liver tumor surgical options smadi jordan, cancer

Liver tumors surgical options: 

Liver tumors surgical options Sameer Smadi MD. Consultant HBP and liver transplantation surgeon Amman-Jordan A.Zyadat , S. Halasa , M. Ghatashah , H. Haboob , I. El- Ghazzawi , G. Dhayat , A. Obeidat , H. garaybeh , I. Athamneh , A. Edwan , A. omari , A. Hiari,T . Beshah , K. Haddadin , N. Quased K. Ajarmeh , S. Al- Qusous , S. Eghazzawi , A. Faori , T. Mnayzel , L. Fayyad, , E. gtaish . S. haddad , W. Obeidat King Hussien medical center Department of surgery

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Two important issues made the liver surgery and transplantation a reality: Regeneration of the liver. The regenerative power of the liver was first described by the Greeks more than 2,500 yrs ago. (mythology of Prometheus). King Hussien medical center Department of surgery

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Understanding of liver anatomy. “A good knowledge of the anatomy is a prerequisite for modern surgery of the liver.” H . Bismuth. King Hussien medical center Department of surgery

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During the last decade, significant technical advances have been accomplished in liver surgery. They allow bilobar resections with very low mortality (around 1%) and low morbidity King Hussien medical center Department of surgery

Mortality trends in liver resection in the last century : 

Mortality trends in liver resection in the last century • 1953 Brunschwig 36 % • 1978 Foster 24 % & 17% • 1984 Adson M 4 % • 1999 Fong Y 3.4 % • 2008 Rees M 1.7% King Hussien medical center Department of surgery

How did we improve the mortality trends ? : 

How did we improve the mortality trends ? • Use of inflow occlusion • Transection techniques • Low CVP • Stapling devices King Hussien medical center Department of surgery

Use of inflow occlusion: 

Use of inflow occlusion James Hogarth Pringle 1863 – 1941 “Notes on the arrest of hepatic haemorrhage due to trauma ” Ann Surg 1908, 48: 541. King Hussien medical center Department of surgery

Why do we have to control bleeding ? : 

Why do we have to control bleeding ? • Avoid life threatening haemorrhage Blood loss morbidity & mortality • Transfusion tumour recurrence . • Liver tolerates ischaemia > bleeding Smyrniotis V et al. World J. Surgery 2005, 29:1384-96 King Hussien medical center Department of surgery

Transection Techniques : 

Transection Techniques • Kellyclamp • Ultrasonic Dissection • Water Jet • Tissue Link • Ligasure • Staplers • Radiofrequency King Hussien medical center Department of surgery

Transection techniques Lesurtel M & Belghiti J. HPB 2008, 10: 265-70 Ultrasonic Dissection vs Kellyclamp vs others : 

Transection techniques Lesurtel M & Belghiti J. HPB 2008, 10: 265-70 Ultrasonic Dissection vs Kellyclamp vs others Found No diffrence in: Resection / Ischaemic Time • Blood loss • Morbidity • Hospital stay • Tumor margins King Hussien medical center Department of surgery

Hepatic Vascular Anatomy: 

. Hepatic Vascular Anatomy Dual Blood Supply Hepatic Artery Supplies ~ 25% of liver blood supply Oxygenated (clean blood) Portal Vein Supplies ~ 75% of liver blood supply Partially deoxygenated blood (Contains byproducts of metabolism/toxins etc) King Hussien medical center Department of surgery

Hepatic vascular anatomy: 

Hepatic vascular anatomy Prepared by Curt Cornell Common HA Left Hepatic Middle Hepatic Right Hepatic Proper Hepatic GDA King Hussien medical center Department of surgery

HV Analysis labeled: 

HV Analysis labeled King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

LIVER ANATOMY: 

LIVER ANATOMY segmental (Couinaud classification): Divides the liver into eight functionally independent segments. Each segment has its own vascular inflow, outflow and biliary drainage . King Hussien medical center Department of surgery

