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LIVER TUMOURS
153
Fig. 3.49 Management of colorectal liver metastases.
Unfit
Colorectal
metastases
Resection
Resection
Resection
Chemotherapy Downstaged
Consider 2-stage
procedure
Ablation, surgery
and ablation
Technically
difficult
Consider
chemotherapy
Chemotherapy
Fit with no
detectable extra
hepatic metastases
in lung or adrenal
Synchronous
technically difficult
extrahepatitic
disease (assuming
removal of the
primary tumour)
Metachronous
technically
straightforward
no extra hepatic
disease
LIVER
154
without chemotherapy if technically feasible and always if we feel that pro-
gression of the tumour might subsequently preclude a potentially curative
resection.
Not infrequently, however, new liver or lung lesions do appear by the time
patients are reassessed for their liver surgery and this should never proceed
without repeat imaging of the abdomen and chest. In this situation, palliative
management can be instituted without the need for further surgery. For meta-
chronous liver disease, little is gained in delaying surgery unless ‘downstaging’
by chemotherapy is required. If doubt exists about the extent of the disease,
then a laparoscopic preoperative assessment is valuable (Pearlstone et al .,
1999 ; Jarnagin et al ., 2000 ). Otherwise a small right subcostal incision is per-
formed seeking small peritoneal and hepatic metastatic disease missed on PET
and CT scanning. Epidurals are routinely used in hepatic resection patients.
Preoperative heparin (preferably low molecular weight given at a sufficient
interval before the epidural) and antibiotics are given and the operation is
performed as described earlier. Postoperatively the patients are extubated and
returned to an HDU for 24–72 hours (depending on the complexity of the
resection); hospital stay is 6–10 days in uncomplicated cases. With good vascu-
lar control, bleeding is rarely a problem. However, with re-do surgery, in deal-
ing with livers postchemotherapy and for idiosyncratic reasons (as with any
major surgery), bleeding can occasionally be difficult to control. Our surgical
strategy is to proceed slowly, make sure the anaesthetist is able to keep up with
blood volume replacement (but not over replace to maintain a low CVP), and
improve exposure. The use of tissue glues has been largely abandoned as they
require a dry surface to be effective and this by definition is never the case with
a bleeding surface.
Argon beam coagulators can be used to seal small vessels and defining large
vessels requiring suture. Such vessels require a 4/0 or 5/0 Prolene with good
exposure and excellent assistance. If, following resection, bleeding remains a
problem, we have no hesitation in packing the liver and planning a pack
removal in 24–36 hours after any coagulopathy has been corrected and ade-
quate resuscitation performed. To date, this strategy has always resolved the
issue and prevents hours of futile and dangerous attempts to control diffuse
bleeding over a large raw surface. Diaphragmatic trauma is not uncommon in
removing tumours adherent to the diaphragm but the connection is usually
inflammatory rather than malignant. Nonetheless, a margin is attempted and
not infrequently results in entry into the pleural cavity. The anaesthetist is
asked to perform a Valsalva manoeuvre and the defect closed, usually without
a pleural drain. If a significant defect has to be produced to ensure clearance
then we close the diaphragm with 3/0 PDS and leave a small chest drain in the
LIVER TUMOURS
155
pleural cavity. This is routed out through the abdomen although it requires an
underwater seal until removal is possible. This avoids the need for a purse-
string suture or any special measures when it is removed.
On completion of the operation, we make every effort to anchor the liver,
particularly for right hepatectomies when the residual left lobe sometimes
tends to fall into the space created by the resection. The falciform ligament is
attached to the anterior abdominal wall and the ligamentum teres is also used
to support the left side, by including it in the abdominal wall closure. If the left
triangular ligament has not been divided this may not be necessary. Although
a few people have abandoned the use of drains we continue to employ the non-
suction variety in all our patients; it adds no morbidity and provides passage
for bile leaks that may occur. A haemodynamically unstable patient, regardless
of drainage, requires immediate reoperation. Little is gained from delay and
an extrahepatic site of bleeding is almost as common as from the resection
site. This is better managed in a relatively fit patient rather than one who has
undergone a large transfusion.
Positron emission tomography (PET) scanning The recent advent of widely
available PET scanning has led to its rapid uptake in many countries. Its use in
various clinical settings, however, remains controversial and at present its use
in isolation is of little value and careful correlation between the clinical find-
ings, CT scan, or MRI images and biopsy confirmation may be required.
