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Malignant Liver Tumours

 

The most common malignant liver tumours

In medicine, one primarily distinguishes between primary and secondary tumours (metastases). The primary malignant liver tumours form in the liver cells themselves or in cells of the bile ducts. The secondary tumours or metastases are scattered cells of a malignant tumour, which developed in another organ, as for instance the large bowel, the rectum, or a kidney. Concerning the formation of the most common tumour of the liver, the hepatocellular carcinoma (HCC), we only know that several factors play a role in the process: viruses (hepatitis), hormones, chemicals (solvents, pesticides), alcohol, and certain habits of nutrition. The HCC may grow in the liver tissue as a single node, scattered or diffusely. Much rarer is the carcinoma of the bile duct (CCC), which develops in the tissue of the bile ducts and whose cause is not known. Quite often, gall stones are found in patients, who have this disease. For this reason, discussions arose that a chronic irritation caused by these stones and the consequent inflammation might account for the formation of this tumour. The appearance of this tumour is characterized by single tumour nodes which show a high share of connective tissue, recognizable from its central cicatrisation. Occasionally, a hybrid form of the two tumours (HCC + CCC) is found in the liver. Its diagnosis is difficult and requires a careful preparation and assessment by a pathologist. Compared with the rarer primary carcinomas of the liver, the secondary malignant tumours of the liver (metastases) are found much more frequently. The liver is the organ, where various migrant cells of malignant tumours of the rectum, of the large bowel, and of the kidney accumulate. However, it is not known whether the liver tissue functions like a sieve and retains metastases.

Its diagnosis is difficult and requires a careful preparation and assessment by a pathologist. Compared with the very rare primary carcinomas of the liver, the secondary malignant tumours of the liver (metastases) are found much more frequently (Fig. 2a ,2b, 3a and 3b ).

How do I recognize a malignant liver tumour?

Patients with a hepatocellular carcinoma often do not show any characteristic symptoms because many pathological changes of the liver are only found by diagnostic chance. Unfortunately, the soft liver tissue can easily neutralize pressure, so that pain due to tension occurs relatively late. In the case of a bile duct carcinoma, an obstruction of the ducts may cause a yellow colouring of the skin and thus give a first indication that there might be a tumour.

Necessary clarifications and diagnostic possibilities

At first, the responsible doctor has to find out the exact medical history and then conduct an intensive physical examination: questions about prior diseases, nutritional habits, previous operations and blood transfusions (hepatitis?), loss of weight, and pains are important. During the physical examination, the doctor makes an approximate assessment of the size and consistency of the liver (Fig. 4), analyses the colour of the skin, and asks the patient whether or not there has been any itching.

In addition, the most important blood factors will be determined, bearing the various functions of the liver in mind: blood picture, coagulation status, level of blood sugar, total protein, and tumour markers. The ultrasound is still very suitable to provide to the doctor a fast orientation of the disease as it has to be found out whether the tumour is benign or malignant, whether it comes from the liver itself, or whether it is a metastasis. Only after this, it can be decided whether further diagnostic methods like CT, MRI (with the use of contrast medium), angiography or PET Scan should be used (Fig. 5)

A biopsy will only be made in exceptional cases because one is afraid of spreading the tumour cells and of the risk of bleedings. If all the findings result in the diagnosis of a malignant tumour, the choice of the best treatment depends on the diagnosis. In case of a surgical therapy, there are two fundamental questions to be answered from the surgeon's point of view: Do the age and physical condition of the patient permit such a great intervention? To clarify these questions, additional examinations of the heart (ultrasound) and the lung (functional test) are often necessary. Then, the surgeon has to ask himself what surgical conception should be chosen. In this context, the following questions are important: In what part of the liver is the tumour located? Is it one node or are there several? Which part of the vascular tree supplies this part of the liver? Which bile ducts run here? How much healthy liver tissue will remain after the removal of the tumour and is it sufficient to guarantee the survival of the patient? Is it a primary malignant tumour or is it a metastasis? Before the operation, an important liver test (GEC, galactose elimination capacity) has still to be carried outand used to answer the question whether the tumour has left enough functioning tissue in the liver.

 

 

 

A liver operation requires high-tech management, also from the anaesthesiologist. Absolute necessities include a preoperative examination, availability of packed blood, and information about the postoperative care at the intensive care unit. If the physical condition of the patient or the localization of the tumour speaks against an operation, an interdisciplinary team of surgeons and oncologists will convene to decide on the further proceedings, e.g. chemotherapy, frigotherapy, or radiation therapy.

Very rare tumours which occur as metastases in the liver can be so-called neuroendocrine tumours. They emanate from the pancreas and settle in the liver (Fig. 6). They develop like malignant tumours, but often grow very slowly and limited to the affected organ. Therefore, combined operations on liver and pancreas are suggested. However, after operation, it is favourable to apply and oncological therapy.

