Surgery

Every patient with a liver tumor should be evaluated for a resection. It is the only chance for cure. Removing the tumor will rid the body of the cancer and also prevent further spread to other regions. Unfortunately, not all patients are eligible for a liver resection.

The liver is a privileged organ in that it has the ability to regenerate if part of it is removed and this allows surgeons to operate upon it successfully. In patients with colon cancer that has spread to the liver, liver resection can cure 25 - 45% of the patients. The operative mortality is less than 2%. To achieve these outcomes requires (1) appropriate selection of surgical candidates and (2) an experienced surgical team (surgeon, anesthesiologist, intensive care staff, etc.) that performs liver operations frequently. Only those patients who are likely to benefit from resection should undergo a surgical procedure.

Patients may also develop metastatic colorectal cancer to both the lungs and liver. In select patients, simultaneous resection of metastases from the lung and liver can provide significant benefit.

Other indications for liver resection are metastases from other sites such as breast, kidney, lung, selected tumors of the pancreas and small intestine and sarcomas. Although these diagnoses are controversial indications, 2 year survival rates of 90% have been obtained. This improved survival occurs in patients who respond to chemotherapy and have disease only in the liver. Other indications for resection are tumors that originated in the liver, called hepatocellular cancer and cholangiocarcinoma.

To be considered for a liver resection, the cancer must be confined only to the liver so that removal will eliminate all disease from the body. Removing a tumor from the liver and leaving other areas in the body with cancer will not be curative. An exception is a patient with a metastatic carcinoid tumor as they can benefit (i.e., improvement in symptoms) from removal of greater than 90% of the liver tumor.

A liver surgeon will devote a significant amount of time to make sure that the appropriate patient is selected for surgery. Routine tests may include a CT scan of the abdomen, pelvis, chest, colonoscopy (if the patient has had a colon cancer). Other important information necessary to make a decision is the number, size, and location of the liver tumors. Only when the surgeon has determined that the cancer is limited to the liver will a recommendation be given to proceed with surgery. To be effective, all tumors must be removed with a margin of 1/2 inch of normal liver in order to remove microscopic cancer cells that may surround the obvious tumor.

A variety of liver resections can be performed. The options range from resection of a lobe (left or right) to segments (or small portions) of the liver. Resection of segments of the liver (called segmentectomy) permit a surgeon to effectively treat multiple liver tumors. My preference is to resect segments whenever possible in order to preserve normal liver and also to treat more tumors. If it is technically feasible, I will resect up to six tumors. In this group of patients I will usually insert an hepatic intra-arterial catheter for post-operative chemotherapy. Clearly, this is an aggressive and controversial approach but it can be effective and potentially curative.

A liver resection can take 2 - 5 hours to perform. In the majority of patients, a liver resection does not require a blood transfusion. The patient will be able to drink fluids on the first post-operative day and often is discharged in 4 - 6 days.

A CT scan from a patient with hepatic metastases from colon cancer is shown here. The tumor isdelineated by the dark area and shown by the arrow. This is in marked contrast to the normal gray color of the liver.

This patient underwent resection of a segment of the liver and the next two images show the specimen with a 1 cm. margin.

The last photograph shows the liver after the tumor has been removed. The patient recovered uneventfully from the surgery.

Unfortunately, the majority of patients with liver tumors are not candidates for resection. Tumors located near important liver blood vessels may be unresectable since certain blood vessels cannot be removed. If the patient has multiple tumors, the surgeon may not be able to completely remove all of them. In this situation, the patients may be candidates for other types of therapy. One effective modality is cryosurgery.

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