Liver sectors : Four: 

Liver sectors : Four King Hussien medical center Department of surgery

Liver resection Why ???: 

Liver resection Why ??? Surgical resection is currently accepted as a safe, and also the only potentially curative treatment available for patients with liver tumor. Chance of long-term survival with colorectal liver mets . rates ranging from 25% to 50% at 5 years King Hussien medical center Department of surgery only

Major liver resection: 

Major liver resection King Hussien medical center Department of surgery

Segmental liver resection: 

Segmental liver resection King Hussien medical center Department of surgery

Rt. Hepatectomy : on the edge of middle hepatic vien : 

Rt. Hepatectomy : on the edge of middle hepatic vien King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

Malignant Disease is a Fact that Can Not be Denied... It is an evil that comes at leisure!: 

Malignant Disease is a Fact that Can Not be Denied... It is an evil that comes at leisure!

Liver tumors: 

Primary - originate in liver Hepatocellular carcinoma (HCC). Metastatic - spread to the liver from another tumor source in the body Colorectal cancer Benign Tumors Hemangioma , adenoma, cysts Liver tumors King Hussien medical center Department of surgery

Hepatocellular carcinoma: 

Hepatocellular carcinoma HCC is a primary liver cancer At the global level, The 5 th most significant in terms of cases The 3 rd for deaths

HEPATOCELLULAR CARCINOMA (HCC) : 

UNOS Database www.unos.org HEPATOCELLULAR CARCINOMA (HCC) Incidence is increasing 3%/year- USA 7%/year - Japan per 100,000 1 million deaths annually Age-Specific Incidence of Hepatocellular Carcinoma (ICD-O Code 8170) SEER Data Base, 1981-1995, El-Serag H and Mason A. N Engl J Med 1999;340:745-750 Everson GT.. Liver Transpl 2000; 6(s upp 2): S2–S10.

Causes of HCC: 

Hepatitis B and C The highest incidence of HCC is seen in China where the major component of the attributable risk is related to chronic hepatitis B (range 40% to 90%) In Europe hepatitis C accounts for ~63% of the attributable risk In the United States hepatitis C is the major contributor Cirrhosis Cirrhosis is a risk factor for the development of HCC Definition: Cirrhosis is a chronic disease of the liver - tissue is replaced by connective tissue (scarring) resulting in the loss of liver function Other factors Other factors are aflatoxins , alcohol, hemochromatosis , and anabolic steroid use which lend to cirrhosis . Definition: Hemochromotosis is an iron overload disease, that causes the body to absorb and store too much iron. The extra iron accumulates in the liver and lends to cirrhosis. Definition: Aflatoxins are naturally occurring mycotoxins that are produced by many species of Aspergillus , a fungus. Aflatoxins are toxic and carcinogenic Causes of HCC King Hussien medical center Department of surgery

Classification/Staging of HCC: 

Multiple existing methods Depending on the objective, methods focus on tumor morphology, liver function, general status. Child-Pugh - CLIP Okuda - MELD BCLC - TNM Milan Classification/Staging of HCC More than 80% of HCCs occur in cirrhotic patients P rognosis is difficult because the underlying liver function also affects the disease. There is no worldwide consensus of any given staging system. Various professional societies/organizations are influencing changes and adoption of standardized methods. King Hussien medical center Department of surgery

Classification/Staging of HCC: 

Classification/Staging of HCC The most utilized systems: Child-Pugh Based on liver function Okuda Based on liver function and tumor extent BCLC (Barcelona Clinic Liver Cancer) Includes more factors Tumor stage Liver function Physical/Performance Status King Hussien medical center Department of surgery

Most acceptable to decide liver transplantation for HCC Milan Criteria: 1996: 

Most acceptable to decide liver transplantation for HCC Milan Criteria: 1996 One lesion less than 5 cm, OR Up to 3 lesions each less than 3 cm

Current Therapies for Primary and Secondary Cancers of Liver: 