A positive PET scan result does not always indicate malignant disease (inflam-
mation being the most common cause of a false positive result), and conversely
PET-negative areas can be involved by tumour (a certain critical mass is
required for adequate uptake to be detectable) (Lai et al ., 1996 ; Ogunbiyi et al .,
1997 ; Maldonado et al ., 2007 ).
With these caveats, we have found PET scanning of particular value to
exclude dissemination in colorectal cancer patients, particularly in areas diffi-
cult to be dogmatic about with conventional imaging. With retroperitoneal
nodes or pelvic disease that may represent recurrence, PET can be helpful and
false positives in these situations are uncommon. Another difficult clinical set-
ting is the finding of multiple liver lesions that appear on cross-sectional imag-
ing to be heterogenous, with some lesion having features of malignancy and
some appearing more likely to be benign. Again, PET scanning can make a
valuable contribution (especially if the lesions are sizeable). It serves as ‘its own
control’ if some lesions prove to be FDG (flurodeoxyglucose) avid and some
are cold.
Lesions found within the liver that are PET negative can often be watched
rather than undergo biopsy or surgery. With PET-positive lesions, resection
LIVER
156
Fig. 3.50 Management of unresectable colorectal liver metastases.
Extrahepatic
disease
Unresectable
metastases
Systemic
chemotherapy
Extensive liver
disease
Limited liver
disease
Debulking only if
technically straight
forward, fit and
symptomatic
Consider ablative
technique
Microwave, electrolysis, or
RFA
Very rare:
• Debulking only for
specific problems such as
rapid progression,
biliary obstruction
No demonstrable
extrahepatic
disease
LIVER TUMOURS
157
will be required. In the intrahepatic situation, especially with very avid (hot)
areas, in an appropriate clinical scenario such as colorectal carcinoma
follow-up, it appears to be very reliable (Iagaru and Quon, 2007 ).
Carcinoid tumours ( Fig. 3.51 )
Primary carcinoid tumours in the liver are rare (Modlin et al ., 2003 ). They
are almost always metastases from the small bowel or colon. If the primary
has been resected because of obstruction, ischaemia, or bleeding then the liver
tumours can be watched as not all hepatic carcinoids will develop the carci-
noid syndrome. Hepatic carcinoid disease that is resectable probably should
be resected but preoperative thin-sliced CT to look for other small-volume
disease must precede this. At laparoscopy, an intraoperative ultrasound is
also useful to locate small deposits ( Fig. 3.51 ). Surgery follows the princi-
ples previously described. Patients with a carcinoid syndrome of flushing,
diarrhoea, and tachycardia represent a difficult group. Debulking of the
tumours within the liver can be a helpful strategy particularly if pharmaco-
logical means have failed. Larger necrotic lesions associated with a carcinoid
syndrome need particularly careful preoperative workup (Landry et al .,
2008 ).
Patients are given one dose of lanreotide 30mg IM on admission and 3 days
of IV octreotide (400mcg/24hours) treatment in hospital prior to surgery
(Lamberts et al ., 1996 ; Kinney et al ., 2001 ). At the beginning of the operation,
the rate of infusion of the octreotide is increased to 800mcg/24hours. This
blockade usually controls adverse events intraoperatively, however the anaes-
thetist needs to be prepared for sudden changes in cardiovascular state as the
tumour is handled during the resection.
Carcinoid tumours fall clinically into quite distinct groups. Some patients
have small numbers of lesions of similar sizes, which can often be resected ( Fig. 3.52 ),
apparently curatively. Many of these patients will develop recurrences but this
may take considerable time and further surgery is often possible. This pattern
can repeat itself and further resections are appropriate.
Some patients will have carcinoid syndrome associated with a large domi-
nant necrotic tumour or a large lesion close to a substantial intrahepatic vein
( Fig. 3.53 ). These lesions should be resected for symptom control but repeat
operations are generally not possible.
A third group of patients will present with miliary disease. These are difficult
to image and frequently appear operable until a laparoscopy and intraopera-
tive ultrasound is performed ( Fig. 3.54 ).
The lesions are numerous and of varying size. There are no surgical options
in these patients, even with dominant nodules or carcinoid syndrome, and
LIVER
158
Fig. 3.51 Management of carcinoid liver metastases.
