The Application Of 3-dimensional Visualization The Diagnosis And Treatment Of Centrally Located Hepatocellular Carcinoma

Research BackgroundAsian countries account for nearly 78% of the roughly 600,000 cases of HCC (hepatocellular carcinoma) reported globally each year. The leading cause is chronic hepatitis B virus infection in Eastern Asia, including China, Hong Kong, Indonesia, Korea, and Taiwan. Chronic hepatitis B virus carriers in Asia account for the majority of the 3.6 billion all over the world. Liver cancer represents 6% and 9% of the global cancer incidence and mortality burden,respectively. Almost three quarters of the new cases occur in areas with low and medium human development;more than half of the global incidence and mortality is in China.Although opinions are widely divided on the treatment of HCC, surgery still dominates in the comprehensive treatment of liver cancer. It can provide opportunities for cure in some patients and can prolong the overall survival time of patients who have surgery.Because the central location of hepatocellular carcinoma can be tricky, it is traditionally resected by right lobectomy (segments V,VI, VII, and VIII), left lobectomy segments II, III, and IV, and extended right/left lobectomy.Nevertheless, if 60% to 80% of the liver parenchyma is removed, patients will suffer from a risk of significant blood loss and postoperative liver failure, especially for those with cirrhosis or poor preoperative liver function. One way to minimize the volume of the resected liver is to remove the central hepatic segments (Couinaud’s segments IVA, IVB, V, and VIII), and preserve the functional parenchyma to prevent postoperative liver failure.The first description of central (medial segmentectomy),or now mesohepatectomy, was reported in 1972.Currently, mesohepatectomy is a priority for the patients with centrally located hepatocellular carcinoma who have no cirrhosis and with normal liver function. Although mesohepatectomy retains more functional liver tissue, there are still risks of postoperative liver failure because of intraoperative blood loss and time spent controlling intraoperative blood flow, In addition, there may be bilateral damage to key structures, which inevitably has a negative effect on the residual liver function. Importantly, there are certain groups of patients who cannot tolerate mesohepatectomy because they have posthepatitic cirrhosis. In China,80% to 90% of liver cancer patients suffer from different degrees of posthepatitic cirrhosis,which require individualized operations to preserve more liver parenchyma.3-dimensional visualization is helpful to the individualized operation planning for centrally located hepatocellular carcinoma.As the 3-dimensional visualization has been applied in the diagnosis and treatment of Centrally Located Hepatocellular Carcinoma in our department for 10 years, we confirmed the effectiveness of 3-dimensional individualized operation planning by case-control study. In recent years, with the application of 3D printing and ICG-fluorescent imaging in in the diagnosis and treatment of Centrally Located Hepatocellular Carcinoma, the 3-dimensional visualized procedure for Centrally Located Hepatocellular Carcinoma was established. This retrospective study aimed to assess the effects of 3-dimensional visualization in the diagnosis and treatment of Centrally Located Hepatocellular Carcinoma.The application of 3-dimensional visualization in the operation planning for centrally located hepatocellular carcinomaPurpose:1. Concentrating on the involvement of resected segments and the anatomic location of tumors relative to the principal hepatic vascular structures, centrally located hepatocellular carcinoma was divided into 5 subtypes by a classification system based on liver anatomy and resection method.2. The application of 3-dimensional visualization in the operation planning for centrally located hepatocellular carcinoma.Methods:1.PatientsIn the Department of Hepatobiliary Surgery of Zhujiang Hospital, the medical records of 116 patients with centrally located hepatocellular carcinoma, who received curative liver resection from April 2006 to March 2014,were retrospectively analyzed.2. The technological process of surgery planning based on 3D reconstruction2.1. Enhanced CT scanning and CT scanning parameters setting. Data were collected by Philips Brilliance 256-MDCT scanner.2.2 Collecting 2D image data and storing data. The 2D images collected by Philips Brilliance 256-MDCT scanner with predefined scanning parameters were processed by MxliteView DICOM Viewer.2.3. Images segmentation and 3D reconstruction. The Medicallmage Three-Dimensional Visualization System (MI-3DVS, proprietary software developed by the authors [software copyright No.:2008SR18798].) allowed segmentation and 3D reconstruction of the CT images, in which thin-sliced CT data were imported into the software to facilitate their automatic registration.2.4.3-dimensional classification of hepatic vein,3-dimensional classification of portal vein,3-dimensional classification of hepatic artery2.5. Surgery planning based on a 3D reconstruction