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LRJ

 

Liver Resection for Tumours

• Only curative procedure for liver tumours
• Resection carries a significant morbidity and mortality

 

 

 

Liver Tumours

Benign:

• Epithelial tumour: Adenoma, FNH, polycystic
• Mesenchymal tumour: haemangioma

 

Malignant:

• Primary: HCC, cholangiocarcinoma, angiosarcoma, leiomyosarcoma
• Secondary: GI, neuroendocrine, lung, breast, kidney, ovarian, GIST

 

 

 

Hepatocellular Carcinoma (HCC)

History

• Risk factors: HBV, HCV, alcohol, cirrhosis, diet, aflatoxin
• Metabolic disorders

Examination

• Signs of liver tumour
• Signs of risk factors: chronic liver disease, chronic alcohol abuse, metabolic disorders
• Signs of metastasis

Investigation

• Haematology
• Biochemistry
• Liver function tests
• Virology
• Tumour markers
• Radiology: USS, CT, MRI, Visceral angiography
• Histology

Treatment:

• Surgical: resection, liver transplantation
• Non-surgical: Local - alcholol injection; regional TACE, intrahepatic chemotherapy
• Immunotherapy
• Gene therapy: suicidal gene, antiangiogenesis. genetic immunotherapy

Patient Selection

• Patients with a solitary tumour or several nodules confined within a single hepatectomy
• Patients with cirrhosis and poor liver function should be excluded

 

 

 

 

Surgical Techniques

• The aim of liver resection: excise tumour with an adequate tumour-free margin of approximately 1cm and to preserve maximal postoperative liver function
• Anatomical resection of the liever based on Couinaud's description

 

 

 

 

Prevention of Intraoperative Haemorrhage

Hazards

• Increased postoperative morbidity and mortality
• Blood transfusion leads to a higher rate of late tumour recurrence
• Risks of blood transfusion

 

Methods available

• Pringle's manoeuvre = compression of the portal triad within the epiploic foramen of winslow
• Hepatic vascular exclusion
• Radiofrequency ablation

 

 

 

 

Survival for HCC following resection

• 5 year survival ~30%
• Approximately ~20% of late deaths are related to liver failure or to complications of portal hypertension
• Survival rates are significantly lower in patients with Child's B or C cirrhosis

 

 

 

 

Prognostic Factors

• Tumour size > 3-5cm
• >3 tumour nodules
• Absence of peritumour capsule or invasion of the capsule
• Invasion of distal branches of the portal vein or hepatic vein
• Presence of satellite nodules

Colorectal Liver Metastasis

• 50% of patients with colorectal cancer will develop liver metastases
• 25% of patients have liver disease at time of diagnosis
• Outcome of patients without treatment is grave with a median survival of <12 months
• Surgical resection is the only treatment option that offers long term survival

Pancreatic Cancer

• 7000 people are diagnosed with pancreatic cancer in the UK each year
• Common belief among doctors is taht the disease is "untreatable"
• Predominantly disease of the elderly
• Late presentation
• High risk surgery
• Poor outcome
• PDFs: smoking, fat, meat, previous cholecystectomy (due to elevations in serum CCK), previous partial gastrectomy, chronic pancreatitis

  Non-endocrine

  Endocrine

  Duct Cell Origin (90%) - DC adenoma - Giant cell ca - Adenosquamous ca - Microadenoma - Mucinous Ca - Cystadnoca (mucinous) Acinar Cell origin (1%) - Acinar cell ca - Cystadenoca Connective tissue origin (<1%) - Osteogenic sarcoma - Leiomyosarcoma - Haemangiopericytoma - Malignant fibrous histocytoma Uncertain histogenesis - Pancreaticoblastoma - Papillary and cystic neoplasm Miscellaneous - Malignant Melanoma - Oncocytoma - Neuroblastoma - Lymphoma

  Functional or non-functional A-Cell: Glucagonoma B-Cell: Insulinoma D-Cell: Gastronoma, somatostatinoma, vipoma Carcinoma

 

 

 

Clinical Symptoms 

• Abdominal pain
• Pain: invasion of tumour into neighbouring coeliac plexus which is a sign that surgery will not be possible
• Jaundice: Carries a good prognosis (jaundice occuring early in the disease directs investigations to the possible diagnosis of cancer of the pancreas)
• Nausea/Vomiting/constipation - cachexia 

 

 

 

Important clinical signs

• Supraclavicular lymph node enlargement
• Ascities
• Other important signs incl. DVT

Patient selection for curative resection

• Aim: resection rate of 75% of those submitted to surgery
• Methods: USS, CT, MRI, ERCP, Angio, Endoscopic USS, PET
• 10-15% resection rate in UK

Surgical Resection

• Whipples vs Pylorus preserving proximal pancreaticoduodenectomy (PPPP)
• Local lymphadenectomy vs radical lympadectomy

Chemotherapy

• Preoperative down-staging: no evidence of value, should be considered in the younger patient
• Postoperative chemotherapy: all patients should be discussed with oncologist, a necessity