Young woman, with 5 cm hepatic adenoma without fat density with high seric levels of AFP. Preoperative biopsy? UP FRONT RESECTION ? Anatomic or no? Laparoscopic or open approach?
This lesion is central between 5/8 and 4 and this lesion involves middle hepatic vein.
Could you post the images? It may help to see the location, relation to vessels, aspect at CT and MRI. It will impact the decision.
The tumor is not deep located so a laparoscopic approach is not only feasible but also desirable. However, the correct diagnosis should be reached because elevation in alfafetoprotein may indicate a malignant liver adenoma. Before biopsy or even better surgery, I believe that a MRI with Primovist may be of help.
Due high level of AFP I think to perform an up front surgery by means of anatomic resection. In my humble opinion is a strong evidence of HCC. My fear is to spread this tumor if we chose performing biopsy by means puncture.
Several questions:
1. Does the patient have any underlying liver disease?
2. Is she using oral contraceptives?
3. Are there symptoms suggesting impending rupture? Or signs of intra-lesional bleeding?
Although the high AFP may sugggest HCC, in a non-cirrhotic liver (or at least a normal liver), the diagnosis of HCC requires confirmation through percutaneous liver biopsy.
This has definite therapeutic implications, as a HCC would require anatomic resection with at least a 1 cm margin. Given the anterior location a laparoscopic resection would be feasible, in experienced centers.
If the pathological diagnosis is adenoma, it should subtyped, as the beta-catenin exon 3 mutation type has a high risk of malignant transformation. If any other subtype, an adenoma with 5 cm could be observed after discontinuation of oral contraceptives, as long as there are no signs suggesting impending rupture. If no involution with suspension of oral contraceptives, then a enucleation would be in order and a laparoscopic approach is an excellent choice.
I totally disagree with ablation for an easily resectable tumour and would not recommend unless the patient has high surgical / anesthetic risk.
Finally, the case should be discussed in a multidisciplinary meeting, with hepatobiliary surgeons, radiologists, hepatologists and pathologists.
This patient doesn't use oral contraceptives besides that presents normal liver.
Nevertheless, as radioablation as resection are have been described for adenoma treatment, the lack of ecrs or even meta analyses comparing these methods for hepatic adenoma treatment leads to individualization of the therapeutic decision that can be based case by case in regarding what is the best method to perform . For us , though enucleation may be possible, we decline it due high risk of dissemination in a possible hcc that would be curable mainly in a young patient. Besides that enucleation in this scenario could lead a bleeding or still unless a difficult control of this bleeding with an unnecessary pringle maneuver. Let's me see, a healthy parenchyma regenerates well, the choice between anatomic or non anatomic resection in benign diseases is only tactical, then in this case, we guess that an anatomic resection would work well because it avoids as unnecessary bleeding or even seeding if hcc is present. We have performed since 2007 lap hepatectomy or enucleation, but in this specific case we are still thinking about this approach and we think that preoperative biopsy could be rassociated a unnecessary risks with little change of final conduct, because there is not fat in this adenoma. Thanks a lot for your attention once! Regards.
This tumor is too large for ablation. I agree with Sergio that a resection is the best approach. The technique of choice can be chosen at surgeons discretion. I would do it laparoscopically with free margins.
The best approach will be the one that the surgeon knows better. I am not sure that mesohepatectomy is the best choice. Maybe too much for this adenoma that we dont know yet if there is malignancy involved. Maybe a non anatomical resection can be easier and safer for the patient. However the intraoperative impression of the surgeon is essential. His feeling along with maybe frozen section biopsy may lead to a larger operation such as central hepatectomy.
Thanks a lot my partners, i like to hear other opinions aiming to decide the best choice of treatment for complex cases like this.
Probably it is 5cm hcc, even with a biopsy indicating adenona, I would still treat it like a hcc.
Besides, considering the location of the lesion the surgery for wouldnt be so different in both cases.
5cm adenoma, no contraceptives, high afp, i wouldn care about the biopsy.
Also, I would think in ablation, because it is important to have a definite diagnosy, not for the surgery, but for the follow up.
Probably it is 5cm hcc, even with a biopsy indicating adenona, I would still treat it like a hcc.
Besides, considering the location of the lesion, the surgery would be almost the same resection.
