Liver Tumours

 

Benign liver tumours


Many liver lesions are benign and incidentally found during investigations for other reasons. However only specialist liver surgeons will be able to decide whether to ignore, investigate further or treat. Some of the most common liver lesions are discussed below.

 

Liver cysts

  • is a yellow pigmentation of the eyes and skin, due to a compromised liver's production of bile. Bile can back up into the blood, causing the skin and eyes to turn yellow and the urine to become dark.

 

Haemangiomas

  • are the most common benign liver lesion, filled with fluid and easy to diagnose on ultrasound. Normally they are not symptomatic and would not need any treatment. However they reach large dimensions (30 cm in diameter) giving pain and discomfort and hence surgical treatment may be required. The surgical treatment is normally by resecting as much as possible of the cystic wall to avoid cysts re accumulating. This can be easily done with keyhole surgery. Aspiration of these cysts is not advised as they have a high chance or recurrence and infection.

 

Focal Nodular Hyperplasia (FNH)

  • is less common benign lesions that affect the liver mainly in young and middle aged females. Again their radiological appearance may be similar to other malignant liver conditions and many radiological tests may be required to define their entity. FNHs are completely benign and do not require any treatment unless symptomatic (painful, compressing other intra abdominal organs). In these cases surgical resection maybe required.

 

Liver adenomas

  • are rare benign live tumour. They are more common in women and are frequently due to the use of the contraceptive pill or HRT. They can also be related to other steroid hormone treatments and drugs, including anabolic steroids used in body building.

 

Cystadenoma

  • are rare benign tumour often affecting the liver. They have a risk for potential malignant transformation, therefore they should be removed surgically if diagnosis is proved or difficult to exclude.

 

Hydatid disease

  • is a parasitic infestation by a tapeworm of the genus Echinococcus. It is not endemic in the UK as in other parts of the world.

 

The parasite (echinococcus) can pass to the man threw a cycle involving; goats (sheep) and dogs. The parasites grow in cysts in the liver and may have no symptoms, but can also give pressure effect leading to obstructive jaundice and abdominal pain. In case of cystic rupture, the classic triad of biliary colic, jaundice, and urticaria is observed. The parasitic infection is usually treated initially with antiparasitic medication (e.g. albendazole), to eradicate the most active disease, followed by surgical resection of the cysts. Malignant liver tumours Primary liver tumours Liver cancers fall into two broad groups: 1.primary cancers which have arisen in the liver 2.secondary cancers which have spread to the liver from another organ.

 

Hepatocellular carcinoma (HCC or hepatoma)

 

Hepatocellular carcinoma accounts for most primary liver tumours. It occurs more often in men than women. It is usually seen in people ages 50-60yrs. The disease is more common in Africa and Asia than in the UK and Europe. In most cases, HCC develops in cirrhotic liverscirrhosis and is highly associated with hepatitis B and/or C infection. Symptoms related to hepatomas occur only when they reach a significant size. Small hepatomas as usually diagnosed during investigations for other reasons or during screening scans in patients known to have cirrhosis. Large hepatomas may give pain and other symptoms such as fatigue, jaundice and ascites. Occasionally they may rupture causing severe intra abdominal bleeding. Liver transplant is the treatment of choice as it has shown to give the longest survival. However only patients with small tumours (< 5 cm in diameter) and with less than 3 lesions in the liver are considered eligible. If transplant is not possible; surgery can be considered in patients with normal livers or when cirrhosis is still at an early stage. Abdominal CT scan If surgery or transplant is not possible, other treatments such as Radiofrequency ablation (RFA) and transarterial chemoembolisation (TACE) can be offered. RFA for small lesions or a combination of RFA and TACE can achieve good results in some patients in terms of tumour ablation, control of tumoral growth or in some cases as a bridge toward surgery or transplant. Traditionally chemotherapy and radiation treatments were not considered. However, new drugs such as Sorafenib tosylate have shown to be effective in blocking the tumour growth. Sorafenib is now approved for patients with advanced hepatocellular carcinoma. Having explained the possible treatment options of this complex condition, every patient with HCC should be seen by a liver specialist for investigation and should be discussed in a liver multidisciplinary meeting with all involved clinicians from different specialities to decide the best management plane.

 

Cholangiocellular carcinoma (CCC)

 

Cholangiocellular carcinoma (CCC) is the second common primary liver tumour after hepatocellular carcinoma (CCC). It can arise from either the distal or proximal extrahepatic duct including bifurcation or from the intrahepatic ducts. It is more common in patients who have had tropical parasitic infestations of the bile ducts (clonorchis) or have had sclerosing cholangitis (chronic inflammation of the bile ducts). Hilar CCC (Klatskin Tumours) can be treated surgically if they are diagnosed in an early stage .The procedure involves the removal of the bile duct and the most involved part of the liver with all the regional nodes. If they are invading the major adjacent vessels (portal vein and hepatic artery), surgical treatment can be difficult. The presence of distant metastasis is a contraindication to surgery. Intra hepatic duct CCCs can be treated surgically by resecting the interested lobe of the liver Distal duct CCCs are treated with a pancreatic head resection (Whipple�s procedure). See pancreas

 

Secondary Liver Cancers

 

These are tumours that have spread to the liver from other organs. These are also calledliver metastasis. The treatment of liver metastasis depends on their origin and many other factors including their distribution, number, location, size and the patient�s general medical conditions. In recent years and thanks to excellent surgical results, aggressive surgical methods have been considered. Surgery in combination with chemotherapy and other ablative treatments such as radiofrequency ablation have permitted more patients to benefit from radical treatment.

 

Colo-rectal liver metastasis

 

In the UK, colorectal liver metastases are the most common. They are caused by cancer spreading from the colon and rectum. The possibility of surgical treatment depends on the tumour distribution and relation with major vascular structures. However using today�s operative criteria, we have been able to push boundaries and offer surgical resection to almost 50% of patients. Today we can potentially treat patients with disease in both lobes of the liver and even in the presence of a large number of metastasis. However all patients have to be assessed individually and their suitability for an operation should be discussed in multidisciplinary meetings. In addition, thanks to the liver�s ability to regenerate, further surgery could still be considered should a patient experience recurrence of a cancer in the future. Thanks to these advances over the years survival in patients with colorectal liver metastases has improved greatly. Post surgical survival depends on factors related to tumour aggressiveness and biology. A combination of surgery and chemotherapy is known to offer the best results. Chemotherapy can be given prior to surgery (neoadjuvant chemotherapy), after surgery (adjuvant chemotherapy) or can be used in a sandwich treatment (before and after). The best course of action would be discussed in a meeting with consultants from different specialities called a Multi-Disciplinary Team Meeting or MDT. In major liver centres, mortality should not exceed 3%. Hence, this surgery should only be considered in specialized centres and by expert liver surgeons. Patients not deemed suitable for liver resection, can benefit from other treatment s such as radiofrequency ablation and palliative chemotherapy.

 

Other Tumours

 

Metastasis from other tumours such as neuroendocrine tumours, Gastro Intestinal Stromal Tumours (GIST), renal cancers and melanoma are frequently treated by surgical resection. In rare cases even metastasis from breast cancer can be considered for resection, however, this depends on various factors and every case is treated and considered individually on its own merits.