Mills-Peninsula Health Services Cancer Symposium - Kimberly Moore Dalal, MD, FACS Medical Director, Surgical Oncology Peninsula Medical Clinic Burlingame, CA

1. Minimally Invasive Liver Resection and
Ablation For Malignancy
Advances in Oncology
Dorothy E. Schneider Cancer Center
Mills-Peninsula Health Services
March 16, 2013
Kimberly Moore Dalal, MD, FACS
Medical Director, Surgical Oncology
Peninsula Medical Clinic
Burlingame, CA

2. Liver cancer
Historical Perspective
“…the liver is so friable, so full of gaping
vessels and so evidently incapable of
being sutured that it seems impossible to
successfully manage large wounds of its
substance.” JW Elliot 1897

3. Liver cancer
Historical Perspective
“…20% of patients died in the operating room
because of exsanguinating hemorrhage…
Another 14% died post-operatively as a
direct consequence of enormous blood loss
during operation…15% died of liver failure
caused by technical factors other than
hemostasis, including 3 bile duct injuries…”
Foster JH, Berman MM. Major Problems in Clinical Surgery 1977;1-342.

4. Liver cancer
OR Team, Bagram, Afghanistan 2007

5. Liver cancer
Liver Resection Today
Author N Operative Mortality (%)
Scheele „91 219 6
Rosen „92 280 4
Gayowski ‟94 204 0
Scheele „95 469 4 Normal livers
Nordlinger ‟95 568 2
Jamison, „97 280 4
Fong ‟99 1001 3

6. Liver cancer
Outline
Laparoscopic liver resections for benign and malignant
tumors
– Benign lesions
– Hepatocellular carcinoma
– Colorectal cancer metastases
Ablation for patients who are not operative candidates

7. Liver cancer
Anatomy

8. Liver cancer
Benign Hepatic Lesions
Tumor Malignant Potential Spontaneous Hemorrhage
Focal nodular hyperplasia No No
Hemangioma No Rare
Cystadenoma Yes No
Adenoma Yes Yes

9. Liver cancer
Case 1: Cystic Lesion of the Liver
51 year old woman
3.5 cm Liver Cyst, Seg 4, first noted on chest CT in 2001
Presented with 3 days RUQ pain
RUQ ultrasound (2/07): complex cystic structure of the
liver with layering
Triple phase liver CT (2/07): Cystic lesion, Seg 4, 6x8x6
cm; Hounsfield units 6 (noncontrast), 11 (iv contrast)

10. Liver cancer
Ultrasound
Complex cystic structure of liver with layering

11. Liver cancer
Triple phase liver CT:
Cystic lesion, Seg 4, 6x8x6 cm

12. Liver cancer
Case 2: Hepatic Adenoma
43 yo F with an incidentally discovered right liver
mass detected on chest CT for workup of cough.
AFP and CEA normal. LFTs normal.
CT and MRI
– 4.2x2.1x2.0 cm mass, Seg 7, consistent with a
hepatic adenoma.

13. Liver cancer
Triple phase liver CT: Seg 7, 4x2x2 cm

14. Liver cancer
Traditional Open “Chevron” Incision

15. Liver cancer
Exposure in an Open Resection

16. Liver cancer
Laparoscopic Port Placement for
Right Liver Lesions
Cho JY, et al., Arch Surg 2009; 144(1):25-29.

17. Liver cancer
Laparoscopic View of the Liver
Machado MA, et al., Surg Endosc, 2009; 23:2615-2619.

18. Liver cancer
Case 2: Hepatic Adenoma, Segment 7
Laparoscopic Resection…9 Months Later

19. Liver cancer
Laparoscopic Liver Surgery
Established
Diagnosis/Staging
Fenestration of Simple Cysts
Evolving
Minor resections (≤ 2 segments) for tumor
Major hepatic resections
Tumor ablation

20. Liver cancer
Laparoscopic Liver Resection
Theoretical Advantages and Disadvantages
Advantages: Disadvantages:
Less post-operative pain Loss of tactile sense
Margins
Less post-operative Staging
morbidity
Limited access/
Shorter hospital stay instrumentation
Improved cosmesis Exposure
Control of major
Quicker return to normal pedicles/hepatic veins
activity Time and money
Quicker initiation of
adjuvant therapies

21. Liver cancer
Laparoscopic Liver Resection
Solutions
Loss of tactile sense
Margins
Staging
Laparoscopic Hand-assisted
Ultrasound techniques

22. Liver cancer
Laparoscopic Liver Resection
Solutions • Hand-assisted
techniques
Limited access/instrumentation • Ligaments intact
Exposure • Improved
Control of major pedicles/hepatic veins retractors
Fear of major hemorrhage
Harmonic Vascular Ligasure
Scalpel Stapler Device
Tissuelink
Argon Beam Coagulator
Water Jet

