Liver Tumors

LIVER TUMORS Kaya Saribeyoglu, MD Istanbul University, Cerrahpasa Medical Faculty Department of General Surgery

Malignant tumors of liver according to WHO 1. 2. 3. 4. 5. 6.

Hepatocellular carcinoma (HCC) Intrahepatic cholangiocarcinoma Cystadenocarcinoma of bile ducts Combined HCC and cholangiocarcinoma Hepatoblastoma Indifferentiated carcinoma

Primary malignant tumors of the liver • • •

Originating from hepatocytes: Hepatocellular carcinoma (HCC) (90%) Originating from intrahepatic bile ducts: Cholangiocellular carcinoma (CCC) (10%) Originating from mesodermal cells (rare): angiosarcoma, epitheloid haemangioendothelioma, sarcoma

Hepatocellular Carcinoma • 90% of all primary liver tumors • Annual mortality is 1: 1 250 000 • Incidence increased significantly especially in the last decade • Closely related to chronic liver disease, especially Hepatitis B and C

Hepatocellular Carcinoma Epidemiology • One of the most common malignancies • Frequently seen worldwide, however especially more common in Africa and Asia • Mean age of occurence is 50-60 in Western countries, but 25-30 in Africa. • Men is affected 4-9 times more than women

HCC Macroscopic types 1. Unifocal expansive 2. Infiltrating 3. Multifocal (diffuse)

Risk Factors for Liver Tumors HCC • Hepatitis B virus • Hepatitis C virus • Alcoholic cirrhosis • Hepatic adenoma • Aflatoxins • Androgens • Oral contraceptives

CCC • Thorotrast • Parasites • Hepatolithiasis • Sclerosing cholangitis

Symptoms of Liver Tumors a. Pain with/without hepatomegaly b. Sudden onset detoriation in a cirrhotic patient with hepatic insufficiency, variceal bleeding or ascites c. Intraperitoneal hemorrhage d. Acute disease with pain and fever e. Distant metastases f. No clinical signs, incidental diagnosis during routine check-up

Laboratory Findings • Hyperbilirubinemia • High alkaline phosphatase and Gamma GT levels • Seropositivity for HBsAg and HCV • High serum alpha-fetoprotein (HCC) and CA 19.9 (CCC) levels

Imaging Studies • • • •

Ultrasonography (US) Computed tomography (CT) Magnetic resonance imaging (MRI) Angiography

Computed Tomography • CT appearence of a solitary hepatocellular carcinoma

Selective Angiography • Hypervascular liver tumor on selective angiography

Other diagnostic methods in liver tumors

• Biopsy: cytology, histopathology • Laparoscopy

TNM Classification T Primary tumor T0 No primary tumor T1 Solitary tumor smaller than 2 cm without vascular invasion T2 Solitary tumor smaller than 2 cm with vascular invasion Multiple tumors in one lobe smaller than 2cm without vascular invasion Solitary tumor larger than 2 cm without vascular invasion T3 Solitary tumor larger than 2 cm with vascular invasion; Multiple tumors in one lobe smaller than 2cm with vascular invasion; Multiple tumors in one lobe larger than 2cm regardless of vascular invasion. T4 Multiple tumors in both lobes, Invasion of branches of V.porta or v.hepatica, Gall bladder invasion, Tumor perforation into peritoneal space. N Regional lymph nodes N0 No lymph node metastases N1 Presence of regional lymph node metastases M Distant metastases M0 No distant metastases M1 Presence of distant metastases

TNM Classification STAGE I STAGE II STAGE IIIA IIIB STAGE IVA IVB

T1 T2 T3 T1,2,3 T4 T1-4

N0 N0 N0 N1 NO/N1 NO/N1

M0 M0 M0 M0 M0 M1

CHILD Classification CHILD

A

B

C

Bilirubine

<2

2-3

>3

Albumine

>3.5

3-3.5

<3

Ascites

_

Neurological disorders Nutritional status

_

Easy to treat minimal

Hard to treat severe

excellent good

insufficient

Differential diagnosis in liver tumors • Benign tumors • Cysts • Liver abscess

Treatment of liver tumors • Resection • Transplantation • Percutaneous local ablation: radiofrequency (RF), ethanol, cryotherapy • Chemoembolisation

Poor Prognosis • Metastastatic foci more than 3 • Vascular invasion • Cirrhosis, abnormal liver functions

Hepatic segments and resection types

C. Right hemihepatectomy D. Left hemihepatectomy

Hepatic segments and resection types

C. Right

trisectionectomy (or trisectorectomy) D. Lateral segmentectomy

• Liver is an organ with high functional reserve and regeneration capacity • 75-80% resection is safe in healthy parenchymal tissue

Case HCC Right hepatectomy

Pekmezci - Sarıbeyoğlu

Pekmezci - Sarıbeyoğlu

Pekmezci - Sarıbeyoğlu

Pekmezci - Sarıbeyoğlu

Transplantation for HCC

• Good results in selected patients • Orthotopic liver transplantation (OLT) is the best available option for early hepatocellular carcinoma (HCC) • High cost, deceased donor graft shortage

Indications for transplantation in HCC

Milan Criteria • • • •

Single tumor size < 5 cm 2 or 3 tumors, size < 3 cm No extrahepatic disease No vascular invasion

Therapy in irresectable malignant liver tumors

1. 2. 3. 4.

Regional therapy Local therapy Systemic medical therapy Supportive therapy and precautions

Regional Treatment Options

a. Chemotherapy via regional artery b. Transarterial chemoembolisation

Local Treatment Options • • • • • • •

Percutaneous alcohol injection Interstisial laser photocoagulation Interstisial thermocoagulation Surgical criotherapy Electromagnetic wave coagulation (microwave, radiofrequency) Radiotherapy Gene therapy

therapy

Systemic Medical Therapy • Systemic chemotherapy • Hormonotherapy

• Mean survival is 13 months in patients with HCC • 5 years survival after curative resection is 44%

METASTATIC TUMORS OF THE LIVER

Prognosis • Mean survival in irresectable metastases: 6 months • In colorectal metastases: 127 days • 5 year survival after surgical therapy: 28-36%

Surgical therapy • Contraindications: Presence of incurable extrahepatic organ metastases • Relative contraindications: Celiac and portal lymph node involvement

Case Ovarian liver metastases Right hepatectomy

Pekmezci - Sarıbeyoğlu

Pekmezci - Sarıbeyoğlu

Pekmezci - Sarıbeyoğlu

Case Colorectal liver metastases Right hepatectomy

Pekmezci - Sarıbeyoğlu

Pekmezci - Sarıbeyoğlu

Pekmezci - Sarıbeyoğlu

Pekmezci - Sarıbeyoğlu

Case Multiple bilobar colorectal liver metastases Multiple metastasectomies