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LIVER TUMOURS

LIVER TUMOURS. ROSE CHERIAN. History. First recorded successful elective resection of a liver tumor in the United States was performed by Tiffany in 1890

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LIVER TUMOURS

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  1. LIVER TUMOURS ROSE CHERIAN

  2. History • First recorded successful elective resection of a liver tumor in the United States was performed by Tiffany in 1890 • Surgeons were reminded of the risk of massive hemorrhage from the liver by Elliot in 1897 reported “liver is so friable, so full of gaping vessels and so evidently incapable of being sutured that it seemed impossible to successfully manage large wounds of its substance.”

  3. Classification

  4. Primary liver tumors Malignant neoplasms • Hepatocellular carcinoma • Cholangiocarcinoma • Hepatoblastoma • Epithelioid hemangiendothelioma • Hepatic sarcomas Benign • Hepatic adenomas • Focal nodular hyperplasia • Hemangiomas

  5. Patient evaluation Clinical • Complete history and physical examination. • Since detection of advanced co morbid disease or more extensive tumor spread, usually extrahepatic metastases, will often eliminate the patient from further consideration of surgery as the principal therapy.

  6. LAB STUDIES • Complete blood count • Serum electrolytes • Liver function test (LFT). • Tumour markers

  7. L F T • Parenchymal (hepatocytes)-AST, ALT • Canalicular (biliary)-ALP, 5´NT, GGT, bilirubin • Synthetic function and metabolism-INR, albumin • History of hepatitis- anti-hepatitis B antibody, hepatitis B surface antigen, and anti-hepatitis C antibody

  8. Tumour markers • Screening for tumors or monitoring tumor status following treatment • Elevated a-fetoprotein levels (normal 1 to 10ng/ml) has a sensitivity of 68% for early Hepatocellular carcinoma(HCC) • Combined with trans-abdominal ultrasound in patients with chronic hepatitis and cirrhosis for early diagnosis of HCC • Sharp steady rise in serum AFP - highly diagnostic • α-fetoprotein-L3, an isotype more closely associated with HCC • abnormal prothrombin or PIVKA-II another tumor marker in HCC.

  9. IMAGING STUDIES • The single most important factor for the current success of liver-directed therapy is better patient selection due to the accuracy of modern imaging studies. • Imaging studies have the following goals: (i) Determination of the number and distribution of the liver lesion(s) (ii) Anatomic and functional characterization of liver lesion(s) (iii)Delineation of the lesion(s) relationship to significant vascular and biliary structures (iv)Detection of extrahepatic and extra-abdominal tumor.

  10. ULTRASOUND • Readily available, least expensive, and least invasive of the imaging modalities for the liver. • Greater detail about intratumoral anatomy and tissue characteristics is provided by ultrasound when compared with CT. • Valuable therapeutic role when used in the ablation of liver lesions, particularly in alcohol ablation.

  11. Intraoperative ultrasonography (IOUS) • Gold standard to detect the number, extent, and association of tumors with intrahepatic blood vessels. • IOUS can be performed laparoscopically or during laparotomy • Prior to proceeding with liver resection for malignancy, all patients should undergo IOUS as a way of excluding the presence of smaller lesions not detected by preoperative studies. • IOUS is necessary for intraoperative image-guided procedures such as biopsy and radiofrequency ablation (RFA).

  12. The use of intraoperative ultrasonography in a laparoscopic left lateral sector liver resection. The ultrasound probe (inset photograph) is used to delineate the thickness of the liver and the location of the portal structures and left hepatic vein in the left lateral sector. Asterisk = inferior vena cava; white arrow = thickness of the liver at the ligamentum venosum groove.

  13. Computed tomography • Modern helical CT scans are and are highly sensitive at spatial discrimination • The smallest detectable lesion size is approximately 1 cm. • Post-liver resection, residual liver volumes can be calculated with CT volumetrics- Important in planning extensive liver resections and living donor transplantation

  14. A CT scan of the upper abdomen showing a widespread (disseminated) carcinoma of the liver (hepato cellular carcinoma). The liver is the large organ on the left side of the picture. Note the moth-eaten appearance.

  15. Triphasic CT • Liver receives vascular inflow from both hepatic artery (30%) and portal vein (70%), while tumors receive their blood flow almost exclusively from the hepatic artery. • After the noncontrast images are obtained contrast injected, scanning repeated at 25 sec (arterial phase) and 70 sec (portovenous phase) • HCCs therefore enhance early on during the infusion of contrast, in the arterial phase • The liver parenchyma enhances during the portal venous phase

  16. Lipiodol computed tomography(LCT) • Lipiodol, which is an ethiodized oil emulsion, is unique in that it is retained (indefinitely) within tumors but not normal or cirrhotic liver. • Lipiodol is mixed with chemotherapeutic drugs so that these drugs will have both a higher concentration and duration of action when retained within the tumor.

