Diseases of the Liver in Margate, FL
Malignant Diseases of the Liver
Malignant are diseases which are cancerous.
Primary Malignant Diseases of the Liver
Primary are malignant tumors which form originally in the liver and do not come by spread from somewhere else.
Hepatocellular carcinoma (HCC)
Hepatocellular carcinoma (HCC) is the most common primary malignant tumor of the liver. It originates from the liver cells themselves. It presents as one or more masses in the liver with typical appearance on CT or MRI. It usually forms in the background of cirrhosis or chronic viral hepatitis, which makes it more challenging to remove due to the underlying disease of the rest of the liver.
Intrahepatic cholangiocarcinoma (ICC)
Intrahepatic cholangiocarcinoma (ICC) arises from the small bile ducts in the periphery of the liver and that is why it is also called peripheral cholangiocarcinoma. It usually presents as a mass, not infrequently a large one, in the periphery of the liver, seen on CT or MRI.
Secondary (metastatic) Malignant Diseases of the Liver
Secondary are malignant tumors which form originally somewhere else in the body as a cancer of another organ and then by means of spread by the blood stream tumor deposits are brought to the liver where they form secondary tumors which are called metastases. Many tumors may spread to the liver, but the most common ones, for which surgery is a treatment option, are the following:
Colo-rectal cancer (CRC)
Cancer that originally develops in the large intestine (colon and rectum) is the most common cancer that spreads to the liver. The liver metastases may be found at the time of diagnosis of colon cancer before any treatment or they may form later after original colon surgery and possibly chemotherapy. They are seen as masses in the liver on CT or MRI. Up to 50% of patients with colon cancer will eventually develop liver metastases at some point of their treatment. Thanks to liver surgery, the survival of patients with liver metastases at 5 years can be increased from close to 0% (without liver surgery) to up to 40-60% (with liver surgery).
Neuroendocrine tumors
Neuroendocrine tumors arise from special cells which produce a variety of hormones. These may be the cells in the pancreas which produce insulin, but there are numerous other cell types which produce other hormones, which are not well-known to the general public. Commonly these tumors are located in the pancreas, but they may also form in the stomach, duodenum, small intestine or large intestine. Some of these tumors produce active hormones, but more commonly they are not-hormonally active and then they are called non-functional. Neuroendocrine tumors are very typical to spread to the liver, where they may have just a few metastases or the metastases may be multiple, sometimes impossible to count. Some of them may be very large and others may be very small. They are seen on CT or MRI. Unique test for neuroendocrine tumors is the modern Gallium-DOTATATE scan and also the older Octreotide-scan. Neuroendocrine tumors are malignant, but they are unique in a way that they grow generally slower than conventional cancers and that makes them uniquely positioned for successful surgical treatment by removing them from the liver along with removal of the primary organ where they form. Thus, patients generally survive much longer than when they have metastases from conventional cancers.
Ovarian, breast, endometrial, renal cancer
These cancers are less commonly treated by liver surgery but liver surgery is a viable option in selected appropriate patients. Liver metastases are usually found on CT or MRI during the initial diagnostic workup or on surveillance during or after treatment of the primary cancer. In these cases liver surgery would be typically performed after a course of chemotherapy is completed.
Benign Diseases of the Liver
Benign are masses in the liver that are not cancerous.
Solid Masses of the Liver
Solid are masses in the liver which are not cystic and not fluid-filled.
Liver adenoma
Liver adenoma is a benign tumor arising from the liver cells themselves and in that sense is the non-cancerous counterpart to hepatocellular carcinoma. It most commonly is seen in women, frequently young women, frequently in the settings of use of oral contraceptive pills (OCP). It may increase in size during pregnancy because of its hormone dependency. Most commonly in women it does not require surgery and with discontinuation of OCP it may shrink in size. Unless it is associated with special mutations, in women it is not likely to progress into cancer. However, in men it is much more likely to turn into cancer. Because of that, in men it is recommended to be removed. In women, even though unlikely to transform into cancer, liver adenoma may become quite large, may cause symptoms of pain, or it may rupture and bleed. In these cases surgery is still needed. Usually these tumors are seen on CT or MRI. A biopsy is needed to confirm that the tumor is an adenoma and not its malignant counterpart hepatocellular carcinoma. Surgical removal is needed if cancer cannot be ruled out with confidence.
