You cannot live without your liver. It is a vital organ. It works 24/7 to metabolize and remove toxins that we ingest every day, including alcohol, the overconsumption of which can cause cirrhosis – damage to the liver. The liver also removes ammonia and bilirubin from the blood and effectuates the development of certain enzymes that are critically important for ongoing health.

Liver Tumors

Liver tumors can be both benign and malignant (cancerous). They are typically found incidentally on radiographic studies such as Ultrasound (US) or Computed Tomography (CT) scan. They rarely cause symptoms other than pain but occasionally can cause biliary obstruction resulting in jaundice (yellowing of the skin). Once identified, the mass can typically be characterized as benign or suspicious for cancer with imaging studies but some do require a biopsy. Benign lesions are usually not treated with surgery unless the patient is symptomatic or there is a risk of the benign lesion becoming cancerous. If the lesion is cancerous, the next steps would be diagnosis and assessing if the cancer has spread.

Diagnosis

There are several types of liver, gallbladder, and bile duct tumors. There are also other types of cancer that can metastasize (spread) to the liver. Each of these lesions have different characteristics that allow physicians to diagnose and treat them properly. The initial diagnostic workup is typically imaging. Usually an ultrasound or CT scan but occasionally an MRI will be required. Once the imaging has been reviewed by a radiologist, the appropriate biopsy can be obtained. The biopsy for liver lesions is usually a CT guided biopsy which is a procedure that occurs in radiology and patients are discharged the same day. In the case of bile duct tumors, an endoscopic ultrasound (EUS) or Endoscopic retrograde cholangiopancreatography (ERCP). This is also an outpatient procedure. Once the biopsy is obtained, it will be reviewed by a pathologist to determine the type of lesion.

Types of Liver Tumors

Benign

• Hepatic Adenoma– Typically found in children of childbearing age as it is associated with oral contraceptives (OCPs). Often found due to pain or symptomatic anemia from bleeding inside the lesion. Lesions in women that are smaller than 4 centimeters can typically be observed but anything larger should be resected as there is a risk of malignant transformation. All adenomas in men should be resected as they are at higher probability of converting to a malignant lesion.
• Focal Nodular Hyperplasia (FNH)– Almost always found incidentally and rarely symptomatic. Typically found in women 30-50 years of age. Can be diagnosed based on imaging criteria alone and does not require a biopsy unless there is concern. Surgical resection is not necessary unless symptomatic. Almost no risk for malignant transformation.
• Hemangioma– Most common benign liver lesion. It is a proliferation of blood vessels within the liver tissue. Occasionally they can cause bleeding and should never be biopsied. These lesions do not require resection unless they are expanding or causing symptoms. Typically do not convert to a malignancy.
• Mucinous Cystic Neoplasm– Uncommon lesion that is rarely found in women over 50. This lesion does have a high risk for transformation and should be resected if possible.

Malignant

• Hepatocellular Carcinoma– Most common form of primary liver cancer. Typically arises from patients with cirrhosis. Many of these patients will require transplantation eventually and resection or ablation can keep them within transplant criteria (Milan Criteria). Usually diagnosed on screening ultrasound and confirmed with cross-sectional imaging (CT/MRI). Can be treated with a variety of modalities including resection, ablation, histotripsy, and finally transplantation. If the patient is not an operative candidate, there are other therapies such as transarterial chemoembolization or injection of radioactive spheres to treat the tumor.
• Cholangiocarcinoma– Technically a tumor of the bile ducts and not the liver parenchyma. Second most common liver cancer overall. Usually found in people 60-70 years of age who present with jaundice or abdominal pain. Typically presents at a fairly advanced stage and surgical treatment is the only option to offer a chance at cure. These tumors are resistant to most systemic treatments and should be resected if at all possible.
• Gallbladder Cancer– Also not a primary liver tumor, this cancer often grows into the liver or has metastatic lesions to the liver. This is a highly aggressive malignancy that should be resected if found early and if there is no evidence of metastatic disease. Typically these cancers will require a resection of the liver around the gallbladder and dissection/removal of the lymph nodes in the area around the gallbladder. Occasionally, this lesion will extend into the common bile duct and require a resection and reconstruction.

Metastatic lesions

• Metastatic colorectal cancer– Roughly 50 percent of patients with colorectal cancer will develop liver metastases. Despite this, the cancer is still curable through liver directed therapies such as resection or ablation. These lesions are frequently detected prior to resection of the primary mass and some patients can undergo colectomy with concurrent liver resection. If the tumor is deemed unresectable due to location, transarterial chemotherapy or radioactive spheres can be utilized for treatment.
• Metastatic neuroendocrine tumors– These tumors typically arise in the appendix, small bowel and pancreas. They often metastasize to the liver and are one of the few cancers that benefit from tumor debulking. Resection and ablation are both effective modalities and often used in conjunction to treat this metastatic disease.
• Metastatic breast cancer– Improvements in breast cancer care has improved survival and liver resection is now an accepted treatment option for certain patients with stage 4 disease. This is a very select group of patients and should be discussed extensively with the multidisciplinary tumor board prior to scheduling an operation.

Surgical Procedures

Open – Open operations are commonly performed for liver lesions. These require large incisions on the upper abdomen. These incisions can be painful and require longer hospital stays for recovery. Despite this, open operations do offer excellent visualization and are preferred for larger liver tumors

Robotic – The advent of the robotic surgical system has given surgeons the ability to perform highly complex operations in a minimally invasive fashion that would otherwise be impossible. These operations reduce hospital stays, have decreased pain, and overall decreased hospital costs. MIIS has extensive robotic training and will perform most cases robotically if possible.

Laparoscopic Options

There are multiple options for removing the liver. However, patients will most likely prefer the immediate benefits of minimally invasive laparoscopic surgery, such as smaller incisions, less blood loss, and often shorter procedure and recovery times. Both an open surgery and a minimally invasive surgery to remove a liver tumor will require general anesthesia and remain in the hospital for one or more days after the surgery.

Not all liver cancers can be treated using a partial hepatectomy. Advanced imaging such as CT or MRI can tell us if the tumor is too large or has spread to other areas of the body. Cirrhosis of the liver also reduces its ability to perform vital functions; therefore, removing part of this less efficient liver may not be possible.

There are risks associated with removing a liver tumor, and testing will help reveal factors that need to be assessed before surgery is pursued. Your surgeon can review your results and recommend the best course of action. Contact us to schedule a consultation with our surgeons.

Specific Operations MIIS offers

Parenchymal Sparing Hepatectomy
This approach can be utilized for single or multiple lesions of the liver. We approach the resection by taking an adequate amount of liver tissue for appropriate oncologic margins but minimize the detrimental effect on liver function. This is our preferred approach to liver surgery and will perform if possible.

Formal Hepatectomy
These resections are reserved for patients with multiple lesions in either the left or right lobe of the liver. We can resect (remove) the right or left lobe in its entirety and the patient will do well as long as they have enough functional liver in the remnant (typically 30% or more). This can be determined with preoperative imaging.

ALPPS Procedure
This procedure is performed in patients who do not have sufficient liver for a formal resection. We ligate the portal vein and transect the parenchyma but leave the hepatic vein. This allows the remnant liver to enlarge. The diseased liver is then removed in 4-6 weeks.

Robotic or Laparoscopic Assisted Ablation
Interventional radiology is typically able to perform most ablations but occasionally the lesions are too close to other structures and require a surgical approach. Surgeons can mobilize the liver and allow for ablations of lesions in locations the interventional radiologists are unable to access.