Surgery for Cancer of the Liver
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Surgeons have made important strides over the last two decades in their ability to treat liver cancer. They have improved operations for removing liver tumors and taken advantage of newer treatments that are less invasive. Where once liver cancer was always a daunting diagnosis, today the surgical team can be more aggressive in resecting, or otherwise treating, tumorous portions of this vital organ.
Liver tumors may be either benign or cancerous. Cavernous hemangioma, hepatocellular adenoma, and focal nodular hyperplasia are examples of the more common benign tumors. Cancerous liver tumors are either primary tumors that originated in the liver (hepatocellular carcinoma or cholangiocarcinoma) or metastatic tumors that have spread to the liver from other locations. These latter tumors can be metastases from other sites such as the breast, kidney, lung, pancreas, small intestine, or soft tissue. Partly because the liver has a blood-filtering role, it is often one of the first organs to which metastatic cancer cells travel and then begin to grow. Benign liver tumors, though, can also become cancerous if neglected.
Every patient with a liver tumor should be considered for resection and should undergo evaluation to determine if he or she is a suitable candidate. Removing the tumor can be effective because it may rid the body of cancer, preventing its growth and spread. For this curative potential to be realized, though, the cancer must be confined to the liver, so that its removal will eliminate cancer from the body. Very rarely will removing the tumor but leaving other cancer behind in the body be effective.
The liver is unique in its vigorous ability to grow back when a portion of the organ is removed. This natural regeneration can sometimes return the liver to its original size in a matter of weeks. Surgeons can remove as much as 85 percent of the liver safely. This is important because the surgical team will usually have to remove a portion of the healthy tissue around a tumor to be sure to remove all of the cancer. At the same time, an adequate portion of the patient’s liver must remain so that the patient does not suffer liver failure before or after this period of healing and regrowth. If the liver cancer is compounded by chronic liver disease related to hepatitis or cirrhosis, the liver regrowth necessary after such an operation may not be possible.
Clearly, knowing as much as possible about the size and position of tumors prior to surgery is very important. CT and MR imaging determine the location of tumors in the liver, the condition of other portions of the liver, and the status of surrounding vessels (veins and arteries). The team may also take advantage of ERCP (endoscopic retrograde cholangiopancreatography) and angiography to evaluate the cancerous area. Gathering this information ahead of time permits a surgical plan that will make the operation safer and that greatly supplements direct examination of the liver during surgery.
The surgical oncologist may perform certain liver resections using minimally invasive laparoscopy, while others cases require open surgical methods. The open liver resection is an operation that takes several hours. Patients typically remain in the hospital for four to five days. Some surgeons are able to perform these operations in such a way that patients rarely need blood transfusions.
Biopsy (open, laparoscopic, or transvenous)
In a liver biopsy, the surgeon or radiologist removes a small sample of cells from the liver, so that the pathologist can examine them microscopically to determine the liver’s health and status. This may be used to determine type of tumors identified on imaging studies and to assess the condition of the noncancerous areas of the liver.
Normally, the biopsy is taken with a fine needle, inserted into the tumor with guidance from ultrasound. But the surgeon may use a special kind of endoscope, called a laparoscope, to more extensively biopsy the liver. This involves making one or more small incisions in the abdomen, through which the surgeon can direct the lighted scope and probe, usually to remove a small piece of tissue from several areas of the liver.
When patients have blood-clotting problems or tend to have fluid in their abdomen, physicians use transvenous biopsy. Physicians insert a tube called a catheter into a vein in the patient’s neck and guide it to the liver. An interventional radiologist then puts a biopsy needle into the catheter and then into the liver.
This form of liver resection involves removal of less than an entire lobe of the liver. Patients tolerate this operation well. Segmentectomy does not produce any hepatic insufficiency. (Other organs for which segmentectomy is used for cancer treatment include the breasts and the lungs.)
In another form of liver resection, the surgeon takes an entire lobe – either the left or the right lobe – of the liver. Called lobectomy, this approach involves removal of 35 to 65 percent of the liver, while leaving the healthy lobe to expand and regrow the organ.
This operation involves resection of one entire lobe and a portion of the opposite lobe. Anywhere from 50 to 85 percent of the liver may be resected. Care must be taken to avoid irreversible liver failure.
Nontransfusion hepatic resection (bloodless surgery)
The ability of the surgical team to prevent blood loss during liver surgery has improved to the extent that transfusions are frequently unnecessary. Patients who, because of their beliefs or wishes, do not want to receive blood transfusions during the operation can undergo nontransfusion (bloodless) hepatic surgery.
Ablation is a word that means directly destroying tissue without removing it. Specialists can ablate liver tumors by various relatively new means including high-energy radio waves.
Radiofrequency tumor ablation is a form of treatment in which the cancer team inserts a special type of needle through the skin of the abdomen and into the tumor site. Using guidance from imaging such as CT or ultrasound, they confirm the placement of the needle and then deploy tiny wires through it and into the tumor. The wires emit radio energy, which creates heat that destroys the cancer tissue. There is typically no bleeding.
The specialist can place radiofrequency needles into multiple tumors. This approach is now an established and FDA-approved procedure for treating liver tumors. The procedure may be done with needles placed through the skin by a radiologist (interventional radiofrequency ablation), or surgically with laparoscopy, or with a standard incision.
Radiofrequency ablation is not a substitute for surgical removal. However, it may be used as a supplement to surgery or for recurrent or unresectable tumors. Use of this procedure is better established for small tumors than for large ones, and is usually reserved for patients whose cancer is restricted to the liver.
For patients who need to undergo surgery to remove liver tumors, the laparoscopic approach permits a faster recovery. For example, patients undergoing this type of surgery typically take half the number of weeks to return to work that patients undergoing conventional surgery do. In laparoscopy, the surgical team can introduce a small scope to view the liver, rather than having to make an incision wide enough for surgeons to get their hands into. The larger incisions of the traditional approach take much longer to heal. Making a smaller incision lower in the abdomen, versus a larger one in the upper abdomen, results in a safer procedure as well. Patients treated with the less-invasive procedure require less pain medication and less time recovering in the hospital. The approach, however, is available only to patients who are appropriate candidates for it, a decision based on the size and type of tumor, the tumor location, the patient's overall medical condition, and other factors.
Patients who do not have an adequate reserve of liver capacity to undergo surgical removal of portions of the liver may be candidates for a procedure that introduces chemotherapy directly to the liver tumor and then blocks blood flow to it. This procedure is called chemoembolization.