5cm adenoma, no contraceptives, high afp, i wouldnt care too much about the biopsy.
Also, I would not think in ablation, because it is important to have a definite diagnosy, not for the surgery, but for the follow up. The percutaneos biopsy doesnt give information about the whole lesion.
Adenomas can present small focuses of degenerated tissue into hcc
I totally disagree with ablation. This is a young woman with a potentially curable tumor that is clearly resectable. There is no underlying liver disease. This is clear indication for upfront surgery. If the surgeon has experience with minimally invasive approach, this should be my recommendation.
dear mr machado, i would not perform conventional single probe thermal ablation because there would be a high risk of risidual tumor...
but, would you really go for invasive resection in a young woman if you had an ablation technology available, which allows you in sano ablation ( with a sufficient safety margin in analogy to r0)???
I totally agree with Dr Machado.
Having the ablation technology available is not an indication to use it in this case.
The young age of the patient, the high afp levels, the size and the location of the tumor, al of this factors, are in favor of resection, if laparoscopic approach is available, better.
FEELINGS or REAL ARGUMENTS?
I am sorry but you could not convince me to go for invasive surgery, if minimal invasive stereotactic rfa can achieve the same local result...
PLEASE CHECK the similar discussion on researchgate:
https://www.researchgate.net/post/Would_you_perform_surgery_or_RFA_on_a_solitary_liver_metastasis_from_colorectal_cancer_segment
I have not seen any quality evidence that a young woman with a 5cm lesion, in contact with the middle hepatic vein, with high levels of afp in a non cirrhotic liver, and not sure about if it is a adenoma or hcc would benefit with with a ablative therapy instead of a mini invasive laparoscopic complete resection.
Besides the risk of comprimising oncological principles(most important), local ablative therapies dont give important histological information about tumor biology like vascular and biliar compromise by neoplasic cells,
This is not a question of feelings but to reach the best for the patient. Agustin is right when he stress the importance to obtain tissue for analysis. We understand that there is a role for RFA ablation in liver surgery, but maybe this is not the case. The same way that we cannot propose surgery for everybody, the same occurs for RFA. This is not the best case scenario for RFA, in my view. The discussion you mentioned before is a totally different case but I respect your position.
This discussion is good as to the patient as to the doctors. Let s me see neither resection is best choice nor rfa is best choice. Every case , we have to individualize in according expertise associated ever with the best evidence of the literature. This case is very difficult to decide, but i am favor a resection with wide margins. An anatomic resection as laparoscopic as open, that is indicated for an initial hcc stage a of BLCC Classification allows a curative scenario, mainly for a young patient like this.
Indeed, very interesting article "Stereotactic Radiofrequency Ablation of Unresectable Intrahe...". The key point is that those lesion were "unresectable"... , in this case you have a probable malignant lesion, easily resectable with curative intention.
I wouldnt risk HER chances of curation, only to avoid a laparoscopic resection.
I understand that you do not trust srfa because you are not familiar with this technique. the local recurrence rate after srfa with intraoperative image fusion for confirmation of sufficient ablation margin is at least equal or less than the r1/r2 rate after resection. therefore it would be an ethical problem to offer resection.
however if the first choice - stereotactic rfa - is not available i would recommend surgery.
Dear Bale, we are familiar with the RFA technique. Every technique, such as surgery, RFA etc, has their indications with advantages, disadvantages. Even if you have the best results in the world, still in this particular case, I would prefer surgery. Using your own words, if a oncologic surgeon with expertize with liver resection is not available I would recommend RFA. However, I personally know Sergio and he is more than capable to remove this tumor with R0.
dear dr machado
i fully agree with you.
one has to select the best method for the patient that is available in terms of outcome and complication rate. therefore in this setting (laparoscopic) resection performed by an experienced liver surgeon would also be my choice.
thermal ablation should only be considered, if the lesion can be completely removed (a0) with the same confidence as with surgical resection (r0). in this patient (tumor size / anatomical location) this is definitely not the case with conventional laparoscopic-, ultrasound- or CT- guided single probe RFA.
https://www.researchgate.net/post/Would_you_perform_surgery_or_RFA_on_a_solitary_liver_metastasis_from_colorectal_cancer_segment
Thanks a lot prof. Marcel and prof reto, amazing discussion.
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