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The Changing Outlook for Patients With Cancer in the Liver

Not long ago, primary and secondary cancers of the liver were thought to be universally fatal conditions, but recent developments in the management of these malignancies have changed this perception. Major liver resection, once a rare exercise in surgical derring-do, is now a common operation in most tertiary referral hospitals. If the liver lesion cannot be resected, it can be frozen, injected, heated, or perfused with various agents.

Primary hepatic cancers are among the most common malignancies in the world. The significant survival rates reported by Chi-leung Liu, MB, BS(HK), and associates in this issue attest to the progress that has been realized in the management of these highly lethal malignancies.Secondary hepatic cancers are also common. Most patients with metastatic colorectal cancer who develop a recurrence after a colon resection will have metastasis in the liver.[1-5] If no other extrahepatic disease is found, resection of deposits in the liver with adequate pathological margin has yielded remarkably good long-term survival rates.[5,6] More recently, data have been published suggesting that repeat resection for recurrent metastases may achieve similar long-term survival benefits![7] The successful surgical treatment of metastatic colorectal disease is an extraordinary biological phenomenon in light of experience with most other types of cancer.

However, most patients with hepatocellular cancer or metastatic colorectal cancer are not candidates for resection at presentation. Fortunately, several nonresectional therapeutic options - cryosurgery, chemoembolization, and regional perfusion with chemotherapeutic agents - are available for patients with an unresectable liver tumor. In this issue, Junsung Choi, MD, reports on regional transcatheter therapy for hepatic neoplasms, and Ramon Sotomayor, MD, and T. S. Ravikumar, MD, FACS, present a comprehensive study on their experience with cryosurgery in the treatment of hepatic tumors.

The good results following liver resection and the existence of therapeutic options for patients with unresectable tumors make the selection of the resectable subset of patients an important step in the patient evaluation. Numerous suggestions have been made regarding the most efficient preoperative imaging schemes to evaluate for resectability, with legitimate differences of opinion about the usefulness of these tests. Computed tomography (CT), delayed CT, arterial portography with CT (CTAP), magnetic resonance imaging, ultrasound, and intraoperative ultrasound (IOUS) have all been described as useful preoperative imaging techniques in patients being considered for hepatic resection.[8-12] While CTAP is very sensitive, it also has a relatively high false-positive rate.[13] At many centers, IOUS and CTAP have been found to be essentially equivalent in the ability to determine resectability of liver tumors.[14,15] For this reason, both techniques are used at our institute: CTAP to identify those patients deserving exploration with intent to resect, and IOUS to confirm the preoperative findings and to evaluate those areas sometimes indicated as "false positive" by CTAP. Laparoscopic ultrasound appears to be equivalent to IOUS and may replace CTAP as the modality of choice for selecting patients for resection.[16] Laparoscopic ultrasound requires general anesthesia and operating room resources, but it may be a useful step just prior to abdominal exploration for liver resection.

No doubt, the current enthusiasm for liver resection as treatment for primary and secondary liver cancers will encourage more aggressive management of patients with these malignancies. There is evidence, however, that patient selection may be an important factor in long-term survival - maybe as important or more important than the surgical management used. For example, patients with solitary colorectal cancer metastasis in the liver have a surprisingly long survival even without treatment. This observation emphasizes the importance of evaluating new treatment algorithms in the context of prospective, randomized trials.[17] We may then have a firmer notion of what is the best treatment for these cancers that were considered so dire just a few years ago.

Richard C. Karl, MD

Juan C. Bolivar Professor of Surgical Oncology
H. Lee Moffitt Cancer Center &
Research Institute
Tampa, Florida

References

  1. Sugarbaker PH. Surgical decision making for large bowel cancer metastatic to the liver. Radiology. 1990;174:621-626.
  2. August DA, Ottow RT, Sugarbaker PH. Clinical perspectives of human colorectal cancer metastases. Cancer Metastasis Rev. 1984;3:303-324.
  3. Registry of Hepatic Metastases. Resection of the liver for colorectal carcinoma metastases: a multi-institutional study of indications for resection. Surgery. 1988;103:278-288.
  4. Sugarbaker PH, Kemeny MM. Management of metastatic liver cancer. In: Tompkins RK, Balch CM, Cameron JL, et al, eds. Advances in Surgery. Vol 22. Chicago, Ill: Year Book Medical Publishers; 1988:1-55.
  5. Foster JH. Survival after liver resection for secondary tumors. Am J Surg. 1978;135:389-394.
  6. Logans SE, Meier SJ, Ramming KP, et al. Hepatic resection of metastatic colorectal carcinoma: a ten-year experience. Arch Surg. 1982;117:25-28.
  7. Pinson CW, Wright JK, Chapman WC, et al. Repeat hepatic surgery for colorectal cancer metastasis to the liver. Ann Surg. 1996;223:765-773.
  8. Heiken JP, Weyman PJ, Lee JK, et al. Detection of focal hepatic masses: prospective evaluation with CT, delayed CT, CT during arterial portography, and MR imaging. Radiology. 1989;171:47-51.
  9. Nelson RC, Chezmar JL, Sugarbaker PH, et al. Hepatic tumors: comparison of CT during arterial portography, delayed CT, and MR imaging for preoperative evaluation. Radiology. 1989;172:27-34.
  10. Small WC, Mehard WB, Langmo LS, et al. Preoperative determination of the resectability of hepatic tumors: efficacy of CT during arterial portography. AJR Am J Roentgenol. 1993;161:319-322.
  11. Merine D, Takayasu K, Wakao F. Detection of hepatocellular carcinoma: comparison of CT during arterial portography with CT after intraarterial injection of iodized oil. Radiology. 1990;175:707-710.
  12. Sitzmann JV, Coleman J, Pitt HA, et al. Preoperative assessment of malignant hepatic tumors. Am J Surg. 1990;159:137-143.
  13. Karl RC, Morse SS, Halpert RD, et al. Preoperative evaluation of patients for liver resection, appropriate CT imaging. Ann Surg. 1993;217:226-232.
  14. Karl RC, Choi J, Yeatman TJ, et al. Role of computed tomographic arterial portography and intraoperative ultrasound in the evaluation of patients for resectability of hepatic lesions. J Gastrointest Surg. 1996. In print.
  15. Soyer P, Levesque M, Elias D, et al. Detection of liver metastases from colorectal cancer: comparison of intraoperative US and CT during arterial portography. Radiology. 1992;183:541-544.
  16. Tandan V, Asch M, Margolis M, et al. Laparoscopic vs open intra-operative ultrasound of the liver. Presented at the 37th Annual Meeting of the Society for Surgery of Alimentary Tract, 1996.
  17. Adson MA. The resection of hepatic metastases: another view. Arch Surg. 1989; 124:1023-1024.

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