Innovative solutions for the treatment of liver cancer and liver metastases
Prof. Dr. med. Karl Jürgen Oldhafer is Professor and Head of the Department of General and Abdominal Surgery, Hepatopancreatobiliary Surgery and Hernia Surgery at Asklepios Hospital Barmbek Hamburg. He specializes in the surgical treatment of liver and pancreatic diseases.
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The treatment of liver cancer and liver cancer metastases is one of the most complex and challenging tasks in oncology. The diversity of primary malignant tumors poses significant difficulties for both doctors and patients. Even more critical is liver metastasis due to other cancers, with some tumors, such as colon or lung cancer, showing a particular predisposition to form liver metastases. Liver involvement in cases of metastasis at stage 4 cancer is particularly severe, often indicating an extremely severe and incurable condition. This has led the medical community to delve deeper into the essence of this complex problem and develop specific treatment programs that include not only palliative procedures but can provide cancer control or even potentially cure the patient.
Content
- Etiology of liver lesions in cases of cancer
- Standard approaches to the treatment of advanced liver cancer
- Principles of radical treatment of liver metastases and liver cancer
- How is liver surgery performed?
- Postoperative follow-up monitoring
- Liver cancer treatment options in European hospitals
Etiology of liver lesions in cases of cancer
Most cases of primary liver cancer are hepatocellular carcinoma, which develops from hepatocytes (the main cells of the liver). Other types of primary liver cancer include cholangiocarcinoma, angiosarcoma, and hepatoblastoma, which originate from other liver cells and structures.
"Much more commonly, the liver is affected secondarily when cancer cells from other organs spread there through the blood vessels or lymphatic system."
Common types of cancer that often metastasize to the liver include:
- Colorectal cancer. Cecal, colon, and rectal cancers account for about 50% of metastatic liver cancer cases because blood from all unpaired abdominal organs enters the liver through the portal vein.
- Breast cancer. Approximately 30% of women with advanced breast cancer have liver metastases.
- Lung cancer. Approximately 30% of patients with advanced lung cancer have liver metastases on CT/MRI scans.
- Upper gastrointestinal tract cancer, most commonly stomach and esophageal cancers. Both lymphogenic/hematogenous and direct contact pathways of liver involvement are relevant here, with the frequency of liver metastasis development ranging from 10 to 40%.
- Pancreatic cancer. Due to the peculiarities of the blood supply, up to 50% of patients with pancreatic cancer also have liver metastases.
The liver is an important detoxification organ that receives blood from all organs and tissues. It is therefore important to perform abdominal CT/MRI scans and exclude the presence of liver metastases for any advanced cancer.
Standard approaches to the treatment of advanced liver cancer
The method of choice for the treatment of primary liver cancer and liver metastases is surgery combined with chemotherapy (regional or systemic; neoadjuvant, intraoperative, or adjuvant). The main condition for a good treatment prognosis is the total removal of all malignant foci.
Challenges faced by surgeons when performing operations for advanced primary cancer or metastatic liver lesions due to the spread of cancer in other localizations include:
- Extensive liver lesions, due to which the patient has almost no organ parenchyma left uninvolved in the tumor process. Due to active blood flow, metastases often spread to both lobes.
- Decreased liver function after chemotherapy or prolonged use of other systemic anticancer drugs.
- Decreased liver function due to concomitant diseases (cirrhosis or hepatitis) or age-related changes.
In this regard, patients with metastatic liver lesions caused by other types of cancer or stage 4 liver cancer received only palliative care for symptom relief. There was no talk that oncology could be controlled and life expectancy increased. The situation changed with the advent of two-stage liver splitting surgery.
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Principles of radical treatment of liver metastases and liver cancer
A unique feature of the liver is its ability to regenerate. It can fully restore its volume and normal function if at least 25% of healthy parenchyma remains after surgery. This gives surgical oncologists the ability to perform interventions that may seem absolutely impossible at first glance.
Curative (radical, that is, potentially bringing the disease under control) surgical treatment of primary and secondary malignant liver tumors has 2 basic principles:
- Total removal of all malignant foci in the liver, regional lymph nodes, and adjacent organs.
- Normal liver function in the postoperative period. This ensures detoxification, participation in all types of metabolism, synthesis of blood clotting factors, synthesis of bile for fat absorption, etc.
