Transcript MAHARANI LAXMI BAI MEDICAL COLLEGE, JHANSI “MANAGEMENT OF LIVER SECONDARIES” Dr. Mukesh PUBLISHED BY www.medicalppt.blogspot.com www.medicalppt.blogspot.com.

MAHARANI LAXMI BAI MEDICAL COLLEGE, JHANSI
“MANAGEMENT OF LIVER
SECONDARIES”
Dr. Mukesh
PUBLISHED BY
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MANAGEMENT OF LIVER SECONDARIES
METASTASIS
The term metastasis connotes the development of secondary
implants discontinuous with the primary tumor, possibly in
remote tissue.
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A liver studded with metastatic cancer
INCIDENCE
Metastasis is the most common neoplasm in an adult liver.
Liver is the second most common site for metastatic spread,
after the lymph nodes.
The primary sites most commonly metastasizing to the liver
are  Ovary (52%)
 Colon (65%)
 Pancreas (63%),
 Rectum (47%)
 Breast (60.6%),
 Stomach (45%)
 Lung (36%),
 Gallbladder
and
extrahepatic bile
 Kidney (26%)
ducts (60.5%), www.medicalppt.blogspot.com
Nearly two-third of patients with colorectal cancer will develop
hepatic metastasis.
25% to 50% of patients dying of cancer are found to have
hepatic metastasis.
TERMINOLOGY
Metachronous - Metastases appearing much latter than
treatment of primary eg. melanoma of chord.
Synchronous - Primary & metastasis detected at the same time.
eg-carcinoma stomach.
Precocious - Metastases appearing before primary is suspected.
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eg-carcinoid, rectal carcinoma.
PATHOPHYSIOLOGY
Metastasis reach to liver by four routes 1. Direct invasion (stomach, colon, bile ducts, gall
bladder)
2. Lymphatics (breast and lungs via mediastinal
nodes)
3. Hepatic artery (lung, melanoma.)
4. Portal vein (colorectal)
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PRESENTATION
Incidental
Dull aching pain in right hypochondrium,
Loss of appetite, asthenia, weakness, mailase,
Jaundice, anemia, vomiting,
Hepatomegaly, ascites
Enlargement of Both lobes, sharp lower border, nodular
surface, hard consistency,
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Prognostic factors 1. No. of metastasis
2. Resection margin status
3. High preoperative CEA
4. Size of largest tumor
5. Stage of primary tumor
6. Disease free interval
7. Synchronous disease
8. Extra hepatic disease
9. Peripheral
nodal status
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Preoperative Patient Evaluation
 Before even thinking on performing a liver resection, it is
necessary a thorough oncologic examination, seeking other
localizations, and also to verify the absence of contraindications.
 Regarding morphological tests, an abdominal US, CT and
afterwards a MRI, allow to acquire a better knowledge
regarding
number
of
metastases,
precise
location,
relationship with the portal pedicle and the hepatic veins.
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 Pulmonary
localizations
must
be
ruled
out
systematically, using CT examination. If these lesions
are
resectable,
they
don’t
constitute
a
contraindication to liver resection.
 A colonoscopy is always performed to rule out
recurrence, even if the primary tumor has already
been resected.
 If necessary, a bone scan or a brain CT can be
performed.
 Regarding the blood chemistry, it consists of liver
function tests, tumor markers, coagulation profile.
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Evaluation of functional hepatic reserve - in patients who
received neoadjuvant chemotherapy or those with a preexistent
liver pathology (hepatitis, cirrhosis. Tests used are- Child pugh class
 Indocyanine green clearance test
 Aminopyrine & phenylalanine breath test
 Galactose elimination rate
 Hippurate ratio
 SPECT
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Treatment Options
A. Surgical resection
B. Ablation
1. Cryotherapy
2. Radiofrequency ablation
3. Laser interstitial thermal therapy (LITT)
4. Microwave coagulation therapy
C. Chemotherapy
1. Neoadjuvant
2. Intra-arterial
3. Systemic
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4. Chemoembolisation
D. Radiotherapy
1. Stereo tactic body radiation
2. Selective interstitial radiation therapy
E. Liver transplantation
AIMS OF TREATMENT
Curative intent - Multimodal treatment may allow complete
tumor clearance
 Combination of surgery + other ablative techniques
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 Neoadjuvant treatment
to improve resectability
Palliative intent
Decision tree for patients with hepatic metastases. Beginning with treatment of the
primary tumor, optimal management
depends on careful weighing of multiple factors
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and making the best individual treatment choice.
