" Dr. Soumil J. Vyas

Liver Metastases - Cancer Spread to the Liver

This is the term reserved for cancer that has spead to the liver from other organs .

The most common types of cancer that spead to the liver , generally start from organs and mos commonly include bowel , breast , pancreas , stomach, lung , ovary and other primary sites.

Generally spread of cancer to the liver , from other sites is considered as advanced disease and was treated only with palliative intent.

However now with progress in cancer treatment , metastatic disease limited to the liver , athough considered as advanced disease can be treated effectively with combination of treatments including surgery / hepatectomy.

Colorectal Cancer Liver Metastases

Cancer of the large intestine - colon and rectum : is the 2nd most common cancer in women and 3 rd most common cancer in men

10% of all cancers world over , originate either from the colon and / or rectum

The highest incidence is in the Western population and the incidence is progressively increasing in India as well.

25% of all colon and rectum cancers have disease spread to the liver ( liver metastases ) , at primary diagnosis of the rectum and colon cancer.

Another 25% of patients who have already been treated for colorectal cancer , will have liver metastases detected at follow up . Hence approximately 50% of all colorectal cancer patients with have liver metastases at some point of time ,during the course of natural history of the disease.

With a phenomenal progress in the range of chemotherapy medications , liver surgery and interventional radiology – many of these patients can be effectively treated with a curative intent . The liver metastases can be successfully treated – removed surgically in combination with other treatments , thereby helpling to control and eradicate disease from the liver .

The same principle can be applied selectively to secondary liver cancer , which has spread to liver from other organs . Selection of patients for liver surgery and liver procedures in such cases has to be individulaised with a multi disciplinary approach between the treating cancer physician ( medical oncologist ) , surgical oncologist , colorectal surgeon and the liver surgeon .

Treatment overview of secondary liver cancer

The choice of treatment for secondary liver cancer depends on
  • Where it has spread from :cancers which have spread to the liver from the large intestine : colon and rectum , have the best outcomes for metastatic liver cancer . Similarly neuro endocrine tumours spread to the liver have a good prognosis and should be treated aggressively with an intent to achieve cure.
  • If any other parts of the body are affected :eg : lung / brain / bones / peritoneum / , etc
  • How much of the liver has been affected – whether limited parts of the liver are affected ( favourable prognosis ) or large parts of the liver are affected ( unvfavourable )

Planning treatment

Treatment for liver metastases is an organised team effort comprising a group of medical professionals and oncologists . Each and every case is studied in detail and passes through a Multi Disciplinary team meeting who come to a consensus for the best and most effective treatment .

The team includes

  • Liver Surgeon / Hepato Biliary and Pancreatic ( HPB ) Surgeon
  • Treating surgical oncologist / colorectal surgeon
  • Medical oncologist – chemotherapy physicians
  • Radiologist : a radiologist with a special interest in liver radiology to analyse in detail the metastatic disease within the liver
  • Interventional Radiologist – interventional radiology plays a pivotal role in the management of metastatic liver disease and offers a host of therapeutic possibilities to enhance the possibility of cure .
  • Histopathologist to study the pathology of the cancer

Treatment for Liver Metastases :

Chemotherapy : Most patient with secondary liver tumours will require chemotherapy . Chemotherapy remains the main stay of treatment of metastatic liver disease and plays an important role in facilitating surgery. Chemotherapy given before surgery, helps in shrinking of the tumours, thereby facilitating surgery. In select cases the liver operation is done first and chemotherapy may be given later.

Surgery – Liver Resection / Hepatectomy :

This involves removal of the parts of the liver , affected with metastases.

Surgery for liver tumours includes – removal of part of the liver bearing the tumour with an adequate part of normal liver ( to obtain tumour free margin ) . Surgery may range from removal of small portion of liver ( wedge resection of liver, minor hepatectomy ) to large portions of the liver ( major hepatectomy ) . The complexity of the operation increases with the extent of liver removed.

Surgery is facilitated by the fact that liver has a good regenerative capacity and can grow significantly and substantially after removal of parts .Upto 70% of tumour bearing liver can be removed if the remaining liver is healthy and permits.

Certain other procedures such as Portal Vein Embolization ( PVE ) can help increase the size of the liver , prior to surgery , thereby facilitating surgery . Sometimes staged liver resection ( two liver operations – at two different times ) , may be required to allow for the healthy non tumour liver to grow back.

Liver surgery is major surgery and needs an experienced team of hepato biliary surgeons to collectively perform the same , for best outcomes.

Surgery may be done through the open technique ( cut on the abdomen ) or key hole technique ( minimally invasive ).

Sometimes both the bowel and the liver procedure can be performed simultaneously ( synchronous resection ) or may be done in a staged manner . The sequence of procedures are determined by joint consultation.

Interventional Radiology in Liver Metastases

Radio Frequency Abation : RFA This procedure can be done either during surgery or through the skin ,under ultrasound / CT guidance – through a needle inserted into the tumor .The RFA procedure makes use of radio waves, to destroy the liver metastases. The high electricity through the needle inserted into the tumour, causes thermal destruction of the tumour. The procedure can be done as day care procedure.

2. Hepatic Artery Chemo Embolization ( TACE ) -

this is direct instillation of chemotherapy drugs into the tumour. This is done as an angiography procedure under a local anaesthetic / sedation.

Other more advanced techniques include – -

- DEB- TACE : trans arterial chemoembolization with drug eluting beads

- SIRT : Selective Internal Radiation Therapy

Take Away Messages

  • Liver Metastases - NOT "End of the Road"
  • Very viable and defined treatment options for management of liver metastases exist
  • These improve disease free survial, overall survial and help in control of cancer
  • Combination of modalities including multi disciplinary consult with medical oncology helps
  • Surgery is the cornerstone and can be tailored to suit the patients requirements depending on disease burden
  • Open / Laparoscopic / Robotic Procedures
  • Parencymal preservation always the cornerstone of treatment of malignant liver disease
  • Multidisciplinary team approach - HCC : Good Prognosis if treated correctly and promptly
  • Role of radiology invaluable and facilitates surgery and successful treatment

Facilities at the Sir H N Reliance Foundation Hospital

Dr Soumil Vyas – MS , DNB, FRCS(Edin) , FRCS ( Upper GI/ HPB ), MNAMS, M.Med ( Surg ) , FAIS, FEBS , provides comprehensive management of liver metastases .

Dr Soumil Vyas- is a trained liver / gall bladder and pancreas surgeon and gastro intestinal surgeon, with speciality in Surgical Oncology. He specialises in the surgical management of the cancers of the gastro intestinal tract – stomach, colon, intestine along with the liver, gall bladder and the pancreas.

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  • Dr. Soumil J. Vyas, is presently Consultant Surgeon within the division of Surgical Oncology / Cancer Surgery and Medicine / Gastro intestinal / Liver, Gall bladder and pancreas surgery (GI & Hepato Biliary and Pancreatic Surgery : HPB surgery) at our flagship hospital – Sir H. N. Reliance Foundation Hospital and Medical Research Centre.

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