (DCC) were evaluated to elucidate prognostic impact of the type of preoperative biliary drainage (PBD). Methods Eighty-eight patients with resected DCC were stratified into two groups according to the type of PBD: the percutaneous transhepatic biliary drainage (PTBD) group (n = 25) and the endoscopic biliary drainage (EBD) group (n = 63). Results Overall 5-year survival rate of the patients in the PTBD group was poorer than in the EBD group (24% vs. 52%, P  = 0.020). On univariate analysis, PTBD, pancreatic invasion, perineural invasion, and lymph node involvement were significant prognostic factors for poor overall survival. On multivariate analysis, PTBD was the only significantly independent prognostic factor for poor overall survival. The incidence of liver metastasis was significantly higher in the PTBD group than in the EBD group (32.0% vs. 13.3%, P  = 0.034). Conclusions PTBD should be avoided as much as possible in patients with DCC since the patients who underwent PTBD had poorer overall survival and higher incidence of liver metastasis than those who underwent EBD.

Tadahiro Takada

Papers

Surgery for mucin-producing pancreatic tumor.

A scoring system for the assessment of the risk of mortality after partial hepatectomy in patients with chronic liver dysfunction.

Morphometric and immunohistochemical study of cholangiolocellular carcinoma: comparison with non-neoplastic cholangiole, interlobular duct and septal duct

Prognostic impact of type of preoperative biliary drainage in patients with distal cholangiocarcinoma

Aortic occlusion balloon catheter technique is useful for uncontrollable massive intraabdominal bleeding after hepato-pancreato-biliary surgery