23. Liver cancer
Laparoscopic Hepatectomy
MSKCC Results (n=44)
•Segmental resection: 27 pts (61%)
•1 segment: 17 pts
(38%)
•>1 segment: 10 pts
2 (22%)
•Left lateral: 6 pts
5 8 7 (13%)
3
D‟Angelica, MD, et al., AHPBA 2006

24. Liver cancer
Laparoscopic Hepatectomy
MSKCC Results (n=44)
Benign 21 pts (47%)
Malignant 23 pts (53%)
23 pts: Negative margins (100%). No local
recurrence.
1 tumor 36 pts (81%)
> 1 tumor 8 pts (18%)
D‟Angelica, MD, et al., AHPBA 2006

25. Liver cancer
Laparoscopic Hepatectomy
MSKCC Results: Comparison to Open
Operative Outcome
LLR OLR
(n=44) (n=91) p
OR time (minutes) 199 161 0.01
Pringle time (minutes) 31 22 0.04
Pringle 45% 75% <0.01
EBL (ml) 161 521 <0.01
Transfusion 2.2% 26% <0.01
D‟Angelica, MD, et al., AHPBA 2006

26. Liver cancer
Laparoscopic Hepatectomy
MSKCC Results: Comparison to Open
Post-operative Outcome
LLR OLR
(n=44) (n=91) p
Length of stay (days) 5.1 6.7 <0.01
Morbidity 13% 28% 0.08
Regular diet (days) 3 3 0.7
Oral analgaesia (days) 3.1 3.5 0.1
Mortality 0% 0% 0
D‟Angelica, MD, et al., AHPBA 2006

27. Liver cancer
Outline
Laparoscopic liver resections for benign and malignant
tumors
– Benign lesions
– Hepatocellular carcinoma
– Colorectal cancer metastases
Ablation for patients who are not operative candidates

28. Liver cancer
Epidemiology of Hepatobiliary Cancer
Estimated U.S. incidence in 2013: 21,670 deaths in men and women
30,640 cases/year1
Annual incidence of HCC with
Hepatitis C cirrhosis is 2-8%,
Hepatitis B cirrhosis 2.5%. Siegel R, et al., CA Cancer J Clin, 2013; 63:11-30.

29. Liver cancer
Diagnosis and Workup for HCC
Often asymptomatic.
Nonspecific symptoms:
anorexia, weight
loss, malaise, upper abdominal
pain.
Paraneoplastic syndromes:
hypercholesterolemia, erythrocyto
sis, hypercalcemia, hypoglycemia
.
Physical signs:
jaundice, ascites
AFP>200 ng/mL + liver
mass =HCC
Zhang BH et al., J Cancer Res Clin Oncol. 2004; 130:417-422.

30. Liver cancer
Child-Pugh Class A Patients are
Candidates for Resection
1 2 3
Encephalopathy None 1-2 3-4
Ascites None Slight Moderate
Albumin (g/dL) >3.5 2.8-3.5 <2.8
Prothrombin time (sec) 1-4 4-6 >6
Bilirubin (mg/dL) 1-2 2-3 >3
Class A = 5-6 points Good operative risk
Class B = 7-9 points Moderate operative risk
Class C = 10-15 points Poor operative risk

31. Liver cancer
Case 3: Hepatocellular Carcinoma
74 yo M with Hepatitis C x 30 years from a blood
transfusion, treated with interferon for one year
Developed pneumonia and asked PCP to
investigate for cirrhosis.
AFP: 4690.
Abd US: 3.4 x 2.4 x 3.1 cm mass, left lateral
segment of liver.
Triple phase Liver CT: 3.5 x 2.5 cm mass,
segment 3. (CT of abdomen and pelvis 3 months earlier negative).

32. Liver cancer
Triphasic Liver CT: Segment III 3.5 cm mass

33. Liver cancer
Principles of Surgery for HCC
Mortality <5% Careful patient selection:
Five-year survival rates > 50% – Comorbidities
– 70% in patients with early – Tumor characteristics
stage HCC and preserved – Size and function of future
liver function. liver remnant
Recurrence at 5 yrs>75%
Liver transplantation for
patients meeting UNOS criteria
– Single lesion < 5cm
– 2 or 3 lesions < 3 cm

34. Liver cancer
Case 3: Hepatocellular Carcinoma
Laparoscopic resection of
segment III
Length of stay 5 days
Bone metastasis @ 7 mos

35. Liver cancer
Outline
Laparoscopic liver resections for benign and malignant
tumors
– Benign lesions
– Hepatocellular carcinoma
– Colorectal cancer metastases
Ablation for patients who are not operative candidates

36. Liver cancer
Epidemiology of Colorectal Cancer
Estimated U.S. incidence of
colorectal cancer: 142,820/year1
51,370 deaths
50% of patients will be
diagnosed with liver metastases
Liver resection->long-term
survival
– 5 year survival: 25-58%
– Surgical techniques
– Chemotherapy
– Unresectable->resectable
1Siegel R, et al., CA Cancer J Clin, 2013; 63:11-30.
2 http://www.hopkinsmedicine.org.