Focal nodular hyperplasia (FNH)
Focal nodular hyperplasia (FNH) is a benign disease of the liver which consists of abnormally organized but otherwise normal liver cells around a central vessel, which gives a characteristic appearance on MRI called “a central scar”. FNH does not have any potential to transform into cancer. The reason to perform surgery is if FNH is large and causes pain or if it cannot be confidently confirmed that is indeed an FNH and not a cancer. In other words, as it presents as a mass on CT or MRI, if we cannot be sure that it is not a cancer, we need to remove it.
Hemangioma
Hemangioma is a completely benign vascular tumor of the liver which has no risk of turning into cancer. It usually has a typical appearance on CT or MRI and the diagnosis can be established with confidence by imaging. No surgery is needed. Occasionally, hemangiomas may grow to a very large size and cause pain and other symptoms from compression to other organs. Sometimes, they may rupture and bleed. In these cases, surgery may be needed to remove them.
Cystic Masses of the Liver
Cystic tumors are masses in the liver which are fluid-filled. Depending on the quality of the fluid, they are divided into the following categories:
Serous Cysts
Serous are cysts in the liver which are filled with thin clear fluid, having an appearance similar to tears. They can be single or multiple. They have no risk to transform into cancer and that is not a concern with them. Because of that, usually when they are seen on CT or MRI, no surgery is recommended. Sometimes however, a single cyst or a group of cysts may grow to a very large size and then it can cause pain and other symptoms from compression to other organs. If that is the case, surgery is recommended. It usually includes partial removal of the wall of the cyst with excellent short term results. After such operation, the cyst may recur. In contrast, when the cyst is completely removed, it cannot recur but complete removal requires much bigger and riskier surgery and because of that, it is not preferred, as the risks of surgery may be greater than the risk of recurrence.
Mucinous Cysts
Mucinous are cysts in the liver, which are filled with fluid that is thicker and may resemble mucus, hence that name. Unlike serous cysts, mucinous cysts have the potential to transform into cancer. That risk is particularly increased if the wall of the cysts becomes thickened or develops areas of growth, which are called mural nodules. That can be seen on CT or MRI and if such findings are present, that is a clear indication to offer surgery. As opposed to serous cysts, partial removal of the wall of the cyst is not acceptable for mucinous cysts and that requires more complex and higher risk surgery to remove the entire cyst, but here that higher risk is justified in order to prevent malignant transformation or to remove early cancer.
Surgical procedures on the liver
Surgical procedures on the liver for solid tumors or cysts include removal of parts of the liver, depending on the location of the lesion in the liver.
Liver resection
Liver resection is a procedure in which part of the liver is removed (resected). It frequently involves removal of the gallbladder as well.
The liver has very large vessels bringing blood to it, called inflow vessels. It has also very large vessels draining blood out of the liver, called outflow vessels. The liver itself is a very vascular organ and bleeds a lot when it is divided. Because of all of the above, liver surgery is associated with significant risks of bleeding, much higher than other surgeries.
The liver has the unique ability to grow back to its original size soon after surgery - in a few weeks. However, the time from the end of surgery to the time when the liver has grown in size over several days to several weeks, is critical for the patient. The part of the liver that is left in the patient after resection is called liver remnant. The size of the liver remnant is of utmost importance. A patient needs a critical minimal volume of liver left after resection in order to survive. If the size of the liver remnant is smaller than that critical volume, then the patient may develop postoperative liver failure and die even if the surgery otherwise has gone well. The critical volume of liver, needed to survive, depends on the quality of the liver tissue. It is measured as a percentage of the entire liver volume before resection. In patients with healthy livers, as little as 20-25% liver remnant may be enough to regenerate and survive. However, if the patient has been treated with chemotherapy preoperatively, as chemotherapy causes fatty liver, then 30-35% of liver remnant would be needed. If the patient has chronic liver disease, i.e. cirrhosis, then 45-55% may be needed to survive. Sometimes, cirrhosis may be so advanced, that liver resection may not be safe altogether.
The estimated liver remnant before surgery is called future liver remnant. That estimation is based on using special CT software that calculates the volume of the entire liver and the volumes of parts of it and then the part that stays (future liver remnant) is calculated as a percentage of the entire liver volume.
