WHEN TO OPERATE PRIMARY LIVER CANCER (HEPATOCELLULAR CARCINOMA)

Primary liver cancer (hepatocellular carcinoma)

In my previous posts I have discussed about cancer spread to the liver, now l will try to explain primary liver cancer or hepatocellular carcinoma.

In healthy liver same thing applies here also i.e 20-30% of normal healthy liver should be left after resecting hepatocellular carcinoma.

But there is some difference is hepatocellular carcinoma.Hepatocellular carcinoma most commonly arises in background of diseases liver.It can arises in healthy liver but such cases are infrequesnt.

So it is mostly seen when entire liver is diseased or cirrhotic.Liver disease in the background can be anything i.e. hepatitis b,hepatitis c,alcholoic or non alchoholic fatty liver disease.

Now ,as you might have realied we do not have mendatory 20-30% healthy liver commonly.

So do we have any options?

 Yes we have.

 We have mainly 3 options

1.     Resection

2.     Transplantation

3.     Bridiging and downstaging therapy like chemoembolization or radioembolization

I will takle all the option one by one.Today I will try to adress to issue When to remove (resect) primary liver cancer (hepatocellular carcinoma).

Primary liver cancer can be removed (surgical resection) if

·      liver function is resanablly preserved. (i.e billirubin, platlet count,albumin, and PT/INR should be nearrly normal) Medically we call it child A cirhorrsis.

·      Here remaining liver should be atleast 40-50% of total liver volume

·      Main vessels (portal vein,hepatic artery etc) should not be involved how ever if their branches are involved liver tumour still can be removed.

·      Some time other test to detect liver function like ICG test (Indigo carmine) or Hepatic artery wedge pressure (HVPG) etc are indicated when confusion about liver status is there

There are some debate as weather to do transplant or resectionin these group of patient with well preserved liver function. Studies have shown that transplant gives little bit better results then resection but in countries like india where brain dead donors are rarely available and liver donations are only option and cost involved with transplants, resection should always kept in mind.

Transplantation for hepatocellular carcinoma will be discussed tomorrow.

HOW TO MAKE UNOPERABLE LIVER CANCER OPERABLE??

In the previous posts of my blog I have mentioned that surgery is the only curative treatment for liver cancer either primary liver cancer or cancer spread to liver.

And all liver cancers are surgically curable if 20% of healthy liver can be spared.

Now the question arises what if by pre operative investigation we find that 20% of healthy liver is not possible to save. Is there a way out????

Answer is thankfully yes.

Research has proved that we can use potential of liver to grow after surgery in pre operative settings also.

Insulin rich blood from gastrointestinal system before going to other part of the body first reach the liver, studies have shown this insulin content of the blood that is reaching liver is the primarily responsible for the growth of liver.

Now if by some way we are able to divert these insulin rich blood from the part that we want to remove to the part that we do not want to remove than this part can grow and can achieve size more than 20% and thus can make surgically incurable liver cancer to surgically curable liver cancer.

There are three ways to achieve it.

1.    Portal vein ligation:

Surgically in the first stage we can ligate that part of blood vessel, which takes blood to the liver. And re assess liver volume after 3-4 week. This method has not gained very much popularity because need of two surgeries and also increase in liver volume is not that satisfactory.

2.     Portal vein embolization:

This is an interventional radiological method by which branch of the vessels supplying the liver can be blocked percutaneously (via small injection on skin). This is the most widely used method where as this procedure can be done non surgically.

Main drawback of this method is it takes 3-6 weeks to achieve desired enlargement of the liver. SO there is always a risk that cancer can spread during this time period.

portal vein embolization   

                 _{ALPPS Procedure vein is ligated and liver is cut but not removed}

3.     Associated portal vein ligation with in situ liver splitting (ALPPS):

This novel method to increase size of liver were discovered recently in 2011 only in which though it requires surgery but liver size is shown to increase to desired level in just 7-14 days. In this method portal vein is tied as in portal vein ligation method but liver is partially cut along with it but not removed. It is shown that this cutting is responsible for rapid increase in size and tumor can be removed by doing second surgery just in 7-14 days. There are encouraging reports of this method and this can be the future of liver surgery.

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 So take home message for today’s discussion is there are many ways and means to cure cancer spread to the liver. You should never loose hope. Fight the disease,take advise of trained liver surgeon and we can bear the disease.

Liver first?? Intestine first?? Or Together?? What should be the ideal treatment strategy in treating simultaneously detected intestinal cancer, which it’s spread to liver

In my yesterday’s post I have just briefly explained that intestinal cancer with spread to liver can be treated but do the confusion ends here??

If one is detected with intestinal cancer that is spread to liver at the same time confusion arises.

What to treat first?? Should we treat intestine cancer first and its spread to liver at a late date?? Or should we treat intestine first and liver at a later date or should we treat them simultaneously??

Recent researches have shown that intestinal cancer cell first reach liver and then to rest of the body so if we want to treat the patient we have to stop cancer from spreading to other part of the body.

So if possible we have to treat liver cancer first which is known now a days as “LIVER FIRST APPROACH”

 what is the liver first approach mean?? Does it mean that surgically remove every tumor that is surgically removable (i.e we can keep 20% of the healthy liver)

Well answer is yes and no. I mean jury is still out some surgeons believe that before attempting surgery patient are given 2-4 doses of liver specific chemotherapy (mind well liver specific chemotherapy) and if tumor remains same or decreases you should immediately go for surgery but if tumor increases in size or number that indirectly suggest that tumor is very aggressive biologically and surgery is not going to help much where as some believe that as surgery is the only chance of cure every surgically resectable disease should be offered surgery regardless of tumor biology.

What to do if 20% of liver cannot be saved??

Well answer is still the same. Start liver specific chemotherapy and resect the disease as soon as it becomes surgically resectable.

So after liver resection is completed after some time you can resect intestinal primary cancer. Intestinal cancer should be given radiotherapy in the mean time to arrest its growth.

When to resect intestinal cancer first??

However there are certain exceptions to this approach. When ever there is complicated intestinal cancer, i.e. if intestinal are occluded (obstructed) or ruptured you have to deal with intestinal cancer first.

When to resect both the things simultaneously??

 Simultaneous resection is a major surgical procedure with very high risk. How ever when liver disease is limited and patient is young, physically very fit this option can be considered with evaluating due risks.

 Liver post tumor removal

Liver metastases: An incurable disease????

Generally cancer is believed to be a deadly disease. Once it spread beyond its primary site people loose all their hope.

Is it really true??

Is it really end of road??

Answer is big no particularly in case of liver metastasis.

Medical science has proved that certain cancers like small and large intestinal cancers; neuroendocrine cancers are still very much curable if the spread is limited to liver.

Intestinal cancer spread to liver before surgery

Cancer completely removed after surgery

_{Cancer cells first travel to liver before reaching any other part of the body}

Particularly in case of intestinal cancer it is believed that cancer cells before spreading to any other part of the body first they reach liver so if cancer is removed surgically when it is spread just to liver and not any other part we can give patient a long and healthy life.

Same thing hold true for neuroendocrine cancers.

Not a proven thing but recent studies shows that breast cancers spread to liver if tackled surgically can improve survival in-patient with breast cancer.

Liver regeneration capacity:

Liver is the only organ in the body who has a unique regeneration capacity and its grows on its own if removed. It is proven that only 20% of normal healthy liver is required for normal life. So 80% of liver can be removed without much risk and 80 % of that removed liver grows back in a month or two.

This unique capacity of liver gives surgeon many options to treat liver disease.