New Advances in the Treatment of Liver Tumors: Laparoscopic Resections


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Presentation on New Advances in the Treatment of Liver Tumors (Laparoscopic Resections) by Dr. Kimberly Moore Dalal, Surgical Oncology & General Surgery, Peninsula Medical Center.

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  • Hassan technique- initial supraumbilical port RUQ and LUQ ports to take down omental adhesions Divide gastrohepatic ligament with ligasure Left gastric artery was identified and retracted in an anterior location. Base of celiac plexus was visualized. A 22 g needle was sheathed in a plastic sheath and inserted. Area was aspirated, then injected 15 cc of 50% alcohol on either side of the celiac pelxus. No evidence of hypotension or blood aspiration.
  • Technique- do we isolate vasculature or go through parenchyma
  • Divide into groups based on margins width- how may > 1cm and how many < 1 cm
  • Hepatobiliary cancers are highly lethal cancers. 4 million Americans with Hepatitis C 1.5 million Americans with Hepatitis B
  • Hepatobiliary cancers are highly lethal cancers. 4 million Americans with Hepatitis C 1.5 million Americans with Hepatitis B
  • 5 probes
  • New Advances in the Treatment of Liver Tumors: Laparoscopic Resections

    1. 1. New Advances in the Treatment of Liver Tumors: Laparoscopic Resections Cancer Care Innovations Dorothy E. Schneider Cancer Center Mills-Peninsula Hospital April 23, 2011 Kimberly Moore Dalal, MD, FACS Surgical Oncology and General Surgery Peninsula Medical Clinic Bruce Allen, MD; Aziz Ahmad, MD; Dirk Baumann, MD; John Beare, MD; Pamela Foster, MD; Stephanie Lin, MD; Andrea Metkus, MD; John Rosenman, MD; Randolph Wong, MD; Albert Wetter, MD
    2. 2. Historical Perspective <ul><li>“… 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 </li></ul>Liver cancer
    3. 3. Historical Perspective <ul><li>“… 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…” </li></ul>Foster JH, Berman MM. Major Problems in Clincal Surgery 1977;1-342. Liver cancer
    4. 4. OR Team, Bagram, Afghanistan 2007 Liver cancer
    5. 5. MASCAL, October 14, 2007 19 Americans injured Liver cancer
    6. 6. Liver Resection Today <ul><li>Author N Operative Mortality (%) </li></ul><ul><li>Scheele ‘91 219 6 </li></ul><ul><li>Rosen ‘92 280 4 </li></ul><ul><li>Gayowski ’94 204 0 </li></ul><ul><li>Scheele ‘95 469 4 </li></ul><ul><li>Nordlinger ’95 568 2 </li></ul><ul><li>Jamison, ‘97 280 4 </li></ul><ul><li>Fong ’99 1001 3 </li></ul>Normal livers Liver cancer
    7. 7. Outline <ul><li>Laparoscopic liver resections for benign and malignant tumors </li></ul><ul><ul><li>Benign lesions </li></ul></ul><ul><ul><li>Hepatocellular carcinoma </li></ul></ul><ul><ul><li>Colorectal cancer metastases </li></ul></ul>Liver cancer
    8. 8. Anatomy Liver cancer
    9. 9. Benign Hepatic Lesions Liver cancer Tumor Malignant Potential Spontaneous Hemorrhage Focal nodular hyperplasia No No Hemangioma No Rare Cystadenoma Yes No Adenoma Yes Yes
    10. 10. Case 1: Cystic Lesion of the Liver <ul><li>51 year old woman </li></ul><ul><li>3.5 cm Liver Cyst, Seg 4, first noted on chest CT in 2001 </li></ul><ul><li>Presented with 3 days RUQ pain </li></ul><ul><li>RUQ ultrasound (2/07): complex cystic structure of the liver with layering </li></ul><ul><li>Triple phase liver CT (2/07): Cystic lesion, Seg 4, 6x8x6 cm; Hounsfield units 6 (noncontrast), 11 (iv contrast) </li></ul>Liver cancer
    11. 11. Ultrasound Complex cystic structure of liver with layering Liver cancer
    12. 12. Triple phase liver CT: Cystic lesion, Seg 4, 6x8x6 cm Liver cancer
    13. 13. Case 2: Hepatic Adenoma <ul><li>43 yo F with incidentally discovered right liver mass detected on CT of chest for workup of cough. </li></ul><ul><li>AFP and CEA normal. LFTs normal. </li></ul><ul><li>CT and MRI </li></ul><ul><ul><li>4.2x2.1x2.0 cm mass, Seg 7, consistent with a hepatic adenoma. </li></ul></ul>Liver cancer
    14. 14. Liver cancer Triple phase liver CT: Seg 7, 4x2x2 cm
    15. 15. Traditional Open “Chevron” Incision Liver cancer
    16. 16. Exposure in an Open Resection Liver cancer
    17. 17. Laparoscopic Port Placement for Right Liver Lesions Cho JY, et al. , Arch Surg 2009; 144(1):25-29. Liver cancer
    18. 18. Laparoscopic View of the Liver Liver cancer Machado MA, et al ., Surg Endosc, 2009; 23:2615-2619.