Current Therapies for Primary and Secondary Cancers of Liver Surgical Resection Transplantation Local: Percutaneous Ethanol Injection ( PEI) Radiofrequency Ablation RFA Radio- Embolization (Yttrium-90) Transarterial Embolization Transcatheter Arterial Chemoembolization (TACE) and DC Beads Cryoablation Microwave Ablation Hepatic Arterial Infusion Pump Systemic: Chemotherapy King Hussien medical center Department of surgery

Treatment Algorithm: 

Treatment Algorithm Treatment Algorythm Llovet , J. M. et al. J. Natl. Cancer Inst. 2008 100:698-711;doi:10.1093/ jnci /djn134

Evolving patterns: 

Evolving patterns Llovet, J. M. et al. J. Natl. Cancer Inst. 2008 100:698-711;doi:10.1093/jnci/djn134

Surgical Resection: 

Surgical resection Possible as the liver has the capacity to regenerate if part of it is removed In a healthy liver up to 75% of the liver may be removed and the remaining portion will return to normal size within six months 1 Management of Hepatocellular Carcinoma. Bruix, Hepatology November 2005 2 The John’s Hopkins Medical Resource Centre http://hopkins-gi.nts.jhu.edu/ Surgical Resection King Hussien medical center Department of surgery

When we resect HCC in cirrhotic liver ,We are trying to be very cautious to preserve as much as we can of liver tissues to prevent post op liver failure : 

When we resect HCC in cirrhotic liver ,We are trying to be very cautious to preserve as much as we can of liver tissues to prevent post op liver failure

Why!?: 

Why!? Unlike that of Prometheus, a cirrhotic liver may not regenerate

Liver resection for HCC: 

Liver resection for HCC Few examples of our cases

Posterior sector tumor: 

Posterior sector tumor King Hussien medical center Department of surgery

Posterior sector resection: 

Posterior sector resection King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

Posterior sector resection on the edge of Rt. Hepatic vien: 

Posterior sector resection on the edge of Rt. Hepatic vien King Hussien medical center Department of surgery

Segmental Resection Posterior sector (Seg. VI+VII): 

Segmental Resection Posterior sector ( Seg . VI+VII) King Hussien medical center Department of surgery

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63 Years old male. HCV. Liver cirrhosis. Child score A. Platelets 150,000 Bilirubin 1.4 HCC segment VII. Decision resection

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

Remnant part of liver was more than 75%: 

Remnant part of liver was more than 75%

Post resection patient developed hepatic failure INR < 6 Packing of the liver Patient passed away next day. : 

Post resection patient developed hepatic failure INR < 6 Packing of the liver Patient passed away next day.

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48 years Liver cirrhosis Child Score : B (7) HCC in seg . VII

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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Patient did well post operatively He is free of recurrence after more than 3 years now

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56 years old male Liver cirrhosis child A score HCC seg VII and VIII

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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Patient did well post operatively Still with out recurrence after 2 years

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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Still with out recurrence after two years.

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28 years old male HCC no cirrhosis Resection done Histopathology: Fibrolamellar tumor

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

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King Hussien medical center Department of surgery

Transplantation: 

Management of Hepatocellular Carcinoma. Bruix, Hepatology November 2005 Transplantation King Hussien medical center Department of surgery

Reasons for Liver Transplantation in Patients with HCC: 

Reasons for Liver Transplantation in Patients with HCC Multicentric Tumors: High risk of recurrence after local treatment Chronic Liver Disease Carcinologic factor Liver insufficiency

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Multifocality

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Bilobar

Milan Criteria: 1996 still most acceptable: 

Milan Criteria: 1996 still most acceptable One lesion less than 5 cm, OR Up to 3 lesions each less than 3 cm

Analysis of effecting factors on recurrence: 

Analysis of effecting factors on recurrence

HCC and the Milan Criteria: 

HCC and the Milan Criteria Mazzaferro V. N Engl J Med 1996;334: 693-9.