When the future liver remnant is smaller than the critical volume needed to survive, additional strategies to grow the future liver remnant before surgery are used to make the surgery safer and to decrease the risk of postoperative liver failure.
Depending on which part of the liver is removed, the liver resections can be different types and have different names:
Right hepatectomy
Right hepatectomy is removal of the entire right half of the liver. As the right half is usually bigger than the left, the liver remnant is much smaller. Because of that, in case of right hepatectomy, consideration to the size of the liver remnant is much more common and strategies to increase it may be more frequently needed.
Left hepatectomy
Left hepatectomy is removal of the entire left half of the liver. As the left half is usually smaller than the right, the liver remnant is much bigger and concerns for its size are less common. The liver resection surface might be larger compared to right hepatectomy and thus left hepatectomy may be associated with greater blood loss.
Trisegmentectomy
Trisegmentectomy is usually done when there are multiple large tumors, occupying most of the liver and only ¼ is not involved. It removes ¾ of the liver and leaves only ¼ in place. Because of that, the size of the liver remnant is always a concern and strategies to increase its size before surgery are almost always needed. Trisegmentectomy may be right or left. Right trisegmentectomy is much more common.
Right posterior sectionectomy
Right posterior sectionectomy removes ½ of the right half of the liver. That part of the liver is behind the rest of the liver (posterior means in the back, rear) and is more difficult to perform because of its rear location. The size of the liver remnant is adequate, so concern for that is uncommon.
Left lateral sectionectomy
Left lateral sectionectomy removes the outer ½ of the left half of the liver and that is the smallest part and also the easiest technically to remove. Thus it has the most liver left and it has the smallest risk of blood loss.
Segmental liver resections
Segmental liver resections may be many different operations with various degrees of difficulty. The liver is divided into 8 segments, all of which look like a pyramid with its base forming part of the surface of the liver and its tip pointing towards the center of the liver. Each segment is defined by one branch of the inflow vessels with provides the inflow blood supply to that particular segment. That inflow branch is the key vessel that needs to be sealed and divided in order to perform the operation. Segments that are posterior (in the back, rear) or at the dome of the liver, or more centrally located, are more difficult to remove as they are nestled between large blood vessels, which need to be preserved, and with a higher risk of bleeding. Segments that are more anterior (to the front) or closer to the free edge of the liver, or more peripherally located, are easier to remove and with smaller risk of bleeding. Because they are only 1/8 of the liver volume each, when segmentectomy is performed, the size of the liver remnant is not a concern. Segmental liver resections are done when there is a tumor in only one segment of the liver.
Non-anatomical liver resections
Non-anatomical liver resections are removals of parts of the liver, usually segments or smaller, which are closer to the surface and formal identification and division of the segmental vessel is not necessary. Typically they are easier to perform but sometimes may have greater blood loss than formal segmentectomy as the internal vascular anatomy of the liver is not followed.
Liver cystectomy
Liver cystectomy is removal of part of the wall of a liver cyst, rarely the entire cyst. If the entire cyst is removed, that usually requires a formal liver resection. As described above, liver cystectomy is a procedure that would be used for a simple liver cyst or a group of cysts, when the peripheral (outside) part of the wall is removed and the inner deeper part of the wall is left in place. Because the wall is thin and avascular, usually the blood loss is minimal and overall the risk of the procedure is much smaller as compared to a liver resection. A possible complication is bile leak, which may not be seen at the time of surgery. Sometimes liver cystectomy is called unroofing or deroofing of a liver cyst. Usually can be performed minimally invasively and the patient can go home on the next day.
Surgical porto-caval shunts
Surgical porto-caval shunts are several different operations which are rarely done nowadays. They have been mostly replaced by interventional radiology procedure called TIPS (Transjugular-Intrahepatic Porto-Systemic Shunt). However, in rare occasions an old-fashioned open surgical porto-caval shunt may be necessary. These operations are done in patients with cirrhosis and portal hypertension (increased pressure in the veins inside the abdomen, caused by cirrhosis). They consist of making a surgical connection between a vein that drains the intestines (portal vein or splenic vein) and a vein that drains directly into the heart (inferior vena cava, IVC or its tributary, the left renal vein). Because they are done in patients with cirrhosis, which is a very serious disease, these procedures are very high risk for bleeding or worsening liver failure.