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

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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

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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

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Anatomy

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Benign Hepatic Lesions

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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)

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UltrasoundComplex cystic structure of liver with layering

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Triple phase liver CT: Cystic lesion, Seg 4, 6x8x6 cm

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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

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Triple phase liver CT: Seg 7, 4x2x2 cm

Traditional Open “Chevron” Incision

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Exposure in an Open Resection

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Laparoscopic Port Placement for Right Liver Lesions

Cho JY, et al., Arch Surg 2009; 144(1):25-29.

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Laparoscopic View of the Liver

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Machado MA, et al., Surg Endosc, 2009; 23:2615-2619.

Case 2: Hepatic Adenoma, Segment 7 Laparoscopic Resection…9 Months Later

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EstablishedDiagnosis/StagingFenestration of Simple Cysts

EvolvingMinor resections (≤ 2 segments) for tumorMajor hepatic resections Tumor ablation

Laparoscopic Liver Surgery

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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

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• 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

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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)

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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

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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

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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

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Zhang BH et al., J Cancer Res Clin Oncol. 2004; 130:417-422.

Child-Pugh Class A Patients are Candidates for Resection

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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).

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Triphasic Liver CT: Segment III 3.5 cm mass

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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

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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

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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.

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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.

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Percent Resection– FLR/TLV 0.20 (20%)1

>40% for cirrhotics, Child’s A

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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

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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

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>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

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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

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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

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Microwave Ablation

Theoretical advantages over RFA– Larger zone of active

heatingPossibly better performance near blood vessels

– Hotter temperature– Use of multiple probes

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Lubner M, et al.,J Vasc Interv Radiol. 2010 Aug;21(8Suppl):S192-S203.

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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

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Microwave Ablation

Preop; AFP 23 1 month postop; AFP 7

10 months postopAFP 24

1 months postop repeatAFP 6

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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!

We can provide state-of-the-art, cutting-edge care to our patients in their own backyard with a personalized touch!

Liver cancer