    19. 19. Case 2: Hepatic Adenoma, Segment 7 Laparoscopic Resection…9 Months Later Liver cancer
    20. 20. <ul><li>Established </li></ul><ul><ul><ul><li>Diagnosis/Staging </li></ul></ul></ul><ul><ul><ul><li>Fenestration of Simple Cysts </li></ul></ul></ul><ul><li>Evolving </li></ul><ul><ul><ul><li>Minor resections (≤ 2 segments) for tumor </li></ul></ul></ul><ul><ul><ul><li>Major hepatic resections </li></ul></ul></ul><ul><ul><ul><li>Tumor ablation </li></ul></ul></ul>Laparoscopic Liver Surgery Liver cancer
    21. 21. Laparoscopic Liver Resection Theoretical Advantages <ul><li>Less post-operative pain </li></ul><ul><li>Less post-operative morbidity </li></ul><ul><li>Shorter hospital stay </li></ul><ul><li>Improved cosmesis </li></ul><ul><li>Quicker return to normal activity </li></ul><ul><li>Quicker initiation of adjuvant therapies </li></ul>Liver cancer
    22. 22. Laparoscopic Liver Resection Theoretical Disadvantages <ul><li>Loss of tactile sense </li></ul><ul><ul><ul><li>Margins </li></ul></ul></ul><ul><ul><ul><li>Staging </li></ul></ul></ul><ul><li>Limited access/instrumentation </li></ul><ul><ul><ul><li>Exposure </li></ul></ul></ul><ul><ul><ul><li>Control of major pedicles/hepatic veins </li></ul></ul></ul><ul><li>Time and money </li></ul>Liver cancer
    23. 23. Laparoscopic Liver Resection Solutions <ul><li>Loss of tactile sense </li></ul><ul><ul><ul><li>Margins </li></ul></ul></ul><ul><ul><ul><li>Staging </li></ul></ul></ul>Laparoscopic Ultrasound Hand-assisted techniques Liver cancer
    24. 24. Laparoscopic Liver Resection Solutions <ul><li>Limited access/instrumentation </li></ul><ul><ul><ul><li>Exposure </li></ul></ul></ul><ul><ul><ul><li>Control of major pedicles/hepatic veins </li></ul></ul></ul><ul><ul><ul><li>Fear of major hemorrhage </li></ul></ul></ul><ul><li>Hand-assisted techniques </li></ul><ul><li>Ligaments intact </li></ul><ul><li>Improved retractors </li></ul>Harmonic Scalpel Vascular Stapler Ligasure Device Tissuelink Argon Beam Coagulator Water Jet Liver cancer
    25. 25. Laparoscopic Liver Resection Solutions <ul><li>Time and money </li></ul>Comparison to open surgery in trials Liver cancer
    26. 26. <ul><li>Segmental resection: 27 pts (61%) </li></ul>2 7 8 5 3 <ul><li>1 segment: 17 pts </li></ul><ul><li> (38%) </li></ul><ul><li>>1segment: 10 pts </li></ul><ul><li> (22%) </li></ul><ul><li>Left lateral: 6 pts </li></ul><ul><li> (13%) </li></ul>Laparoscopic Hepatectomy MSKCC Results (n=44) D’Angelica, MD, et al ., AHPBA 2006 Liver cancer
    27. 27. 23 pts: Negative margins (100%). No local recurrence. Laparoscopic Hepatectomy MSKCC Results (n=44) Liver cancer D’Angelica, MD, et al ., AHPBA 2006 Benign 21 pts (47%) Malignant 23 pts (53%) 1 tumor 36 pts (81%) > 1 tumor 8 pts (18%)
    28. 28. Operative Outcome Laparoscopic Hepatectomy MSKCC Results: Comparison to Open Liver cancer 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
    29. 29. Laparoscopic Hepatectomy MSKCC Results: Comparison to Open Post-operative Outcome Liver cancer 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
    30. 30. <ul><li>For well-selected patients, laparoscopic liver resection is safe and does not compromise operative or oncologic outcomes. </li></ul><ul><li>While laparoscopic liver resection is associated with some benefits, these can only be definitively proven in randomized controlled trials. </li></ul>Summary Liver cancer
    31. 31. Outline <ul><li>Laparoscopic liver resections for benign and malignant tumors </li></ul><ul><ul><li>Benign lesions </li></ul></ul><ul><ul><li>Hepatocellular carcinoma </li></ul></ul><ul><ul><li>Colorectal cancer metastases </li></ul></ul>Liver cancer
    32. 32. Epidemiology of Hepatobiliary Cancer <ul><li>Estimated U.S. incidence in 2010: 24,120 cases/year 1 </li></ul><ul><li>Annual incidence of HCC with Hepatitis C cirrhosis is 2-8%, Hepatitis B cirrhosis 2.5%. </li></ul><ul><li>18,910 deaths in men and women </li></ul>Jemal A, et al ., CA Cancer J Clin, 2010; 60:27-300. Liver cancer
    33. 33. Diagnosis and Workup for HCC <ul><li>Often asymptomatic. </li></ul><ul><li>Nonspecific symptoms: anorexia, weight loss, malaise, upper abdominal pain. </li></ul><ul><li>Paraneoplastic syndromes: hypercholesterolemia, erythrocytosis, hypercalcemia, hypoglycemia. </li></ul><ul><li>Physical signs: jaundice, ascites </li></ul><ul><li>AFP>200 ng/mL + liver mass =HCC </li></ul>Liver cancer Zhang BH et al ., J Cancer Res Clin Oncol. 2004; 130:417-422.
