Transcript Acute Pancreatitis

Malignant hepatic
lesions
Prepared by:
Dr. yasser Baashan
Anatomy of the liver
The liver is divided either into lobes or segments
Lobes (Gross anatomy):
- A large right lobe and small left lobe utilizing the line
of attachment of the falciform ligament
- Used customarily by the anatomist
Segments (Functional anatomy):
- Based on the blood supply and the biliary drainage the
liver is divided into 8 segments (I-IIIV)
- It is possible to resect a single of several segments
without compromising the rest of the liver
Liver lobes
Liver segments
Assessment of liver function
“Hepatic functional reserve”
- It is essential for the surgeon to estimate the ability of the
hepatic remnant to be sufficient after liver resection
- A number of scoring systems and functional tests are used:
- Child-Pugh Score
- MELD Score
- CT-Volumetry
- Others ( Not often used clinically)
- Indocyanine Green Clearance (IGC)
- Protrombin activity after administration of vit. K
- Dynamic Single Photon Emission Computed Tomography (SPECT)
- Aminopyrin breath test
Child-Pugh Score
Parameter
1 Point 2 Points
3 Points
Serum bilirubin (mg/dl)
<2
2-3
>3
Albumin (g/dl)
> 3.5
2.8-3.5
<2.8
Protrombin time ( sec.)
<
4-6
>6
Ascitis
None
Slight
Moderate
Encephalopathy
None
Grade 1-2 Grade 3-4
A: 5-6 points B: 7-9, C: 10-15
Currently partial hepatectomy is only offered to patients with Child A and
most favorable Child B
MELD Score
“Model for End stage Liver Disease”
Score = 0.957 x loge creatinine (mg/dL) + 0.378 x loge
bilirubin (mg/dL) + 1.120 loge INR
Range: 4-60
Patients receive liver transplantation with MELD > 15
CT-Volumetry
- Applied in patients planned for extended hepatic resection who have
a small future liver remnant
- Involves rapid sequence, thin sections helical CT-Scan that directly
measures liver volume
- The volume of the liver segments remaining after resection is
divided by the total estimated liver volume to obtain a percentage of
the future liver remnant
- This percentage should be:
> 20% (in patients with normal liver parenchyma)
> 40% (In patients with cirrhosis)
- If the future liver remnant is not adequate then portal vein
embolisation is considered to induce hypertrophy of the liver
remnant
Malignant tumors of the liver
Primary:
1- HepatoCellular Carcinoma (HCC)
2- Intrahepatic cholangiocarcinoma
3- Others (rare): - Hepatoblastoma
- Cystadenocarcinoma
- Angiosarcoma
- Non-Hodgkins’s lymphoma
- Epitheliod haemangioendothelioma
Metastatic:
1- Colorectal
2- Neuroendocrine
3- Non-Colorectal, Non-neuroendocrine
Breast, lung, melanoma, soft tissue sarcoma, upper GIT tumors,
urologic, gynecologic
Hepatocellular carcinoma
- On of the most common solid cancers
- Geographical distribution parallels the incidence of hepatitis B
and C (Highest in far east and sub-Saharan Africa)
- Majority of cases associated with HBV and HCV
- Usually develops in a back ground of cirrhosis but can originate
in normal liver
- Cirrhotic HCC
- Viral cirrhosis: HBV, HCV (Risk of HCC 3-5% per year)
- Non-viral cirrhosis: Haemochromatosis (7-9% per year)
Alcoholic (1-4 per year)
Primary biliary cirrhosis
Wilson’s disease
- Non-cirrhotic HCC
Fibrolamellar variant, HBV, HCV (rare)
- There are no marked difference between cirrhotic and noncirrhotic HCC in the symptoms, size of tumor at presentation,
serum markers and HBV status
- HCC has poor prognosis with fatal outcome (median survival of
4 months in symptomatic patients)
Surveillance for HCC
- Should be considered for the following high risk groups:
- Viral cirrhosis:
HBV
HCV
- Non-viral cirrhosis: Haemochromatosis
Alcoholic
Primary biliary cirrhosis
- Using abdominal US and AFP
- The surveillance interval should be 6 months
Diagnosis of HCC
- A focal lesion in the liver of a patient with cirrhosis is highly
likely to be HCC
- Hypervascular mass in CT/MR combined with AFP > 400
ng/ml is diagnostic
- Initial assessment should be by spiral computed tomography
(CT) of the liver (local spread) and thorax (metastases)
- Magnetic resonance imaging (MRI) with contrast enhancement
may increase the accuracy of detection of other liver lesions
- Biopsy is rarely required for diagnosis. Biopsy of potentially
operable lesions should be avoided where possible
Investigating a mass in cirrhotic liver:
Liver mass on ultrasound
AFP raised
AFP normal
Asses for surgery
CT/MR
Diagnostic of HCC
Major diagnostic doubt
Biopsy
Negative
Follow up at 6 months
Investigating a mass in non-cirrhotic liver:
Liver mass on ultrasound
AFP raised
AFP normal
Exclude testicular primary