 

 

 

 

Wie kann ein bösartiger Lebertumor behandelt werden?


Various diseases make the removal of parts of the liver necessary: benign and malignant liver tumours, metastases, parasitic infestation of the tissue (fox tapeworm), or tumours of the gall bladder or the bile ducts. Depending on the disease, size, extension, and above all, location of the tumour, differing partial resections are carried out. They are named after certain sections of the liver: segment resection (one or more segments) of the right or left part of the liver, which may be extended within certain limits. One example: the partial liver resection to the right (hemihepatectomy) involves the removal of segments V, VI, VII, and VIII. If it has to be extended, the standard is to remove also segment IV, located to the left of the gall bladder. The maxim and objective of the surgeon in this context is to remove "as much as necessary and as little as possible" of the tissue. Unfortunately, this is even for specialist not easy due to the highly complicated anatomy of the liver. In the case of a malignant tumour, a safe distance must also be kept. There are various and different methods of partial liver resection, whose fundamental sequence, however, is similar. The above mentioned hemihepatectomy (right) may serve as an example.

When the operation begins, the patient lies on his back, with his right arm stretched out and his left arm alongside his body. The incision is made along the right and left costal arch and may be extended a little in the middle and to the top, having the appearance of a three-edged star (Fig. 7).

After cutting the abdominal wall, the surgeon will first try to feel the outlines of the liver with his hands and will palpate it (tumour and tissue assessment), then he will also check the neighbouring organs. After this, the liver is partly mobilized by disconnecting certain ligaments (which fix the organ to the abdominal wall) or by partly cutting them. If or if not the preceding diagnosis and the actual findings are coherent, the surgeon may decide on an intraoperative ultrasound to perhaps reassess his concept. Basically, there are now two different options for the removal of liver tissue:

1. All important supplying or deferent vessels and the bile ducts are tied up, followed by the actual transection of the liver tissue (finger fracture) or with instruments, which support the homeostasis of the tissue (Such as ultrasonic dissector or a Habib Sealer) (Fig. 8a and 8b.)

2. When the liver tissue has been transacted, the blood supply is controlled and the vessels are tied up

The procedure may differ, depending on the surgeon and on the given situation. If the surgeon has chosen the first alternative, he will first expose the hepatic porta. There, the great arterial and venous vessels and also the bile ducts are located, entering the liver in a thick cord of tissue. Now, the gall bladder and its supplying vessels are exposed as far as the papilla. The gall bladder is then removed for two reasons:

1. The surgeon will have a better view of the papilla, which is very important. (Fig. 9)

2. Complications (inflammations) after the operation are avoided, which could occur around the gall bladder.

 

 

 


 

 

 

 

 

The vessels are clipped off, pierced and tied up, as is the bile duct. With that, the blood supply to the areas to be excised has been interrupted. Now, the right part of the liver must be further mobilized, so that the deferent vessels at the back can be exposed (Fig. 10 and 11).

With that, the blood supply to the areas to be excised has been interrupted. The no longer perfused liver tissue loses colour and usually shows a nice border to the normally perfused tissue (Fig. 12)

 

Now, the lymphatic nodes around the hepatic porta are closely inspected, if necessary removed and examined by a pathologist. The thick cord of the hepatic porta is tied with a rubber hose, so that the blood supply can be controlled in this place (Pringle manoeuvre). The cord is now carefully exposed, so that finally the artery on the right side, the portal vein, and the bile duct become visible. The vessels are clipped off, pierced and tied up, as is the bile duct. With that, the blood supply to the areas to be excised has been interrupted. Now, the right part of the liver must be further mobilized, so that the deferent vessels at the back can be exposed. Now, the liver tissue is cut, which has already been demarcated after the vessels had been tied up. Different techniques can be used here: application of clips, diathermy, or the clamp technique with piercing. Diffuse bleedings of larger areas from the liver tissue can be stopped by using argon coagulation, smaller ones by using diathermy. Finally, the deferent vein of the liver is removed and sutured. Now, the diseased liver tissue can be totally removed and sent to the pathologist.

The most important task for the surgeon now is a scrupulous suppression of bleedings. Then, the severed areas of tissue are "dried out" with the use of argon coagulation, and the tied off vessels are checked. Special attention is given to the severed bile ducts because a postoperative leakage must be avoided by all means. Only in exceptional cases, a drain is laid into the area. After this, the abdominal wall is closed layer by layer. Depending on the primary disease, for instance in the case of metastases, an additional treatment after surgery could be useful to increase the curative effect: local chemotherapy, thermotherapy, frigotherapy, or laser therapy. Many liver operations follow the above mentioned basic principles. Yet, the surgeon is often forced to choose atypical variants due to the local findings. He has to take special care that the remaining liver tissue is well supplied with venous and arterial blood.