Surgical resection
80%-90% of resections of hepatic metastasis are for
colorectal cancers.
First hepatic resection for hepatic metastasis-by Garre in
1988.
1949 total right lobotomy by Wangensteen.
1959-hepatic artery infusion.
1972 implantable pump.
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Functional anatomy
It is composed of eight segments each of which is supplied by a
single portal triad composed of a portal vein hepatic artery &
bile duct.
Segmental anatomy of the
liver as seen at laparotomy in
the
anatomic
position
(Surgical and radiologic
anatomy of the liver and
biliary tract)
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Anatomical Resections
They follow the liver segmentation principles described by
Couinaud. They are considered as minor, when less than 3
segments are resected, or major, when resection includes more
than 3 segments.
Nomenclature for Most Common Major Anatomic Hepatic
Resections
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The most common approach to a anatomic resection in most
common order,
 Mobilization of liver
 Dissection of inflow and outflow structure
 Division of inflow
 Division of outflow
 Parenchymal transection
Non-Anatomical Resections
They include the resection of a portion of the liver
independently of the liver scissors and glissonian pedicles.
They refer mainly to metastasectomies. The liver resection
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depends on the size of the tumor.
Rules to Respect During Hepatectomy
Independently of the type of liver resection, one must follow
these rules in order to avoid postoperative complications:
1. Functional liver parenchyma preservation of at least 30% of
the total liver mass, to avoid hepatic insufficiency.
2. Limit blood loss, in order to avoid transfusions, because it is
a known risk factor that favors recurrence.
3. Resect the 1 mm margin, to reduce the risk of recurrence.
4. Resect glissonian pedicles destined to the remaining
segments, to avoid segmental exclusion, ischemia and
necrosis, and biliarywww.medicalppt.blogspot.com
fistulas.
ABLATION
1. Cryotherapy
 Destruction of tumor cells by freez thraw.
 Probe positioned over tumor
 Liquid nitrogen is circulated through tip of probe
 Temp lowered to -100° C
 1-3 cycles of freezing for 15 mins with spontaneous
periods of thraw
 Lethal temp -20° C
 Intracellular or extra cellular ice forms
 Ice ball of ~3-6cm
Complications
biliary,
abscess,
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haemorrhage, coagulopathy,
cryoshok
myoglobinuria,
2. Radiofrequency ablation
 Radiofrequency waves (high frequency alternating
current - 460khz) are converted into thermal energy
 Friction from rapidly moving ions results in heat
 Temp of ~60°C
 Coagulative necrosis
 Open/laparoscopic or percutaneous technique
 Effective with tumors upto 5 cm
Complications - bilioma’s, biliary fistula’s, stricture’s
abscess
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3. Laser interstitial thermal therapy (LITT)
 Placement of laser fiber or fibers directly into the
tissue to be treated.
 Infrared laser producing lethal thermal injury to tumor
cells
 LITT utilizes diod laser or more frequently Nd-YAG
laser
 Coagulative necrosis
 Procedure is usually performed under MRI.
 Extensive use ifwww.medicalppt.blogspot.com
MRI is its major drawback.
4. Microwave coagulation therapy
 Uses microwave of frequency 2450 Mhz
 Produces heat by stimulation of water molecule
 Produces rapid frictional heating and coagulative
necrosis
5. Intratumoral alcohol injection
 Causes denaturation of protein leading to cell death..
 Can be used for tumors <3cm.
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RADIOTHERAPY
1. Stereo tactic body radiation
 Tolerance of liver to radiation is poor.
 Conformational radiation therapy using multiple field &
beam angles is used to deliver large doses to a target
sparing surrounding normal tissues.
2. Selective interstitial radiation therapy
 Micro spheres containing yttrium 90 (sir spheres)
 Injected via hepatic artery
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 Tumor cells receive a higher proportion of there blood
supply via hepatic artery.
 200-300 Gy to tumor ,15-50 Gy to liver
 B radiation with a penetrance of 2-3 mm
 Half life of 64 hours.