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Screening for early detection of HCC in all cirrhotic liver

Liver Transplantation for HCC: 

Liver Transplantation for HCC Transplantation decision Transplantation Tumor growth Vascular invasion

Our cases: 

Our cases 54 years old male Gynecologist Cirrhotic liver HCC 7 cm IVC invasion

HCC: 7cm, IVC invasion. Beyond Milan: 

HCC: 7cm, IVC invasion. Beyond Milan King Hussien medical center Department of surgery

Transplanted: 

Transplanted Recurrence after 2 years Recurrence was out side the liver (pelvis)

Hebatoblastoma: 3years female : 

Hebatoblastoma : 3years female King Hussien medical center Department of surgery

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King Hussien medical center Departement of surgery

Liver transplantation (LDLT) from her mother : 

Liver transplantation (LDLT) from her mother She is doing very fine till now

34 years old male cirrhotic. liver resection at JUS with resection margins involved : 

34 years old male cirrhotic. liver resection at JUS with resection margins involved

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Transplanted by LDLT Well after one year now

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60 years old male HBV cirrhotic Child score 8 (B) Admitted as a case of encephalopathy His CT scan

Recurrence to spine after 1.5 years Underwent decompression of spinal cord by neurosurgeon last week: 

Recurrence to spine after 1.5 years Underwent decompression of spinal cord by neurosurgeon last week

62 years old female multicenteric HCC beyond Milan Child score C : 

62 years old female multicenteric HCC beyond Milan Child score C

Early recurrence within 3 months : 

Early recurrence within 3 months

Transplantation for malignancy at KHMC: 

Transplantation for malignancy at KHMC Hepatocellular ca. (HCC) 8 cases Hebatoblastoma one case Cholangio ca + HCC one case King Hussien medical center Department of surgery

Results of HCC after liver transplantation: 

Results of HCC after liver transplantation Total cases : 10 patients 5 cases beyond milan Recurrence: Three cases Two patients had recurrence after 1.5 years. Other patient early recurrence Mortality: 2 patients out of 10 (20%) Survival rate: 80%

Transplantation for HCC Where should we stop?: 

Transplantation for HCC Where should we stop? Majno P and Mazzafero V. L iver Transplantation 12:896-898, 2006

Transplantation for HCC Where should we stop?: 

Transplantation for HCC Where should we stop? S hould it be considered the for tumors that are beyond the Milan’s Criteria Family pressure may take us over the limits.

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Pruett, Hepatology 2002 The Titanic Consideration Limited resource of cadaver , excessive demand and pressure More passengers on board !! Catastrophic results somtimes

Radio Frequency Ablation: RFA: 

RF ablation (RFA) Performed under ultrasound or CT guidance An RF needle is inserted deep into the lesion and multiple electrodes are deployed The generator is then activated to achieve high temperatures within the tumor causing local tissue destruction Duration of the treatment 6–40 minutes 1 Therapy in Liver Diseases 2003: Hepatocellular Carcinoma. Llovet et al. Journal of Hepatology Vol 38 2003 2 Management of Hepatocellular Carcinoma. Bruix, Hepatology November 2005 Radio Frequency Ablation: RFA

Radio Frequency Ablation: RFA: 

Radio Frequency Ablation: RFA

Trans-arterial Chemo-embolization TACE: 

TACE Possible because The liver has a unique blood supply. The portal vein supplies 70-75% of the hepatic blood supply, while the hepatic artery supplies 25% 95% of the blood of both primary and metastatic hepatic tumors is derived from the hepatic artery Llovet JM, Bruix J. Systemic Review of Randomized Trials for Unresectable Hepatocellular Carcinoma: Chemoembolisation Improves Survival. Hepatology, Vol. 37, No. 2, 2003. Trans-arterial Chemo- embolization TACE

Drug Eluting Sphere Embolization (deTACE): 