  17. Magnetic resonance imaging • MRI has not achieved the same widespread popularity as CT for routine imaging of the liver • MRI does offer excellent delineation of lesion morphology and characteristics as a result of using multiple pulse sequences. • MRI scans are more sensitive for detecting early HCC and in distinguishing HCC from macroregenerative nodules. • Ability to characterize reliably benign liver lesions, such as cysts or hemangiomas, from malignant lesions is a major advantage of MRI.

  18. Nuclear scans • Normal liver tissue contains Kupffer cells- take up 99Tcm-sulfur colloid. Tumours lack Kupffer cells, and are visualized as photopenic defects on liver–spleen scans. • 99Tc- albumin scan is useful in distinguishing complex FNH from an adenoma. This agent is taken up by Kupffer cells in FNH while most adenomas are "cold" because they lack Kupffer cells.

  19. Positron emission tomography (PET) • The alteration of biochemical processes within tumors usually precedes their detection by gross anatomic changes. • Enhanced glycolysis and glucose retention in tumor cells is the basis for 18F-fluorodeoxyglucose PET imaging • Only modest success in hepatocellular carcinoma.

  20. Fusion of positron emission tomography and computed tomography to demonstrate a large malignant tumor involving the right liver lobe(CT-PET)

  21. Percutaneous Biopsy • As the specificity of imaging studies had improved percutaneous biopsy is rarely indicated • In patients in whom the diagnosis is not evident a percutaneous biopsy can be done with ultrasound or CT guidance. • The target lesion should be accessed through a quantity of normal liver tissue sufficient to avoid free rupture of tumor into the peritoneum

  22. Diagnostic laparoscopy • Because of the limitations of CT and MRI for detection of extrahepatic tumor recurrences, diagnostic laparoscopy has been considered as an initial step in surgical exploration. • One-third of patients with HCC will be deemed unresectable by laparoscopy due to the detection of unrecognized intrahepatic tumor spread or peritoneal seeding

  23. MALIGNANT NEOPLASMSHepatocellular carcinoma • Most common primary malignant tumor of liver in adults. • Hepatocellular carcinoma causes an estimated one million deaths annually • High mortality - both patient presentation at a late stage of the disease and poor hepatic function resulting from cirrhosis

  24. HCC- Etiology Environmental and viral. • The most prominent factor worldwide is chronic hepatitis from HBV and HCV infection. • The annual cumulative risk in chronic viral hepatitis without cirrhosis is approximately 1 %, while with cirrhosis the risk ranges from 3 to 10 %. • Most potent natural carcinogen is a product of Aspergillus fungus called aflatoxin B1. • In low-incidence areas, alcohol-induced hepatic cirrhosis has a major etiologic association -its role as a cocarcinogen rather than a direct carcinogenic agent.

  25. Other risk factors: • Wilson’s disease, • Tyrosinemia, • glycogen storage disease, • oral contraceptives(by causing hepatic adenoma), • Androgens and anabolic steroids, • Organochlorine pesticides, • Tamoxifen (animal studies) • Hemochromatosis • Alpha 1-antitrypsin deficiency.

  26. HCC-Clinical presentation Presenting symptoms and signs are related to the tumor stage • The most common, and often the first complaint is right upperquadrantabdominal pain, which may be accompanied by abdominaldistention. • Anorexia or early satiety with weight loss is present in one-third of patients. • In a patient with cirrhosis, the development of unexplained upper abdominal pain, weight loss, fever, enlargement of the liver, or ascites should alert the possibility of HCC.

  27. The physical findings associated with HCC depend on the stage of the disease. • Hepatomegaly is present in more than 90% of patients; the liver is irregular and nodular on palpation. • A hepatic arterial bruit or a friction rub may be present. • Ascites is found in up to 50% of patients. Splenomegaly indicates long-standing cirrhosis.

  28. If present, jaundice is usually slight or moderate; it tends to become deeper with progression of the disease. • The Budd-Chiari syndrome - malignant invasion of the hepatic veins. • Paraneoplastic manifestations- • hypoglycemia caused by ectopic production of insulin like growth factor(IGF)(most common) • erythrocytosis • hypercholesterolemia

  29. PATHOLOGIC DIAGNOSIS Four major gross patterns and two special forms of HCC have been described. • (1) expanding type, the tumor is encapsulated and grows by compressing the surrounding parenchyma. • (2) spreading type, the tumor is poorly defined and occurs in hepatic cirrhosis. • (3) multifocal pattern in which several small tumors of similar size are found in multiple sites in the liver. • (4) A indeterminate pattern is seen in up to 25% of cases.

  30. Two special forms of HCC. (1) The fibrolamellar form - 2% to 4% of cases • In young women and is characterized by neoplastic hepatocytes with fibrosis arranged in lamellar fashion. • Not associated with elevated serum AFP, chronic viral hepatitis, or cirrhosis. • Survival following surgical resection is significantly better, even with extrahepatic metastases. (2) The other special form, cholangiocellular carcinoma, appears to be a combination of cholangiolar elements as well as hepatocellular elements. • These tumors behave more like cholangiocarcinoma and tend to occur in noncirrhotic livers, with a male predominance. • The outcome for patients with this form of HCC is uniformly fatal.

