Minimally Invasive Liver Resection and Ablation For Malignancy
Advances in OncologyDorothy E. Schneider Cancer Center
Mills-Peninsula Health ServicesMarch 16, 2013
Kimberly Moore Dalal, MD, FACSMedical Director, Surgical Oncology
Peninsula Medical ClinicBurlingame, CA
Historical Perspective
“…the liver is so friable, so full of gaping
vessels and so evidently incapable of
being sutured that it seems impossible to
successfully manage large wounds of its
substance.” JW Elliot 1897
Liver cancer
Historical Perspective
“…20% of patients died in the operating room
because of exsanguinating hemorrhage…
Another 14% died post-operatively as a
direct consequence of enormous blood loss
during operation…15% died of liver failure
caused by technical factors other than
hemostasis, including 3 bile duct injuries…”
Foster JH, Berman MM. Major Problems in Clinical Surgery 1977;1-342.
Liver cancer
OR Team, Bagram, Afghanistan 2007
Liver cancer
Liver Resection TodayAuthor N Operative Mortality (%)
Scheele ‘91 219 6Rosen ‘92 280 4Gayowski ’94 204 0 Scheele ‘95 469 4 Nordlinger ’95 568 2 Jamison, ‘97 280 4Fong ’99 1001 3
Normal livers
Liver cancer
Outline
Laparoscopic liver resections for benign and malignant tumors– Benign lesions– Hepatocellular carcinoma– Colorectal cancer metastases
Ablation for patients who are not operative candidates
Liver cancer
Anatomy
Liver cancer
Benign Hepatic Lesions
Liver cancer
Tumor Malignant Potential Spontaneous Hemorrhage
Focal nodular hyperplasia No No
Hemangioma No Rare
Cystadenoma Yes No
Adenoma Yes Yes
Case 1: Cystic Lesion of the Liver
51 year old woman
3.5 cm Liver Cyst, Seg 4, first noted on chest CT in 2001
Presented with 3 days RUQ pain
RUQ ultrasound (2/07): complex cystic structure of the liver with layering
Triple phase liver CT (2/07): Cystic lesion, Seg 4, 6x8x6 cm; Hounsfield units 6 (noncontrast), 11 (iv contrast)
Liver cancer
UltrasoundComplex cystic structure of liver with layering
Liver cancer
Triple phase liver CT: Cystic lesion, Seg 4, 6x8x6 cm
Liver cancer
Case 2: Hepatic Adenoma
43 yo F with an incidentally discovered right liver mass detected on chest CT for workup of cough.
AFP and CEA normal. LFTs normal.
CT and MRI – 4.2x2.1x2.0 cm mass, Seg 7, consistent with a
hepatic adenoma.
Liver cancer
Liver cancer
Triple phase liver CT: Seg 7, 4x2x2 cm
Traditional Open “Chevron” Incision
Liver cancer
Exposure in an Open Resection
Liver cancer
Laparoscopic Port Placement for Right Liver Lesions
Cho JY, et al., Arch Surg 2009; 144(1):25-29.
Liver cancer
Laparoscopic View of the Liver
Liver cancer
Machado MA, et al., Surg Endosc, 2009; 23:2615-2619.
Case 2: Hepatic Adenoma, Segment 7 Laparoscopic Resection…9 Months Later
Liver cancer
EstablishedDiagnosis/StagingFenestration of Simple Cysts
EvolvingMinor resections (≤ 2 segments) for tumorMajor hepatic resections Tumor ablation
Laparoscopic Liver Surgery
Liver cancer
Laparoscopic Liver ResectionTheoretical Advantages and Disadvantages
Advantages:
Less post-operative pain
Less post-operative morbidity
Shorter hospital stay
Improved cosmesis
Quicker return to normal activity
Quicker initiation of adjuvant therapies
Liver cancer
Disadvantages:Loss of tactile sense
MarginsStaging
Limited access/ instrumentation
ExposureControl of major pedicles/hepatic veins
Time and money
Laparoscopic Liver ResectionSolutions
Loss of tactile senseMargins
Staging
LaparoscopicUltrasound
Hand-assisted techniques
Liver cancer
Laparoscopic Liver ResectionSolutions
Limited access/instrumentationExposure
Control of major pedicles/hepatic veins
Fear of major hemorrhage
• Hand-assisted techniques
• Ligaments intact• Improved
retractors
HarmonicScalpel
VascularStapler
LigasureDevice
Tissuelink
Argon Beam Coagulator
Water Jet
Liver cancer
• Segmental resection: 27 pts (61%)
2
7853
• 1 segment: 17 pts (38%)
• >1 segment: 10 pts (22%)
• Left lateral: 6 pts (13%)
Laparoscopic HepatectomyMSKCC Results (n=44)
D’Angelica, MD, et al., AHPBA 2006
Liver cancer
Benign 21 pts (47%)Malignant 23 pts (53%)
23 pts: Negative margins (100%). No local recurrence.