37. Liver cancer
Determinants of Outcome for CRC
Liver Metastases: Fong Score
• Extrahepatic disease
• Positive margins
• Node (+) colorectal primary
• Disease-free interval < 1 year
• More than 1 hepatic tumor
• Largest hepatic tumor > 5 cm
• CEA > 200 ng/mL
Fong et al Ann Surg 1999;230:309
Fong Y, et al., Ann Surg. 1999 Sep;230(3):309-318.

38. Liver cancer
Preoperative Portal Vein Embolization Can
Increase the Future Liver Remnant
Percent Resection PVE
– FLR/TLV 0.20 (20%)1
>40% for cirrhotics, Child‟s A
1Chun YS, et al., J Gastrointest Surg. 2008 Jan;12(1):123-8.

39. Liver cancer
Case 4: 61 year old Woman, Synchronous
Colon Cancer Metastases to Liver
Open sigmoid
colectomy for
obstructive sigmoid
colon cancer 9/11
CEA 600
CT: bilateral
metastases
Xelox->cetuximab
and xeloda

40. Liver cancer
Case 4: Tremendous Response to
Chemotherapy
Sept 2011, CEA 600 Mar 2013, CEA 16 (up from 6)

41. Liver cancer
Laparoscopic Resection of Two
Colon Cancer Metastases to Liver
Cirrhotic liver and gallbladder Adhesion to recurrent tumor
Intraoperative ultrasound Post-ablation

42. Liver cancer
>1 cm Margins are Preferred,
but > 1 mm Margins are Favorable
• Multivariate analysis (n=1019)
• > 1 tumor
• Size > 5 cm
• Node positive primary
• Bilateral resection
• Margins
Margin N (%) Median survival (mo) P
Involved/<1mm 112 (11) 30 mos Ref
1 – 10 mm 563 (55) 42 mos <0.01
> 10 mm 344 (33) 55 mos <0.01
Are C, et al., Ann Surg. 2007 Aug;246(2):295-300.

43. Liver cancer
Outline
Laparoscopic liver resections for benign and malignant
tumors
– Benign lesions
– Hepatocellular carcinoma
– Colorectal cancer metastases
Ablation for patients who are not operative candidates
– Tumor size and function
– Liver function
– Comorbidities

44. Liver cancer
Radiofrequency Ablation
High-frequency alternating current flows
from electrical probe through tissue to
ground
– Ionic agitation results in frictional heating and
coagulation of surrounding tissue
Probe Extension RF current
insertion of prongs application

45. Liver cancer
Radiofrequency Ablation
Advantages Disadvantages
– Performed – Poor performance
percutaneously, near blood vessels
laparoscopically, or at – One probe
laparotomy Many tumors require
– Low complication rate multiple, overlapping
May be related to size ablations
of ablation (<3 cm) – Slow

46. Liver cancer
Microwave Ablation
Theoretical
advantages over RFA
– Larger zone of active
heating
Possibly better
performance near blood
vessels
– Hotter temperature
– Use of multiple probes
Lubner M, et al.,J Vasc Interv Radiol. 2010 Aug;21(8Suppl):S192-S203.

47. Liver cancer
Case 5: Segment IV B 2.6 cm mass,
Cirrhosis
77 year old woman
Child‟s Pugh Class A
cirrhosis due to
autoimmune hepatitis
AFP: 23
CT: 2.6x2.6 cm
heterogeneously
enhancing nodule
segment IVB of liver
FNA: HCC

48. Liver cancer
Microwave Ablation
Preop; AFP 23 1 month postop; AFP 7
10 months postop 1 months postop repeat
AFP 24 AFP 6

49. Liver cancer
Microwave Ablation
Cirrhotic liver and gallbladder Adhesion to recurrent tumor
Intraoperative ultrasound Post-ablation

50. Liver cancer
Summary
Laparoscopic liver resections are safe and oncologically
sound in highly selected patients in the hands of surgeons
with a laparoscopic skill set.
Patients with malignant liver tumors can be considered for
resection based on tumor characteristics, future liver
remnant size and function, and patient comorbidities.
Radiofrequency and microwave ablations are alternative
ways to treat small liver tumors which are not amenable to
resection.

51. Liver cancer
Mills-Peninsula Multidisciplinary
Gastrointestinal Tumor Board
Second Tuesday of each month, Peninsula Hospital
12:30 pm-1:30 pm, CME + lunch
Tailored approach to treatment plan
Team:
– Surgical oncologists, Interventional radiologists, Gastroenterologists
– Medical oncologists, Radiation oncologist, Pathologist
– GI nurse navigator, Clinical trials nurse, Physician liaison
– YOU!
We can provide state-of-the-art, cutting-edge care to our
patients in their own backyard with a personalized touch!