Depending on the primary disease, for instance in the case of metastases, an additional treatment after surgery could be useful to increase the curative effect: local chemotherapy, thermotherapy (Fig 13), frigotherapy (Fig. 15 and 16), or laser therapy.

Many liver operations follow the above mentioned basic principles. Yet, the surgeon is often forced to choose atypical variants due to the local findings. He has to take special care that the remaining liver tissue which is well supplied with venous and arterial blood. However it will be dangerous when liver tissue is being removed .If the entire organ is diseased; the liver will transform itself fibrous or even cirrhotic (fig. 17). Cirrhosis means a transformation of smooth liver tissue into smaller or larger nodes, resulting in a loss of function of the total liver. If additional tissue is lost by surgery, the function can be reduced even further. After chemotherapy, in presence of a fatty liver or even later on of a fibrosis or cirrhosis, the cross section will suffer of severe bleeding. In this case, coagulation devices, such as the Habib Sealer, and the argon beam ,aswell as other methods which eliminate the blood supply such as the fibrin glue ,will be an important role for homeostasis.

If primary tumours or liver metastasis are too large for a resection, different procedures will be applied before the operation, to scale down its’ size. The aim of every procedure is to obtain as much healthy liver tissue as posible and simultaneously to minimize the tumour. For as in the situation of Liver metastasis or Colon carcinoma, chemotherapy will be used to minimize the tumour or to destroy the smaller metastasis. If the tissue of the remaining liver is too small from a previous operation, a branch of the portal vein towards the left or right liver part can be closed to minimize the blood perfusion from one part of the liver (making it smaller) and at the same time enlarges the other part of the liver. Specialist of the interventional radiology can achieve this closure of the portal vein by a small incision of the loin and insert special catheters through the vein until it reaches the portal vein. Using this technique of closing a branch from the portal vein an artificial hypertrophy (enlarging)- Atrophy (minimizing) –complex can be created. This potential is based on the fact, that by loss of liver tissue, the remaining tissue can comparatively enlarge itself again. If it’s the case of a liver fibrosis or cirrhosis, the remaining part of a healthy liver can’t grow effectually.

This is followed by intraoperative views of different findings (fig.18,19 and 20).

 

 

What happens after the treatment?

After every major liver operation, the patient stays for 1 - 2 days at the intensive care unit. Here, an adequate pain therapy and a balanced infusion therapy are carried out. The liver data are controlled, and a close monitoring is maintained to make sure that complications like bleedings are immediately detected. In the normal ward, the patient gradually receives adequate food and is slowly induced to get up and move around. The stitches are removed on the 10th day after the operation. Depending on the disease, surgeon and oncologist may discuss the possibility of an additional therapy in the form of an intravenous chemotherapy and talk about it with the patient. If the tumour has already advanced, it may be necessary to consult a pain therapist, who will suggest an individual combination of medicaments for the patient.

History

Already in Greek mythology, more precisely in the story of Prometheus, the liver plays an important role: Prometheus, "the one who thinks ahead", tried to cheat Zeus in favour of man, and Zeus in turn withdrew the fire from man as a penalty. But Prometheus stole the fire again to bring it back to earth. So Zeus had him chained to a rock, where eagles came to tear his liver to pieces every day, which, however, renewed itself during the night until Heracles one day liberated him from his pains. This story hints at one of the most important qualities of the liver: its capability for regeneration. For centuries, it had been mainly the military surgeons who tried to treat open injuries of the liver. But then, it was the introduction of general anaesthesia and antisepsis at the end of the 19th century that enabled Karl Langenbuch to perform the first operation of the liver in 1888. At the same time, the basic research as to the regeneration of the liver and the arrest of bleeding (haemostasis) in the liver was carried out. Between 1899 and 1914, it was especially the Viennese surgeon and scientist Emerich Ullmann, who was relatively unnoticed, but promoted the research of transplantation and who must therefore be called "father of organ transplantation", as a belated honour. Yet, the foundation for modern liver surgery was laid in the fifties by the great Parisian school led by Jacques Hepp. In 1954, his assistant Claude Couinaud published the standard work on the anatomy of the liver. He was able to prove the complex inner structure of eight sections, which are determined by the liver veins. Also, the immunology of transplantation had greatly progressed in the meantime. So in 1967, Tom Starzl was able to carry out the first successful transplantation of a liver even if the immunosuppressive therapy was still insufficient. The scientific efforts to develop immunosuppressive therapies went on until 1972. Then, by chance, a substance called cyclosporine was found, drawn from a fungus that grows in the earth. It was able to reliably suppress the rejection of an organ, and consequently, the rate of survival of transplanted patients rose dramatically.

 

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