1 tumor 36 pts (81%)
> 1 tumor 8 pts (18%)
Laparoscopic HepatectomyMSKCC Results (n=44)
Liver cancer
D’Angelica, MD, et al., AHPBA 2006
LLR(n=44)
OLR(n=91) p
OR time (minutes) 199 161 0.01
Pringle time (minutes) 31 22 0.04
Pringle 45% 75% <0.01
EBL (ml) 161 521 <0.01
Transfusion 2.2% 26% <0.01
Operative Outcome
Laparoscopic HepatectomyMSKCC Results: Comparison to Open
Liver cancer
D’Angelica, MD, et al., AHPBA 2006
LLR(n=44)
OLR(n=91) p
Length of stay (days) 5.1 6.7 <0.01
Morbidity 13% 28% 0.08
Regular diet (days) 3 3 0.7
Oral analgaesia (days) 3.1 3.5 0.1
Mortality 0% 0% 0
Laparoscopic HepatectomyMSKCC Results: Comparison to Open
Post-operative Outcome
Liver cancer
D’Angelica, MD, et al., AHPBA 2006
Outline
Laparoscopic liver resections for benign and malignant tumors– Benign lesions– Hepatocellular carcinoma– Colorectal cancer metastases
Ablation for patients who are not operative candidates
Liver cancer
Epidemiology of Hepatobiliary Cancer
Estimated U.S. incidence in 2013: 30,640 cases/year1
Annual incidence of HCC with Hepatitis C cirrhosis is 2-8%, Hepatitis B cirrhosis 2.5%.
21,670 deaths in men and women
Siegel R, et al., CA Cancer J Clin, 2013; 63:11-30.
Liver cancer
Diagnosis and Workup for HCC
Often asymptomatic.
Nonspecific symptoms: anorexia, weight loss, malaise, upper abdominal pain.
Paraneoplastic syndromes: hypercholesterolemia, erythrocytosis, hypercalcemia, hypoglycemia.
Physical signs: jaundice, ascites
AFP>200 ng/mL + liver mass =HCC
Liver cancer
Zhang BH et al., J Cancer Res Clin Oncol. 2004; 130:417-422.
Child-Pugh Class A Patients are Candidates for Resection
Liver cancer
1 2 3
Encephalopathy None 1-2 3-4
Ascites None Slight Moderate
Albumin (g/dL) >3.5 2.8-3.5 <2.8
Prothrombin time (sec) 1-4 4-6 >6
Bilirubin (mg/dL) 1-2 2-3 >3
Class A = 5-6 points Good operative riskClass B = 7-9 points Moderate operative riskClass C = 10-15 points Poor operative risk
Case 3: Hepatocellular Carcinoma
74 yo M with Hepatitis C x 30 years from a blood transfusion, treated with interferon for one year
Developed pneumonia and asked PCP to investigate for cirrhosis.
AFP: 4690.
Abd US: 3.4 x 2.4 x 3.1 cm mass, left lateral segment of liver.
Triple phase Liver CT: 3.5 x 2.5 cm mass, segment 3. (CT of abdomen and pelvis 3 months earlier negative).
Liver cancer
Triphasic Liver CT: Segment III 3.5 cm mass
Liver cancer
Principles of Surgery for HCC
Mortality <5%
Five-year survival rates > 50%– 70% in patients with early
stage HCC and preserved liver function.
Recurrence at 5 yrs>75%
Careful patient selection: – Comorbidities– Tumor characteristics– Size and function of future
liver remnant
Liver transplantation for patients meeting UNOS criteria – Single lesion < 5cm– 2 or 3 lesions < 3 cm
Liver cancer
Case 3: Hepatocellular Carcinoma
Laparoscopic resection of segment III
Length of stay 5 days
Bone metastasis @ 7 mos
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Outline
Laparoscopic liver resections for benign and malignant tumors– Benign lesions– Hepatocellular carcinoma– Colorectal cancer metastases
Ablation for patients who are not operative candidates
Liver cancer
Epidemiology of Colorectal Cancer
Estimated U.S. incidence of colorectal cancer: 142,820/year1
51,370 deaths
50% of patients will be diagnosed with liver metastases
Liver resection->long-term survival – 5 year survival: 25-58%– Surgical techniques– Chemotherapy– Unresectable->resectable
1Siegel R, et al., CA Cancer J Clin, 2013; 63:11-30.2 http://www.hopkinsmedicine.org.