  31. Patient evaluation and selection • Prognosis of patients with HCC is determined not only by the tumor's stage, but also by the functional status of the patient's liver. • Child's classification give an excellent initial idea of treatment limitations imposed by hepatic dysfunction. • quantitative assessment of liver function is usually required. Indocyanine green clearance - accurate indicator of hepatic reserve.

  32. Adverse tumor factors include • multicentricity, bilobar distribution, • size greater than 5 cm, • capsular invasion, extrahepatic metastases, and • vascular invasion or thrombosis.

  33. Surgical resection Patients selected meet the following criteria: • a solitary HCC less than 10 cm in diameter or • up to three smaller HCC in a surgically accessible location(s); • no vascular invasion of main portal trunk, or hepatic vein; • no extrahepatic tumor (with the exception of fibrolamellar hepatocellular carcinoma); • Child's class A or well compensated B; • adequate liver function by quantitative studies; • intact performance status; excellent control of significant comorbid medical illnesses, particularly diabetes mellitus and renal insufficiency. The operative goal is as limited a resection as possible to achieve a 1-cm margin of normal tissue

  34. A right subcostal incision (A) with a midline extension to the xiphoid (D) is the most common choice; an extension to the left subcostal area (C) is sometimes added to provide further operative exposure

  35. HEPATIC RESECTIONS

  36. Non-anatomic resection • A non-anatomic resection or partial lobectomy is frequently used, particularly in patients with cirrhosis. • Regardless of technique, the principal goal during parenchymal transection is to maintain more than a 1-cm margin

  37. Ablative techniques • Percutaneous ethanol injection • Cryoablation • Radiofrequency ablation • Embolization and chemoembolization • Systemic chemotherapy

  38. Cryosurgical techniques also have shown applicability to treating hepatocellular carcinoma. A probe containing circulating liquid nitrogen is introduced directly into the primary liver tumor and the lesion is frozen using ultrasound guidance. Cryosurgery can be applied to tumors up to six centimeters in size but, unlike ethanol injection, requires an open surgical procedure.

  39. Radiofrequency ablation is a newer technique that is particularly well-suited for destruction of hepatocellular cancers. A 14 gauge needle is directed into the tumor by ultrasound or CT guidance and an alternating current is applied, similar to microwave. The heat generated exceeds 100 degrees Celsius and destroys the tumor. RFA appears to be safer than cryosurgery, although it's effectiveness compared to cryosurgery is less clear. RFA can be done using minimally invasive techniques such as percutaneously (through the skin) or laparoscopically using a video camera system. For larger, more difficult tumors, a more traditional surgical approach may be needed.

  40. A schematic diagram demonstrating a patient undergoing radiofrequency (RF) ablation of a malignant liver tumor (top half of illustration). The multiple array RF electrode is inserted into the liver tumor with the intent of producing complete coagulative necrosis of the tumor and a surrounding zone of nonmalignant hepatic parenchyma. The RF needle electrode and grounding pads from the patient are attached to a radiofrequency generator. The lower portion of the diagram shows the ionic agitation that occurs around the multiple array RF needle electrode when alternating current from the RF generator is applied. Ionic agitation produces frictional heating in the tissue, resulting in coagulative necrosis of tissue around the electrode.

  41. CHEMOEMBOLIZATION

  42. PREVENTION PRIMARY PREVENTION • Prevention of HBV and HCV infection are the most effective ways of preventing HCC. • Vaccination in early childhood, particularly in endemic areas, has been the most effective strategy in preventing chronic HBV infection • Prevention of HCV infection is more difficult because there is no vaccine or effective postexposure prophylaxis available. • Because transmission is primarily parenteral, universal precautions against exposure to blood-borne infectious agents will be effective against HCV.

  43. SECONDARY PREVENTION • Effective secondary prevention is dependent on early detection and resection of small tumors. • Patients with chronic viral hepatitis or cirrhosis of any etiology are candidates for semiannual or annual screening with α-fetoprotein, withultrasonographic follow-up of those with α-fetoprotein > 20 ng/mL for early detection of liver tumors.

  44. Cholangiocarcinoma • Cholangiocarcinomas account for 10 per cent of all primary hepatic malignancies and are second to hepatocellular carcinoma in incidence. • Two types – Hilar and peripheral cholangiocarcinoma • The much commoner hilar form usually situated at the confluence of the right and left hepatic duct. • Peripheral cholangiocarcinoma develops in the small intrahepatic bile ducts and is associated with etiologic factors including • Hepatobiliary parasites, particularly flukes, and intrahepatic lithiasis.

  45. CLINICAL FEATURES • Hilar cholangiocarcinoma – jaundice,pruritus, abdominal pain, fever , wt loss . • Peripheral cholangiocarcinoma - vague abdominal pain ,unexplained wt loss , progressive weakness.

  46. Technique of transhepatic percutaneous cholangiography; B, corresponding percutaneous cholangiograph (after catheter is introduced).

  47. Computed tomography (CT) image showing cholangiocarcinoma in the hilum of the liver.

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