    34. 34. Child-Pugh Class A Patients are Candidates for Resection Liver cancer Class A = 5-6 points Good operative risk Class B = 7-9 points Moderate operative risk Class C = 10-15 points Poor operative risk 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
    35. 35. Case 3: Hepatocellular Carcinoma <ul><li>74 yo M with Hepatitis C x 30 years from a blood transfusion, treated with interferon for one year </li></ul><ul><li>Developed pneumonia and asked PCP to investigate for cirrhosis. </li></ul><ul><li>AFP: 4690. </li></ul><ul><li>Abd US: 3.4 x 2.4 x 3.1 cm mass, left lateral segment of liver. </li></ul><ul><li>Triple phase Liver CT: 3.5 x 2.5 cm mass, segment 3. (CT of abdomen and pelvis 3 months earlier negative). </li></ul>Liver cancer
    36. 36. Triphasic Liver CT: Segment III 3.5 cm mass Liver cancer
    37. 37. Principles of Surgery for HCC <ul><li>Mortality <5% </li></ul><ul><li>Five-year survival rates > 50% </li></ul><ul><ul><li>70% in patients with early stage HCC and preserved liver function. </li></ul></ul><ul><li>Recurrence at 5 yrs>75% </li></ul><ul><li>Careful patient selection: </li></ul><ul><ul><li>Comorbidities </li></ul></ul><ul><ul><li>Tumor characteristics </li></ul></ul><ul><ul><li>Size and function of future liver remnant </li></ul></ul><ul><li>Liver transplantation for patients meeting UNOS criteria </li></ul><ul><ul><li>Single lesion < 5cm </li></ul></ul><ul><ul><li>2 or 3 lesions < 3 cm </li></ul></ul>Liver cancer
    38. 38. Case 3: Hepatocellular Carcinoma <ul><li>Laparoscopic resection of segment III </li></ul><ul><li>Length of stay 5 days </li></ul><ul><li>Bone metastasis @ 7 mos </li></ul>Liver cancer
    39. 39. Epidemiology of Colorectal Cancer <ul><li>Estimated U.S. incidence of colorectal cancer: 142,570/year 1 </li></ul><ul><li>51,370 deaths </li></ul><ul><li>50% of patients will be diagnosed with liver metastases </li></ul><ul><li>Liver resection->long-term survival </li></ul><ul><ul><li>5 year survival: 25-58% </li></ul></ul><ul><ul><li>Surgical techniques </li></ul></ul><ul><ul><li>Chemotherapy </li></ul></ul><ul><ul><li>Unresectable->resectable </li></ul></ul>1 Jemal A, et al ., CA Cancer J Clin, 2010; 60:27-300. 2 Liver cancer
    40. 40. Determinants of Outcome for CRC Liver Metastases: Fong Score <ul><li>Extrahepatic disease </li></ul><ul><li>Positive margins </li></ul><ul><li>Node (+) colorectal primary </li></ul><ul><li>Disease-free interval < 1 year </li></ul><ul><li>More than 1 hepatic tumor </li></ul><ul><li>Largest hepatic tumor > 5 cm </li></ul><ul><li>CEA > 200 ng/mL </li></ul>Fong et al Ann Surg 1999;230:309 Liver cancer Fong Y, et al ., Ann Surg. 1999 Sep;230(3):309-318.