Liver cancer
Determinants of Outcome for CRC Liver Metastases: Fong Score
• Extrahepatic disease• Positive margins• Node (+) colorectal primary• Disease-free interval < 1 year• More than 1 hepatic tumor• Largest hepatic tumor > 5 cm• CEA > 200 ng/mL
Fong et al Ann Surg 1999;230:309
Liver cancer
Fong Y, et al., Ann Surg. 1999 Sep;230(3):309-318.
Preoperative Portal Vein Embolization Can Increase the Future Liver Remnant
PVE
1Chun YS, et al., J Gastrointest Surg. 2008 Jan;12(1):123-8.
Liver cancer
Percent Resection– FLR/TLV 0.20 (20%)1
>40% for cirrhotics, Child’s A
Liver cancer
Case 4: 61 year old Woman, Synchronous Colon Cancer Metastases to Liver
Open sigmoid colectomy for obstructive sigmoid colon cancer 9/11
CEA 600
CT: bilateral metastases
Xelox->cetuximab and xeloda
Liver cancer
Case 4: Tremendous Response to Chemotherapy
Sept 2011, CEA 600 Mar 2013, CEA 16 (up from 6)
Cirrhotic liver and gallbladder Adhesion to recurrent tumor
Intraoperative ultrasound Post-ablation
Laparoscopic Resection of Two Colon Cancer Metastases to Liver
Liver cancer
>1 cm Margins are Preferred, but > 1 mm Margins are Favorable
• Multivariate analysis (n=1019)• > 1 tumor• Size > 5 cm• Node positive primary• Bilateral resection• Margins
Margin N (%) Median survival (mo) P
Involved/<1mm 112 (11) 30 mos Ref
1 – 10 mm 563 (55) 42 mos <0.01
> 10 mm 344 (33) 55 mos <0.01
Are C, et al., Ann Surg. 2007 Aug;246(2):295-300.
Liver cancer
Outline
Laparoscopic liver resections for benign and malignant tumors– Benign lesions– Hepatocellular carcinoma– Colorectal cancer metastases
Ablation for patients who are not operative candidates– Tumor size and function– Liver function– Comorbidities
Liver cancer
Radiofrequency Ablation
High-frequency alternating current flows from electrical probe through tissue to ground– Ionic agitation results in frictional heating and
coagulation of surrounding tissue
Probe insertion
Extension of prongs
RF current application
Liver cancer
Radiofrequency Ablation
Advantages– Performed
percutaneously, laparoscopically, or at laparotomy
– Low complication rateMay be related to size of ablation (<3 cm)
Disadvantages– Poor performance
near blood vessels– One probe
Many tumors require multiple, overlapping ablations
– Slow
Liver cancer
Microwave Ablation
Theoretical advantages over RFA– Larger zone of active
heatingPossibly better performance near blood vessels
– Hotter temperature– Use of multiple probes
Liver cancer
Lubner M, et al.,J Vasc Interv Radiol. 2010 Aug;21(8Suppl):S192-S203.
Liver cancer
Case 5: Segment IV B 2.6 cm mass, Cirrhosis
77 year old womanChild’s Pugh Class A cirrhosis due to autoimmune hepatitisAFP: 23CT: 2.6x2.6 cm heterogeneously enhancing nodule segment IVB of liverFNA: HCC
Liver cancer
Microwave Ablation
Preop; AFP 23 1 month postop; AFP 7
10 months postopAFP 24
1 months postop repeatAFP 6
Liver cancer
Microwave Ablation
Cirrhotic liver and gallbladder Adhesion to recurrent tumor
Intraoperative ultrasound Post-ablation
Summary
Laparoscopic liver resections are safe and oncologically sound in highly selected patients in the hands of surgeons with a laparoscopic skill set.
Patients with malignant liver tumors can be considered for resection based on tumor characteristics, future liver remnant size and function, and patient comorbidities.
Radiofrequency and microwave ablations are alternative ways to treat small liver tumors which are not amenable to resection.
Liver cancer
Mills-Peninsula Multidisciplinary Gastrointestinal Tumor Board
Second Tuesday of each month, Peninsula Hospital
12:30 pm-1:30 pm, CME + lunch
Tailored approach to treatment plan
Team: – Surgical oncologists, Interventional radiologists, Gastroenterologists– Medical oncologists, Radiation oncologist, Pathologist– GI nurse navigator, Clinical trials nurse, Physician liaison– YOU!
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Liver cancer