When cancer has spread to both lobes of the liver, it is very difficult to follow these principles because if the surgeon removes all the affected tissues, the patient will suffer from liver failure, a life-threatening condition, after surgery.
These requirements are met when performing an innovative operation – two-stage liver resection ALPPS (Associated Liver Partition and Portal Vein Ligation for Staged Hepatectomy). This surgical procedure allows the doctors to expand the possibility of radical treatment for unresectable or conditionally unresectable liver tumors and metastases and give patients a chance for recovery. Surgeons are no longer limited to classical anatomical resections, as ALPPS surgery is successfully performed for bilobar lesions and the preservation of less than 25% of healthy liver parenchyma.
How is liver surgery performed?
The success of the surgical intervention largely depends on its thorough planning. Preoperative preparation necessarily includes the following examinations:
- Imaging tests (ultrasound, CT/MRI) to assess the parameters of the primary tumor, the number and size of liver metastases, and the presence of fibrotic changes or steatosis
- Laboratory liver function tests, such as transaminase levels, bilirubin fractions, LDH, alkaline phosphatase, and protein fractions
- Blood tests for infections: all types of hepatitis and AIDS
During surgery planning, it is important for surgeons to assess the volume of the future liver remnant (FLR) and its functional reserve. Nowadays, doctors can do this using modern computer programs, supplementing their clinical experience. For example, the Fraunhofer MEVIS team has developed software that analyzes data from imaging tests using mathematical models. The results of computer modeling allow surgeons to opt for complex surgery without any fear for the health of patients.
The first stage of the operation is splitting the liver totally or partially along the falciform ligament to the retrohepatic segment of the inferior vena cava with embolization or ligation of the right portal vein branch. The patient stays in the operating room for up to 3 hours. The surgeon sanitizes the left lobe of the liver, so it should not even contain microscopic malignant foci. This stage is followed by a blockage of blood flow in part of the portal vein. It leads to hypertrophy of the liver tissue, thus initiating the regeneration process.
The second stage of the operation is performed when the healthy parenchyma hypertrophies and liver function test parameters return to normal levels. This means that the functional reserve of the liver allows the doctors to proceed to the final stage of the operation, that is, extended right hemihepatectomy and removal of regional lymph nodes. Depending on the clinical case, there may be 1-2 weeks to 1-1.5 months between surgical procedures. The team of surgeons individually selects the optimal treatment for each patient.
Postoperative follow-up monitoring
The medical team pursues the following goals in the postoperative period:
- Make sure that the liver functional reserve is normal and that there is no liver failure
- Make sure that the treatment is radical and there is no tumor growth
- Provide patients with symptomatic treatment in order to improve their general health condition, and if necessary, plan rehabilitation
The patient spends the first day after surgery in the intensive care unit with constant monitoring of vital signs. In specialized clinics, this period is immediately followed by activation when the patient is transferred to a regular room, and they are allowed to move, gradually expanding the diet. Thanks to this, hypertrophy of the remaining hepatic parenchyma occurs more actively, and recovery is easier.
During the postoperative period, the team of oncologists can perform one or more courses of chemotherapy. After discharge from the hospital, the patient receives recommendations on nutrition and the intake of medicines, as well as information about follow-up examinations.
Liver cancer treatment options in European hospitals
Clinical trials show that ALPPS surgery ensures good long-term results for patients with extensive or multiple metastatic liver lesions and people with hepatitis or cirrhosis. The surgical intervention is technically complex because the surgeon must delicately isolate blood vessels and preserve the viability of both liver lobes.
It is very important to choose a hospital with a multidisciplinary team of oncologists and experienced surgeons for liver cancer treatment. Among the best in this field of medicine are European countries, particularly German hospitals. If you are planning to go abroad for surgery, you should first study information about hospitals, doctors, and treatment success rates.
On the Booking Health website, you will find profiles of highly specialized clinics and the current cost of treatment. This may range from a comprehensive medical care program that begins with diagnosis clarification and ends with rehabilitation to the price of a single service, such as ALPPS surgery or chemoembolization. On the website, you can also find out the next available appointment date and make your treatment appointment.
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Authors:
The article was edited by medical experts, board certified doctors Dr. Nadezhda Ivanisova and Dr. Vadim Zhiliuk. For the treatment of the conditions referred to in the article, you must consult a doctor; the information in the article is not intended for self-medication!
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Sources:
NIH, National Library of Medicine
International Journal of Surgery Case Reports
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