Asses for surgery
Diagnostic of HCC
Search for non-liver primary
CT/MR
Major diagnostic doubt
Biopsy
Negative
Follow up at 6 months
α-Fetoprotein:
-
Normal serum protein synthetize by fetal liver cells and yolk sac
The most useful marker for HCC and teratomas of testis/ovary
Normal range 10-20 ng/ml
A level > 400 ng/ml is diagnostic for HCC
A rising level even if does not reach 400 ng/ml is diagnostic
A level between 20-400 ng/ml my indicate small HCC,
regenerative nodules of cirrhosis or teratomas of testis/ovary
- Two third of HCC <4 cm have a level < 200 ng/ml
- Up to 20% of HCC does not produce AFP even when large
CT-Scan:
- The smallest detectable lesions size 1cm
- As HCC is a hypervascularized lesions they will light up during
the arterial phase
- Isodense or hypodense during the portal phase
- Limited ability to differentiate HCC from macronodular
regenerative nodules of cirrhosis
Magnetic Resonance Imaging (MRI):
More sensitive than helical CT in detecting early HCC and in
distinguishing between HCC and macroregenerative nodules
Positron Emission Tomography (PET):
Less useful because many of these tumors do not have a
significantly higher intake of the radioisotope when compared
with the surrounding hepatic parenchyma
Treatment of HCC
Surgical:
Resection
Orthotopic liver transplantation
Ablative:
Alcohol injection
Thermal ablation (cryotherapy, radiofrequency
ablation RFA, microwave)
Transarterial: Embolization
Chemoembolization
Systemic:
Chemotherapy
Hormonal
Immunotherapy
External-beam Radiation Therapy
Surgical treatment of HCC:
Indication: Single small HCC (≤ 5cm) or up to 3 lesions ≤ 3cm
(Milan criteria)
Options:
1. Liver transplantatioin
Cirrhotic liver
2. Hepatic resection
Non-cirrhotic liver
Child A cirrhotic liver not suitable for Tx
- Pre- and postresection chemotherapy is not recommended
- In patients with limited residual functional reserve (small liver
remnant) resectability my be achieved by:
1. Portal vein embolisation
2. Two-stage hepatectomy
3. Combination of surgery and ablation
Nomenclature for Most Common Major Anatomic Hepatic
Resections:
Type of resection
Segments
Right hepatectomy
V-VIII
Extended right hepatectomy
IV-VIII
Left lobectomy
II, III
Left hepatectomy
II-IV
Extended left hepatectomy
II, III, IV, V, VIII
Other common sublobar resections:
Right posterior sectorectomy VI, VII
Right anterior sectorectomy V, VIII
Single segment or bisegmental resections
Right hepatectomy
Left lobectomy
Extended right hepatectomy
Left hepatectomy
Extended left hepatectomy
Radiofrequency ablation (RFA):
-
-
Application of a high-frequency alternating current from the
tip of an electrode to the surrounding tissues
increase
tissue temperature
coagulative necrosis
May be applied via a percutaneous, laparoscopic, or open
approach
After RF ablation CT scans demonstrate cystic areas ideally
larger than the original tumors
Safe and effective for patients who do not meet the criteria for
surgery or as a bridge to transplantation
Alcohol injection:
- The simplest ablative therapy
- Absolute alcohol is used to destroy the tumor
- Suitable for peripheral lesions < 3cm
Transarterial embolisation/chemoembolisation (TACE):
- Based on the fact that HCC supply is from the hepatic artery
- Induces ischemic necrosis of HCC
- Embolisation particles are sponge or oils (lipiodol) that are selectively
taken by HCC (with or without chemotherapeutic agents)
- Suitable for large/multifocal HCC
Pre TACE Angiography
Post TACE Angiography
Pre TACE CT-Scan
Post TACE CT-Scan
Colorectal cancer liver metastases
-
The liver is often the first site of metastases
- The only site of spread in 30-40%
- 20-35% of patients have clinically detectable liver met. at initial
presentation
- 40-50% eventually develop liver met. after resection of primary
usually within the first 3 years
- 20-30% of liver met. are potentially resectable
- Survival:
Without treatment
median < 8 months, 5-years exceptional
After resection
5-years survival 25-44%
Investigations for detection of hepatic
and other metastases
Investigations in patients with primary colorectal cancer:
1. CT-Scan Abdomen and pelvis
2. Chest CT (chest x-ray is considered satisfactory)
3. Colonoscopy or Barium enema
4. Baseline measurements of CEA
Investigations for follow-up after curative resection of primary:
1. CT-Scan Abdomen and pelvis (as a minimum in the two years
following resection)
2. Colonoscopy repeated after 5 years
3. Serial CEA measurements
Investigations to detect extrahepatic met. in patients with
liver met.