    41. 41. Preoperative Portal Vein Embolization Can Increase the Future Liver Remnant <ul><li>PVE </li></ul><ul><li>Percent Resection </li></ul><ul><ul><li>FLR/TLV 0.20 (20%) 1 </li></ul></ul><ul><ul><ul><li>>40% for cirrhotics, Child’s A </li></ul></ul></ul>1 Chun YS, et al ., J Gastrointest Surg. 2008 Jan;12(1):123-8. Liver cancer
    42. 42. >1 cm Margins are Preferred, but > 1 mm Margins are Favorable <ul><li>Multivariate analysis (n=1019) </li></ul><ul><ul><ul><li>> 1 tumor </li></ul></ul></ul><ul><ul><ul><li>Size > 5 cm </li></ul></ul></ul><ul><ul><ul><li>Node positive primary </li></ul></ul></ul><ul><ul><ul><li>Bilateral resection </li></ul></ul></ul><ul><ul><ul><li>Margins </li></ul></ul></ul>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 1 Are C, et al ., Ann Surg. 2007 Aug;246(2):295-300. Liver cancer
    43. 43. Summary <ul><li>Laparoscopic liver resections are safe and oncologically sound in highly selected patients in the hands of surgeons with a laparoscopic skill set. </li></ul><ul><li>Patients with malignant liver tumors (primary or metastatic) can be considered for resection based on tumor characteristics, future liver remnant size and function, and patient comorbidities. </li></ul>Liver cancer
    44. 45. Radiofrequency Ablation <ul><li>High-frequency alternating current flows from electrical probe through tissue to ground </li></ul><ul><ul><li>Ionic agitation results in frictional heating and coagulation of surrounding tissue </li></ul></ul>Liver cancer Probe insertion Extension of prongs RF current application
    45. 46. Radiofrequency Ablation Liver cancer
    46. 47. Radiofrequency Ablation Pre-ablation 3-days post 2 months post Liver cancer
    47. 48. Radiofrequency Ablation <ul><li>Advantages </li></ul><ul><ul><li>Performed percutaneously, laparoscopically, or at laparotomy </li></ul></ul><ul><ul><li>Low complication rate </li></ul></ul><ul><ul><ul><li>May be related to size of ablation (<3 cm) </li></ul></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Poor performance near blood vessels </li></ul></ul><ul><ul><li>One probe </li></ul></ul><ul><ul><ul><li>Many tumors require multiple, overlapping ablations </li></ul></ul></ul><ul><ul><li>Slow </li></ul></ul>Liver cancer
    48. 49. Microwave Ablation <ul><li>Theoretical advantages over RFA </li></ul><ul><ul><li>Larger zone of active heating </li></ul></ul><ul><ul><ul><li>Possibly better performance near blood vessels </li></ul></ul></ul><ul><ul><li>Hotter temperature </li></ul></ul><ul><ul><li>Use of multiple probes </li></ul></ul>Liver cancer
    49. 50. Microwave Ablation Liver cancer
    50. 51. Factors Determining Resectability of CRC Mets <ul><li>Fong Score (CRC mets) </li></ul><ul><ul><li>Fong et al. Ann Surg 1999 </li></ul></ul><ul><li>• Functional hepatic reserve </li></ul><ul><ul><li>Child-Pugh score </li></ul></ul><ul><ul><li>MELD score </li></ul></ul><ul><ul><li>Volumetric calculations </li></ul></ul>
    51. 52. Resectability of Colorectal Cancer Metastases Liver cancer
    52. 53. After portal vein embolization, left liver hypertrophied and right liver atrophied Metastases resected Staged Resections
    53. 54. Hepatocellular Carcinoma Risk Factors <ul><li>Hepatitis B viral infection </li></ul><ul><ul><li>Asia and Africa </li></ul></ul><ul><li>Hepatitis C viral infection </li></ul><ul><ul><li>Europe, Japan, North America </li></ul></ul><ul><li>Inherited errors of metabolism </li></ul><ul><ul><li>Hemochromatosis, alpha 1-antitrypsin deficinecy, Wilson’s disease </li></ul></ul><ul><li>Autoimmune hepatitis </li></ul><ul><li>Primary biliary cirrhosis </li></ul><ul><li>Excessive alcohol intake </li></ul><ul><li>Aflatoxin exposure </li></ul><ul><li>Non-alcoholic fatty liver disease </li></ul>Liver cancer
    54. 55. Margins and HCC Randomized prospective trial <ul><li>169 patients randomized </li></ul><ul><li>2 cm vs 1 cm margin </li></ul><ul><li>Actual margin 1.9 vs 0.7 cm </li></ul><ul><li>Well matched </li></ul><ul><li>Improved survival in wide margin </li></ul>Shi M, et al ., Ann Surg 2007, 245(1):36-43. Liver cancer
    55. 56. Local Recurrence Rates for RFA Mulier S, et al ., Ann Surg. 2005 Aug;242(2):158-71. Liver cancer
    56. 57. Liver cancer