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Neuroendocrine Tumors of the Liver

Neuroendocrine Liver Metastases successfully cleared with surgery.

liver_resection

What are liver metastases and where do they come from?

By definition, liver metastasis is cancer that has spread to the liver from somewhere else in the body. Liver is the most common site for cancers to spread to after the lymph nodes. Most of these originate from cancers of the colon, rectum, pancreas, stomach, esophagus, breast, lung, melanoma and some other less common sites. In the past liver metastases were often considered advanced disease and frequently sent for palliative care. However, today the paradigm has shifted completely. Depending on where they originate from, aggressive surgical resection and often coupled with chemotherapy will lead to significant improvement and long term survival in this patient population. We at the Liver and Pancreas Center have traditionally had a very aggressive approach to metastatic disease and offer both Laparoscopic and Standard Open Surgery depending on size, location and number of metastases. (metastasis= single, metastases= multiple)

Neuroendocrine/ Carcinoid Liver Metastases

Neuroendocrine related and carcinoid tumors are rare slow growing tumors that can arise from the pancreas, lung, thymus, stomach, duodenum, small bowel, colon and rectum. Carcinoid tumors, were first described in 1907 by Siegfried Oberndorfer. The term "carcinoid" means "cancer-like" and are cancerous, except very slow-growing. A carcinoid tumor is often associated with an increased production of serotonin (5-HT), a chemical transmitter that causes a specific set of symptoms including flushing, diarrhea, weight loss, heart palpitations etc. This set of symptoms is called “carcinoid syndrome”. As a note, carcinoid tumors that originate in the digestive tract generally do not produce symptoms unless the tumors have spread to the liver. We offer a comprehensive evaluation and an individualized treatment plan for each patient presenting with liver metastases. If these lend themselves to a surgical resection, then they should be removed. If there are numerous metastases in the liver than alternative strategies are utilized viz. chemotherapy, chemoembolization, Yttrium-90 microsphere radioembolization, radiofrequency or microwave ablation.

What is a Liver Resection?

Liver resection is “resecting or removing a portion of the liver”. This can often range from being a straight forward wedge resection to fairly complex resections where the whole lobe of the liver needs to be removed. The illustration enumerates the various types of resections that are commonly done. The key is to remove the tumor and yet be able to leave behind enough functional liver. Usually 30-40% volume of liver left behind is considered sufficient volume. The Liver is one of the few organs in the body that regenerates back to almost 100% in volume in approximately 3 months. This allows the liver to return to complete function, and also allows for repeated resections if deemed necessary in cases of recurrence.

Can liver resections be done laparoscopically?

Yes. A good number of these cases can be done using the minimally invasive techniques, i.e. by making very small incisions (5- 10 mm) for introducing instruments to allow dissection. However, it is important to note that not all cases lend themselves to a laparoscopic resection and that decisions have to be made on a case by case basis. Dr. Singh is one of the few surgeons in the United States doing these major surgeries laparoscopically and was invited to speak at the 93rd Annual Clinical Congress of the American College of Surgeons on Laparoscopic Liver Resections.

Can liver resections be done using Robotic Technology?

Yes. Robotic technology offers all the advantages of minimally invasive surgery without the technical challenges of a conventional laparoscopic approach. Plus, robotic technology shows the surgical field in 3-D, which allows greater precision than the 2-D laparoscopic view. Once again, decisions are made on a on a case by case basis upon reviewing the scans and making sure we are not compromising on the quality of the cancer operation. At the Liver and Pancreas Center, we are using the Da Vinci Robotic Surgical System to perform these surgeries.

What is Radiofrequency Ablation (RFA) or Microwave Ablation (MWA)?

As implied by the name, “radiofrequency waves” or “microwave waves” are delivered through a needle tip and used to generate heat and kill tumor cells. The procedure may be performed on an outpatient basis or in conjunction with major surgery in the operating room and is usually done under the guidance of an imaging method such as ultrasound or computed tomography (CT) scanning. A very small needle-electrode with an insulated shaft is inserted directly into the tumor. The energy at the needle tip causes ionic agitation and frictional heat in the surrounding tissue, which, when hot enough, leads to cell death and coagulation necrosis. The killed tumor cells are not removed, but are gradually replaced by scar tissue. Radiofrequency ablation and microwave ablation are not a substitute for surgical resection but they can be extremely useful in carefully selected patients. Tumor is ablated by precisely delivered heat energy, leaving normal tissue intact. Ablation is performed via laparoscopic or open approaches, and can be combined with surgical resection. This can also be performed by the radiologist on an outpatient basis. Our surgeons use ablative techniques judiciously for procedures undertaken with palliative or curative intent.