1. CT-Scan chest, abdomen, pelvis
2. Biopsy of hepatic lesions ?
3. PET
Patients with high risk primary disease (T4, perforation)
4. Laparoscopy
Treatment of colorectal metastases
- Liver resection
- Ablative therapy
- Chemotherapy and neoadjuvant chemotherapy
Liver resection:
Patients without extrahepatic disease:
Indication: When it is possible to remove all macroscopic
disease with clear (negative) margin and leave
sufficiet functioning liver
- Acceptable residual functioning volume is 1/3 of liver
volume or a minimum of two segments
- In patients with small residual functioning volume
resectability may be achieved by:
1. Portal vein embolisation
2. Two-stage hepatectomy
3. Combination of surgery and ablation
Liver resection in patients with extrahepatic disease:
Indications:
- Resectable/ablatable pulmonary metastases
- Resectable/ablatable isolated extrahepatic sites (spleen, adrenal, or
respectable local recurrence)
- Local direct extension of liver metastases (to diaphragm/adrenal)
Contraindications:
- Non-treatable primary tumor
- Widespread pulmonary disease
- Locoregional recurrence
- Peritoneal disease
- Extensive nodal disease, such as retroperitoneal, mediastinal or portal
nodes
- Bone or CNS metastases
Ablative therapy:
Indications:
- Patients who are not candidate for resection
- Associated comorbidity that preclude resection
- Patients who refuse surgery
- Tumor downsized by chemotherapy but are not resectable
Chemotheray and neoadjuvant chemotherapy:
Indications:
- Advanced disease unsuitable for resection or ablation
- Downsizing of tumor if they are unable to be resected initially
due to location or inadequate hepatic functional reserve
Regimens:
Firstline:
Oxaliplatin, 5-fluorouracil, folinic acid (Folfox)
Secondline: Irinotecan, 5-fluorouracil, folinic acid (Folfiri)
Increase resectability with chemotherapy
Synchronous metastases
- Normally colorectal cancer and liver resection would not be
performed synchronously. Liver resection should be performed
after recovery from primary surgery
If radical resection of primary
Liver resection before chemo.
Unfavorable primary (perforation, extensive nodes)
Adjuv. chemo before
liver resection
- New strategy (Liver first strategy)
Chemo
Liver Chemo
CRC
- To downstage the metastases in 80%
- To select responders, avoiding unnecessary surgery in non-responders
- To deliver preoperative rectal radiotherapy without the fear that liver
metastases would meanwhile progress beyond the possibility of cure
- Accessible small met. detected preop. may be considered for
combined resection
- Lesions discovered at operations should not be biopsed
(significant risk of local dissemination)
Follow-up after liver resection
- Continue for 5 years
- Using CT-Scan chest and abdomen
- Recurrent lesions are treated in the same way as the initial
hepatic metastases
Non-resectable metastases
- Resectability is becoming a new end-point in strategies involving
chemotherapy in non-resectable patients
- 15-30% of patients could be switched to resectability
- Benefit in survival: 35% at 5 years
Thank You!