technique.The reconstructed models were exported as Standard Template Library files and imported to the Free Form Modeling System (SensAbleTechnologies, Inc), on which the spatial distribution of the anatomic structure, hepatic artery blood supply, types of hepatocellular carcinoma,and the variation of hepatic artery were all presented.2.6. Classification system for centrally located hepatocellular carcinoma based on 3D reconstructionConcentrating on the involvement of resected segments and the anatomic location of tumors relative to the principal hepatic vascular structures, centrally located hepatocellular carcinoma was divided into 5 subtypes by a classification system based on liver anatomy and resection method.Type ⅠThis type of hepatocellular carcinoma occupies the liver parenchyma of segments Ⅴ, Ⅷ,or both. They are characterized by their close proximity to or even direct violation of the adjacent portal vein. They do not adhere to or compress the right hepatic vein trunk.Complete excision of these lesions is required in the resection of segments Ⅴ, Ⅷ ± partial irregular resection of segment Ⅳ.Type ⅡThis type of hepatocellular carcinoma invades the liver parenchyma of segments IVa, IVb, or both. It is characterized by its close proximity to/or even direct violation of the left hepatic vein trunk, In addition, it does not adhere to or compress the left hepatic vein trunk. For these reasons, the solution is to completely resect segments Ⅳa, Ⅳb partial irregular resection of segments Ⅴ and Ⅷ. Complete excision of these lesions was required in the section of Ⅳa, Ⅳb ± partial irregular resection of segments Ⅴ and Ⅷ.Type ⅢThis type of hepatocellular carcinoma occupies the most liver parenchyma of segments Ⅳ,Ⅴ, and Ⅷ. These lesions are characterized by their wide and deep invasion of the parenchyma, or their close proximity to the middle hepatic vein. In addition, the liver function is not abnormal, so enough liver can be reserved. These lesions require mesohepatectomy (resection of segments Ⅳ, Ⅴ, and Ⅷ ± Ⅰ).Type ⅣThis type of hepatocellular carcinoma occupies themost liver parenchyma of segmentsⅤ, Ⅷ, and Ⅳ. The lesions are characterized by their close proximity to, or a direct violation of, the left/right portal vein trunk or the left/right hepatic vein. Liver function is not abnormal and enough liver can be reserved. These lesions require a traditional operative procedure including right lobectomy (segments Ⅴ, Ⅵ, Ⅶ, and Ⅷ), left lobectomy (segments Ⅱ,Ⅲ, and Ⅳ), and extended right/left lobectomy.Type ⅤAs shown in Figure 1E, this type of hepatocellular carcinoma occupies the superficial liver parenchyma of segments Ⅴ, Ⅷ, and Ⅳ. The lesions are characterized by not being close to either the portal branch or the hepatic vein. In this situation, irregular resection of liver parenchyma is an option.Result1.Patient demographics and clinical characteristicsThe 2 groups shared similarities in preoperative data.2. Surgery methods and intraoperative dataThe 2 groups were not different in terms of operative methods, intraoperative blood transfusion, and intraoperative blood loss. But group A had a slightly shorter operative time and a lower rate of hepatic inflow occlusion.3. Postoperative complications and clinical outcomesThere was no difference in the number of postoperative complications, while the patients of group B were more susceptible to Clavien III (needed procedural intervention),Clavien IV (needed ICU care), or Clavien V (death) complications (3.3% vs 14.3%; p= 0.048). The cases of bile leakage (1 in group A and 6 in group B)and intra-abdominal abscess (1 in group A and 5 in group B) were lower in group A than in group B, but not significantly. The patients who had all received major hepatectomy (extended hepatectomy or mesohepatectomy) were treated with full abdominal drainage. The 2 groups had a significant difference in the number of ascites (2 in group A and 8 in group B; p= 0.048).No significant differences were found in the 2 groups with respect to alanine aminotransferase, aspartate transaminase, or prothrombin time. What’s more, hemoglobin was lower in group A than in group B, but not significantly. Group B showed a significantly higher total bilirubin (23.2± 16.1 g/L vs 31.1± 24.1 g/L;p= 0.032) and a significantly lower albumin (29.3± 5.2 g/L vs 27.8± 7.9 g/L; p= 0.033).ConclusionAlthough the surgical strategy for centrally located HCC remains controversial, individualized hepatectomy may be a safer choice, especially when the preservation of liver function is critical for centrally located HCC patients. The findings of this study show that operation planning based on 3D reconstruction models may be a reasonable and effective method for treating selected patients with centrally located HCC.The application of 3-dimensional visualized procedure in the the diagnosis and treatment of Centrally Located Hepatocellular CarcinomaPurpose:1.The construction of the 3-dimensional visualized procedure in the the diagnosis and treatment of Centrally Located Hepatocellular Carcinoma2.The application of the 3-dimensional visualized procedure in the the diagnosis and