MANAGEMENT OF

LARGE LIVER TUMOR

By Dr. Ramcharan Thiagarajan

FACS, American Board CertifiedConsultant Surgical Gastroenterology &

Hepato-Pancreatic Biliary SurgeryFortis Hospitals Limited

Bangalore, India

Anatomy and functions of liver

• The liver is the largest internal organ of the body weighing approximately 1.3kgs in women and 1.5kgs in men

• Has dual blood supply

• Surrounded and wrapped by large blood vessels

Liver : FunctionHas more than 500 functions:• processing digested food from the intestine• controlling levels of fats, amino acids and glucose in the blood • combating infections in the body • clearing the blood of particles and infections including bacteria • neutralising and destroying drugs and toxins • manufacturing bile • storing iron, vitamins and other essential chemicals • breaking down food and turning it into energy • manufacturing, breaking down and regulating numerous hormones

including sex hormones • making enzymes and proteins which are responsible for most chemical

reactions in the body• Makes proteins which helps blood to clot

Liver : Amazing fact

• Liver has the capacity to regenerate. Can regenerate almost to 90% within 4-6 weeks time

• We all need only 30% of our Liver to have normal functions

Liver Disorder: Manifestations

• Asymptomatic• Abnormal Liver function tests• Right upper abdominal pain, fever, fatigue,

malaise, generalized weakness• Jaundice, itching, bleeding tendency• Confusion, drowsiness, Swelling of abdomen,

leg swelling

Liver Disorder: Tests

• Physical exam• Blood investigations: T. bilirubin, SGOT, SGPT,

GGT, SAP, Albumin, prothrombin time, alphafetoprotein

• Ultrasound• CT• MRI

Common Liver Problems in India

• Hepatitis A, B• Amoebic hepatitis, Amoebic Hepatic Abscess• Hydatid Cysts• Fatty Liver• Liver Cirrhosis from Alcohol, Hepatitis B,

Crptogenic causes• Liver tumors and cysts

Understanding liver tumor

• Benign liver tumours Benign liver tumours stay in the liver and do not spread to other organs or parts of the body. Usually they only grow for a limited amount of time and produce no symptoms. Most benign tumours are found by chance. Occasionally, they may need surgical removal if they are large, liable to bleed or cause any discomfort

• Hemangioma, Focal nodular hyperplasia, Adenomas and Liver cysts are commonly seen benign Liver conditions

.

MalignancyMalignant tumours There are two broad categories of liver cancer: secondary and primary

1. Secondary liver cancer Secondary liver cancer, sometimes called metastatic, is a cancer that first develops elsewhere in the body and then spreads to the liver.

2. Primary liver cancer Primary liver cancers are cancers that start in the liver. The two main types are:

• Hepatoma, also called hepatocellular carcinoma (HCC)• Biliary tree cancer, which includes cholangiocarcinoma (bile duct cancer)

and gallbladder cancer

Secondary Liver cancer

Metastasis from• Colorectal• Breast cancer• Lung cancer• Stomach cancer• Pancreatic cancer

Liver cancer

• 4th leading cause of cancer related death in the world, third most common among men

• Asians have higher incidence because of hepatitis B endemicity

Incidence of liver tumor in India?

• 3.9 men per 100,000 population with liver cancer in India

• 2.0 women per 100,000 population with liver cancer in India

• Statistics in India: tip of the iceberg

Colorectal cancer• 9% of all cancer deaths in US• Lifetime incidence is about 5% after age of 40 overall• Rates are declining in US because of screening

programs• Diet and environmental factors on genetic

background• Earlier thought to be uncommon in India, common

only in western countries. But incidence is increasing although we do not have an estimate. Mainly thought to be due to adaptation of western lifestyle

Reasons for liver tumor? Primary liver cancer 1. Hepatoma The main cause is cirrhosis, where the liver has become scarred as a result of

damage over a long period of time. Causes include the viral infections hepatitis B and C, the cirrhosis due to excessive alcohol, or haemochromatosis(a rare hereditary disease caused by an overload of iron in the body)

2. Biliary tree cancer

In most people, there is no clear reason why they develop cholangiocarcinoma or gall bladder cancer. However, people who have the following problems are more likely to develop cholangiocarcinoma:

• a liver problem called primary sclerosing cholangitis (PSC) • chronic inflammation of the bile ducts due to multiple stones within the liver or

parasite infections (liver fluke)

Risk factors• Chronic liver infection (hepatitis)• Chronic hepatitis B• Chronic hepatitis C• Cirrhosis - about 5% of cirrhosis cases get liver cancer later• Aflatoxin• Aspergillus flavus• Gender - males about twice as often as females• Family history of liver cancer• Age - more common over 60 than in younger adults

Risk factor

Colon cancer risk factors: • Environmental and genetic factors increase likelihood of

colorectal cancer• Familial polyposis coli• Personal and family history of cancer• Inflammatory bowel disease• Alcohol• Obesity• Smoking• Change in protective factors such as physical activity and diet

How is liver Tumor diagnosed? • Physical exam• Liver function tests• Alpha-fetoprotein (AFP) blood test• CT scan• Ultrasound• MRI• Angiogram• Liver biopsy

– Fine-needle aspiration biopsy– Core biopsy– Laparoscopy– Surgical biopsy

Liver Tumor staging • Stage I: T1, N0, M0: There is a single tumor (any size) that has not grown into any

blood vessels. The cancer has not spread to nearby lymph nodes or distant sites• Stage II: T2, N0, M0: Either there is a single tumor (any size) that has grown into blood

vessels; OR there are several tumors, and all are less than 5 cm (2 inches) in diameter. The cancer has not spread to nearby lymph nodes or distance sites