Carcinoid liver
metastases
Primary
previously
resected
No syndrome
Chemotherapy
Resectable
disease
Surgery
Suitable for
debulking
Not suitable for
debulking
Chemotherapy
Synchronous
primary still
in situ
Carcinoid
syndrome
Unresectable
disease
Unresectable
observe
Primary
resectable
LIVER TUMOURS
159
Fig. 3.54 Miliary disease.
Multiple lesions of different
sizes. Often additional
disease (peritoneal, lung,
retroperitoneal). All inves-
tigations apart from
laparoscopy and ultrasound
understage the disease.
These patients are
inoperable.
Fig. 3.53 Dominant or
single lesion. May have
necrotic centre and often
located near a major
hepatic vein. These
patients should be offered
surgery for symptoms
even if not potentially
curative.
Fig. 3.52 A small number
of lesions of similar sizes.
Potentially curative and
operable. May be recurrent.
LIVER
160
intervention will almost certainly worsen the situation. Management must
include chemotherapy and medical control of symptoms.
Management of neuroendocrine metastases ( Figs. 3.55 and 3.56 )
Metastatic neuroendocrine tumours of the pancreas produce a variety of symp-
toms depending on whether the primary lesion is still in place and hormonally
active. The potential symptoms cover an extremely wide spectrum but the
majority of deposits are either detected during routine surveillance after the
resection of a pancreatic lesion or present with jaundice or capsular pain.
The indolent and variable course of the primary and secondary tumours
justifies an aggressive approach and the mainstay of treatment remains hepatic
resection where appropriate. Although this is frequently not possible with
curative intent, bulk reduction (cyto-reduction) is usually associated with an
improved quality of life and an improvement in survival (Sutcliffe et al .,
2004 ).
The rational for cytoreduction takes into account the known behaviour of
these tumours (the majority are low-grade malignancies as defined by the
WHO classification, see Table 1.7) (Solcia et al ., 2000 ) and available chemo-
therapeutic regimens and somatostatin analogues are largely ineffective. In
addition, because of the competitive nature of the released hormones, the effect
of these tumours only becomes apparent when they exceed a critical mass.
Subsequently the effect is dose dependant and as a result a reduction of the
tumour mass treats the symptoms very effectively (even if not permanently).
This usually results in a significant improvement in performance status and
resection is appropriate if cytoreduction in the order of 90% can be achieved
(Que et al ., 1995 ; Chambers et al ., 2008 ). With this approach a significant
number of patients will survive for many years and the average duration of
symptom relief is 2 years (Sarmiento et al ., 2003 ; Knox et al ., 2004 ). Recurrent
metastases are occasionally suitable for re-resection, but if widespread are
treated by embolization or chemoembolization unless there is additional ext-
rahepatic disease when systemic chemotherapy is used (Kaltsas et al ., 2001 ,
2004 ; Oberg, 2003 ). The role of liver transplantation, which has been investi-
gated, remains unclear (Fernandez et al ., 2003 ).
Management of metastatic gastrointestinal stromal cell (GIST)
tumours ( Fig. 3.57 )
The management of these tumours has changed with the advent of an effective
chemotherapy option, imatinib mesylate (Glivec®), a tyrosine kinase inhibitor
that prevents pro-growth signals sent by enzymes in some tumour cells includ-
ing GIST tumours (Din and Woll, 2008 ; Branconi et al ., 2008 ; Date et al ., 2008 ;
Keun-Park et al ., 2008 ).
LIVER TUMOURS
161
Fig. 3.55 Management of incidentally discovered neuroendocrine metastases.
Symptomatic
Neuroendocrine
metastases
Asymptomatic
Observation
Observation
Chemotherapy/
clinical trial
Progression
Stable
Ablation
Resection
LIVER
162
Fig. 3.56 Management of symptomatic neuroendocrine liver metastases.
Hepatic
neuroendocrine
metastases
Staging CT, MRI,
octreotide scan
Resectable
Resection
Resection and
ablation
Liver transplant
Limited
Diffuse
Localized
Recurrent
Non resectable
Extensive/
diffuse
Re-resect
Non-resectable
Embolization,
chemoembolization
SRS therapy
chemotherapy
Asymptomatic
Symptomatic
Percutaneous or
laparoscopic
ablation
Chemotherapy if
progression
>90% resectable
<90% resectable
Potential for
debulking