Drug Eluting Sphere Embolization ( deTACE ) Embolic as a drug carrier Embolic and drug effect Single agent therapy Targeted to tumor Decreased toxicity Image courtesy of www.biocompatibles.com

58 years old male HBV liver cirrhosis with HCC Patient is reluctant to do liver transplantation. We offer him TACE: 

58 years old male HBV liver cirrhosis with HCC Patient is reluctant to do liver transplantation. We offer him TACE

After TACE AFP dropped from 450 to 50 : 

After TACE AFP dropped from 450 to 50 Patient developed encephalopathy so he is convinced to proceed for LDLT. We used TACE as abridging for transplantation

Liver cirrhosis with HCC : 

Liver cirrhosis with HCC 18 Years old male HBV . Liver cirrhosis with HCC. No donor available. RFA + TACE as a bridge till availability of donor. AFP Decreased from < 1000 Decreased to 30

HCC Postoperative follow-up: 

HCC Postoperative follow-up AFP Monthly – first year Every 3 months - thereafter Abdomen USG Every 3 months -- first two years Every 6 months -- thereafter Abdomen CT / MR Every six months - First 2 years , then yearly

Secondary liver metastasis: 

Secondary liver metastasis Colorectal- neuroendocrine Non-Colorectal- neuroendocrine

predicting recurrence after hepatic resection for metastatic colorectal cancer Clinical risk score (CRS) : 

predicting recurrence after hepatic resection for metastatic colorectal cancer Clinical risk score (CRS) Fong et al, Annals of Surgery 1999; 230: 309 1- Nodal status of primary 2- Disease-free interval from primary to discovery of the liver metastases of < 12 months 3- Number of tumors > 1 4- Preoperative CEA level > 200 ng /ml 5- Size of largest tumor > 5 cm Overall actuarial survival 37% at 5 years, 22% at 10 years Clinical Risk Score (CRS) predictive of long term outcome (p<0.0001) Actuarial survival 60% if CRS =1, 14% if CRS = 5

Why can we use major liver resection for colorectal liver mets. But not in HCC?: 

Why can we use major liver resection for colorectal liver mets . But not in HCC?

Three examples in patient with colorectal liver mets.: 

Three examples in patient with colorectal liver mets . 54 years old female Sigmoid colectomy two years before presentation to us She was offered adjuvant chemotherapy after colectomy . She decided not to take the medication . Presented to us two years later with this CT scan:

Tri segmentectomy OR Extended Rt. hepatectomy: 

Tri segmentectomy OR Extended Rt. hepatectomy

Major liver resection: 

Major liver resection King Hussien medical center Department of surgery

Extended Rt. hepatectomy: 

Extended Rt. hepatectomy

2nd patient: 

2nd patient 67 years old male patient. Diagnosed by gastroentrologist to have sigmoid tumor with liver mets . His CT scan which was done out side showed:

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Before Lt. portal ligation 6 weeks after portal ligation and folfox + avastin for 6 cycles

Major liver resection: 

Major liver resection King Hussien medical center Department of surgery

3rd patient: 

3 rd patient 48 years old female patient Referred from Qatar with colorectal liver mets . Received 30 cycles of chemotherapy Her CT scan:

Major liver resection: 

Major liver resection King Hussien medical center Department of surgery

Extended Lt. hepatectomy: 

Extended Lt. hepatectomy

Conclusion: 

Conclusion A lot of patient who may benefit from surgical resection are missed in Jordan because of either : lack of knowledge and experience of the treating physician or surgeon in the modalities of management of liver tumor. Or they heard about the modalities but they don’t know that it can be done in our center

Evolving patterns: 

Evolving patterns Llovet, J. M. et al. J. Natl. Cancer Inst. 2008 100:698-711;doi:10.1093/jnci/djn134

Take home message: 

Take home message Although we lack proper tumor board but still We are confident to say: What is done at KHMC concerning liver surgery is far more advanced than any center in Jordan. We are still the only team who perform Liver transplantation by pure Jordanian hands

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Literatür 2004 Thank You !!!