• Stage IIIA: T3a, N0, M0: There are several tumors, and at least one is larger than 5 cm (2 inches) across. The cancer has not spread to nearby lymph nodes or distant sites

• Stage IIIB: T3b, N0, M0: At least one tumor is growing into a branch of the major liver blood vessels (portal vein or hepatic vein). The cancer has not spread to nearby lymph nodes or distant sites

• Stage IIIC: T4, N0, M0: A tumor is growing into a nearby organ (other than the gallbladder); OR a tumor has grown into the outer covering of the liver. The cancer has not spread to nearby lymph nodes or distant sites

• Stage IVA: Any T, N1, M0: Tumors in the liver can be any size or number and they may have grown into blood vessels or nearby organs. The cancer has invaded nearby lymph nodes. The cancer has not spread to distant sites

• Stage IVB: Any T, Any N, M1: The cancer has spread to other parts of the body. (Tumors can be any size or number, and nearby lymph nodes may or may not be involved)

Treatment Options• Surgery

– Partial hepatectomy– Liver transplantation– Radiofrequency ablation– Laser therapy, microwave therapy– Percutaneous ethanol injection– Cryosurgery

• Chemotherapy– Hepatic arterial chemoembolization– Hepatic arterial infusion pump– Chemoembolization

• Radiation therapy• Radioactive seed embolization

Treatment of Liver cancer

• Surgery is the best option for primary or secondary Liver cancer

• Liver cancer is resistant/ partially sensitive to chemotherapy

• Other modality are to be considered only if the patient is not a candidate for surgical therapy

• Treatment requires meticulous planning and strategies

Case history

• A 60-year-old man from Lagos, Nigeria, presented to Fortis Hospitals, Bangalore, with a history of severe abdominal pain and fatigue for the preceding four months

• He was treated at various hospitals in Nigeria and finally diagnosed to have a large liver mass

• Referred here for further management

On examination• In severe distress• Wheel chair bound• Severe tenderness in right upper abdomen• Investigated completely, no spread of tumor, hepatitis B

negative• Hb : 7.5 g/dL• Tumor markers negative• Liver function tests: normal enzymes. Low albumin level, no

jaundice• Heart and lungs stable to undergo surgery

• Large liver mass 20 x 13 x 18 cms size occupying two-third of the right lobe of the liver, compressing the inferior vena cava, Left lobe compressed but normal Left lateral segment free. Mildly enlarged lymph nodes around the appendicular region

• Left lobe of liver looked normal with no evidence of disease

Surgery

• Lymphnode in ileocaecal region showed mets from colonic carcinoma

• Radical Right hemicolectomy done• In the same settimg primary and secondary

tumours resected as against primary followed by secondary

Histopathology• Primary:Adenocarcinoma colon,moderate grade• Tumour invading muscularis propria but not

beyond. Both surgical margins are free of tumour• Reactive hyperplasia, 13/13 lymph nodes at level of

tumour and 3/3 nodes away from tumour• Vascular pedicle free of tumour• Complete removal of tumour

Hospital Course

• Excellent immediate hospital course• Liver functions almost back to normal on 3rd day• Started eating and ambulating by 5th day• Developed blood clot, part of hypercoagulable condition

associated with cancers• Recovered from that episode was placed on blood thinners• Developed bleeding problem from colon which resolved

spontaneously• Now recovering well with enhanced nutrition, staying in

hospital, waiting to go back to Lagos after rehabilitation

Plan

• He requires post-operative chemotherapy to prevent recurrence of cancer

• Usually will start around 6-8 weeks after surgery

• Reason for chemo: disease free survival is high following chemotherapy

Colon cancer in Liver

• Overall one third of patients with colorectal cancer present with tumor just isolated to liver and with no evidence of spread elsewhere. These are the best candidates for surgery

• 5 year survival after resection of liver mets is close 40-50% with surgical mortality less than 5 %

• 5 year with chemo alone is less than 10%• With no real treatment just few months• Chemo followed by surgery is an option but lot of ifs: the

tumor should not have spread on treatment, no liver toxicity associated with chemotherapy

Requirement for Resection

• Stable heart-lung function• No involvement of major hepatic vascular

structures, bile duct• No involvement of celiac, paraaortic lymph

nodes• No extrahepatic non contigous spread• Adequate functional reserve of liver

Why is this unique?

• Massive liver tumour resection: done in very few places. This size will deter definitive surgery to patients and therefore preclude many from surgical resection

• Primary and secondary addressed at the same time as against sequential or palliative

• Centers are there in Bangalore with this expertise and therefore attracts patients from elsewhere nationally and internationally

• Any Liver problem: please get the right information

Thank you

60%

Portion of liver to be removed for adult transplant

40%

• After liver resections for metastases from colorectal cancer , the 1, 3, 5 and 10-year overall survival rates were 90.6%, 51%, 27.5%, and 16.9%, Aldrighetti L, Castoldi R, Di Palo S :Prognostic factors for long-term outcome of hepatic resection for colorectal liver metastases Chir Ital. 2005 Sep-Oct;57(5):555-70. Dipartimento di Scienze Chirurgiche, Istituto Scientifico Universitario Ospedale San Raffaele, Università Vita-Salute San Raffaele, Milano