treatment of Centrally Located Hepatocellular CarcinomaMethods:1.PatientsIn the Department of Hepatobiliary Surgery of Zhujiang Hospital, the medical records of 31 patients with centrally located hepatocellular carcinoma, who received curative liver resection from March 2013 to March 2016,were retrospectively analyzed.2.3-dimensional visualized operation planning for centrally located hepatocellular carcinoma2.1 Enhanced CT scanning and CT scanning parameters setting. The specific content is the same as mentioned in first part.2.2 3-dimensional classification of hepatic vein,3-dimensional classification of portal vein,3-dimensional classification of hepatic artery. The specific content is the same as mentioned in first part.2.3 Classification system for centrally located hepatocellular carcinoma based on 3D reconstruction. The specific content is the same as mentioned in first part.2.4 Surgery planning based on a 3D reconstruction technique. The specific content is the same as mentioned in first part.3.3D printing in the operation planning for centrally located hepatocellular carcinomaHow to construct the 3D printed model is the same as mentioned in next part. Real-time compare the 3D printed model with intraoperative condition, through adjust the 3D printed model to the proper anatomical position,the surgeon can rapidly identificate and locate the key parts, which provide intuitive navigation to the surgery. What’s more,the rapid location of tumors and transection line guarantee real-time guidance of important vessels separation and tumor resection.4. ICG-fluorescent imaging in the diagnosis and treatment of Centrally Located Hepatocellular CarcinomaFluorescent imaging using indocyanine green (ICG) has the potential to detect liver cancers through the visualization of the disordered biliary excretion of ICG in cancer tissues and noncancerous liver tissues compressed by the tumor. The specific content is the same as mentioned in next part.With the aid of ICG-fluorescent imaging (Surgical navigation system, SNS, Institute of Automation of, Chinese Academy of Sciences), liver molecular navigation can accurately identificate and locate the tumors,and design the transection line. The tissues beside the transection line and the resected tissues all received intraoperative gross examination and intraoperative frozen section, to confirm the accuracy of liver molecular navigation.The ICG-fluorescent imaging equipment was fixed at the 60cm distance to surgical site, which not pollute the field of operation.5. The construction of the 3-dimensional visualized procedure in the the diagnosis and treatment of Centrally Located Hepatocellular Carcinoma3-dimensional visualized operation planning has been used In the Department of Hepatobiliary Surgery of Zhujiang Hospital for 10 years. Based on the application of 3-dimensional operation planning,3D printing and ICG-fluorescent imaging in the diagnosis and treatment of Centrally Located Hepatocellular Carcinoma, the 3-dimensional visualized procedure for Centrally Located Hepatocellular Carcinoma was established. The 31 patients in this study all received liver resection guided by the 3-dimensional visualized procedure for Centrally Located Hepatocellular Carcinoma. The specific content is the same as mentioned in next part.Result1.3-dimensional visualized operation planning and surgery methods.5 patients with type Ⅰ lesions, received Segment V, Ⅷ±partial irregular resection;2 patients with type Ⅱ lesions, received Segment Ⅳ±partial irregular resection; 2 patients with type Ⅲlesions, received Mesohepatectomy; among the 7 patients with typeⅣ lesions,6 patients received right/left semi-hepatectomy and the other received right extended hepatectomy; 15 patients with type V lesions, received Irregular resection.2. The result of 3D printingThere were 14 patients with Centrally Located Hepatocellular Carcinoma received 3D printing, which were all belong to type Ⅰ、Ⅱ、Ⅲ、Ⅳ lesions.3D printed models facilitate acquisition of intuitionistic and omnidirectional information about the hepatic parenchyma, bile duct system, and tumors in great detail. Besides,3D printed models has power in evaluating preoperative blood supply, impaired function of the drainage area, resection scope, and necessity of vascular reconstruction, which are extraordinarily important to complicated patients with distortion of the hepatic vascular anatomy, extended hepatectomy, and mesohepatectomy.3. The result of ICG-fluorescent imagingAmong the 15 type V patients,11 patients received liver resection guided by ICG-fluorescent imaging. All of tumors of the 11 patients were detected as fluorescing lesions. In this way, the surgeons can implement the accurate liver resection.4. Data of the intraoperation and postoperation. The specific content is the same as mentioned in next part.ConclusionThe 3-dimensional visualized procedure could facilitate the diagnosis and treatment of Centrally Located Hepatocellular Carcinoma. The combination of operation planning and intraoperative navigation, enables the accuracy and standardization of liver resection and operative staging standardization.