 Percutaneous cannulation of hepatic artery
 Administration of spheres
 Spheres selectively lodge into tumor cells
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CHEMOTHERAPY
1. Neoadjuvant
 Patients at high risk of recurrence should receive
neoadjuvant chemotherapy.
 Drugs include oxaliplatin, irinotecan, 5fu, leucovorin.
 20-30 % of patients who were unrespectable will be
rendered potentially respectable.
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2. Hepatic artery infusion therapy (implantable
pump)
 Rationale is that hepatic metasis is perfused almost
exclusively by hepatic artery.
 Injection of floxuridine into hepatic artery demonstrates
mean tumor fudr levels are significantly increased
 Can be administered by implantable pumps
 Most common problems with hai are hepatic toxicity &
ulceration of stomach & duodenum.
 Addition of dexamethasone in hai has resulted in
decreased toxicity.
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This schematic shows the catheter inserted into the gastroduodenal artery
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for hepatic infusion
3. Systemic
 Does not improve survival following resection or ablation.
 Leads to systemic & hepatic toxicity.
 Usually not tolerated by the patients.
4. Chemoembolization
 Administration of intra-arterial chemotherapy f/b infusion
of one of a number of embolic agents such as degradable
starch, gelatin powder pvc,
 Best accepted use is for patients with unrespectable
metasteses from characinoid or islet cell tumors.
5. Targeted therapy
 Cetuximab (monoclonal antibody to egf.
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 Bevacizumab (monoclonal antibody to vegf)
PORTAL VEIN EMBOLIZATION
 If portal vein branch of particular segment is blocked it
leads to ipsilateral lobe atrophy & contralateral lobe
hypertrophy .
 Lead to the concept initiating hypertrophy of segment
of liver that would remain following a major liver
resection.
 Percutaneous approach is the standard technique for
portal vein embolization.
 Studies shown that future liver volume increased from
19%-36% of total liver volume pre embolization to 31www.medicalppt.blogspot.com
59% postembolization.
LIVER TRANSPLANTATION
Which could an option when resection could not be tolerated
owing to inadequate liver reserve, rarely is performed for
metastatic disease because of high risk of recurrence related to
immunosuppressant.
Valid Indications and New Operative Strategies
A patient with liver metastases limited to one segment without
extrahepatic dissemination is always a candidate for liver
resection. The challenge for hepatobiliary surgeons is to achieve
the necessary resources and strategies that allow the patients’
benefit.
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Patients can be divided into four groups
1. Patients with a voluminous hepatic metastases in which
resection leaves an insufficient amount of functional liver
parenchyma.
2. Patients with bilobar metastases.
3. Patients with recurrence after resection.
4. Patients with a primary colorectal tumor and synchronous
liver metastases.
Patients with a Voluminous Liver Metastases
Two alternative may be offered: Tumor downsizing with
systemic or local chemotherapy, and hypertrophy of the
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future remaining liver
(non-tumoral) by portal embolization.
 Downsizing: the use of neoadjuvant chemotherapy
with 5-fluorouracyl, folinic acid and oxalyplatin,
achieved an adequate tumoral downsizing, with similar
results
as
those
patients
initially
resectable.
Liver parenchyma (usually left lobe), surgeons look for
hypertrophy of the non-tumoral liver.
 Portal Embolization: When resection is not viable due
to
insufficient
functional
nce
embolization
is
performed, hypertrophy is evaluated 5-6 weeks after
the procedure. If the future remaining liver is >30%,
then hepatectomy can be performed.
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 Hepatectomy associated to resection and tumoral
destruction by local treatment: Here, the greater
lesions are resected and the lesser ones are destroyed
locally by either RFA or cryotherapy.
 Two-stage
Hepatectomy
after
neoadjuvant
chemotherapy: The goal is to achieve an adequate
downsizing of the tumor that allows for a resection in
a one-stage or two-stage procedure.
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Patients with Recurrence after Resection
Surgery is the only curative option for these patients. It has
been shown that patients with a liver recurrence isolated or
associated with a resectable extrahepatic metastases,
resection of all the tumoral tissue achieves an overall
survival similar to patients without recurrence.
Patients with a Primary Colorectal Tumor and
Synchronous Metastases
Surgical strategies remain controversial. Those who favor
simultaneous resection, and those who oppose it, differ in
terms of oncological basis, immunological techniques and
patient comfort.
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