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Dr. Mukesh PUBLISHED BY www.medicalppt.blogspot.com

MAHARANI LAXMI BAI MEDICAL COLLEGE, JHANSI. DEPARTMENT OF SURGERY. “MANAGEMENT OF LIVER SECONDARIES”. Dr. Mukesh PUBLISHED BY www.medicalppt.blogspot.com. MANAGEMENT OF LIVER SECONDARIES METASTASIS

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Dr. Mukesh PUBLISHED BY www.medicalppt.blogspot.com

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  1. MAHARANI LAXMI BAI MEDICAL COLLEGE, JHANSI DEPARTMENT OF SURGERY “MANAGEMENT OF LIVER SECONDARIES” Dr. Mukesh PUBLISHED BY www.medicalppt.blogspot.com www.medicalppt.blogspot.com

  2. MANAGEMENT OF LIVER SECONDARIES METASTASIS The term metastasis connotes the development of secondary implants discontinuous with the primary tumor, possibly in remote tissue. www.medicalppt.blogspot.com A liver studded with metastatic cancer

  3. INCIDENCE Metastasis is the most common neoplasm in an adult liver. Liver is the second most common site for metastatic spread, after the lymph nodes. The primary sites most commonly metastasizing to the liver are - • Ovary (52%) • Rectum (47%) • Stomach (45%) • Lung (36%), • Kidney (26%) • Colon (65%) • Pancreas (63%), • Breast (60.6%), • Gallbladder and extrahepatic bile ducts (60.5%), www.medicalppt.blogspot.com

  4. Nearly two-third of patients with colorectal cancer will develop hepatic metastasis. 25% to 50% of patients dying of cancer are found to have hepatic metastasis. TERMINOLOGY Metachronous -Metastases appearing much latter than treatment of primary eg. melanoma of chord. Synchronous -Primary & metastasis detected at the same time. eg-carcinoma stomach. Precocious -Metastases appearing before primary is suspected. eg-carcinoid, rectal carcinoma. www.medicalppt.blogspot.com

  5. PATHOPHYSIOLOGY • Metastasis reach to liver by four routes - • Direct invasion (stomach, colon, bile ducts, gall bladder) • Lymphatics (breast and lungs via mediastinal nodes) • Hepatic artery (lung, melanoma.) • Portal vein (colorectal) www.medicalppt.blogspot.com

  6. PRESENTATION • Incidental • Dull aching pain in right hypochondrium, • Loss of appetite, asthenia, weakness, mailase, • Jaundice, anemia, vomiting, • Hepatomegaly, ascites • Enlargement of Both lobes, sharp lower border, nodular surface, hard consistency, www.medicalppt.blogspot.com

  7. Prognostic factors - • No. of metastasis • Resection margin status • High preoperative CEA • Size of largest tumor • Stage of primary tumor • Disease free interval • Synchronous disease • Extra hepatic disease • Peripheral nodal status www.medicalppt.blogspot.com

  8. Preoperative Patient Evaluation • Before even thinking on performing a liver resection, it is necessary a thorough oncologic examination, seeking other localizations, and also to verify the absence of contra-indications. • Regarding morphological tests, an abdominal US, CT and afterwards a MRI, allow to acquire a better knowledge regarding number of metastases, precise location, relationship with the portal pedicle and the hepatic veins. www.medicalppt.blogspot.com

  9. Pulmonary localizations must be ruled out systematically, using CT examination. If these lesions are resectable, they don’t constitute a contraindication to liver resection. • A colonoscopy is always performed to rule out recurrence, even if the primary tumor has already been resected. • If necessary, a bone scan or a brain CT can be performed. • Regarding the blood chemistry, it consists of liver function tests, tumor markers, coagulation profile. www.medicalppt.blogspot.com

  10. Evaluation of functional hepatic reserve - in patients who received neoadjuvant chemotherapy or those with a preexistent liver pathology (hepatitis, cirrhosis. Tests used are-- • Child pugh class • Indocyanine green clearance test • Aminopyrine & phenylalanine breath test • Galactose elimination rate • Hippurate ratio • SPECT www.medicalppt.blogspot.com

  11. Treatment Options • A. Surgical resection • B. Ablation • Cryotherapy • Radiofrequency ablation • Laser interstitial thermal therapy (LITT) • Microwave coagulation therapy • C. Chemotherapy • Neoadjuvant • Intra-arterial • Systemic • Chemoembolisation www.medicalppt.blogspot.com

  12. D. Radiotherapy • Stereo tactic body radiation • Selective interstitial radiation therapy • E. Liver transplantation • AIMS OF TREATMENT • Curative intent -Multimodal treatment may allow complete tumor clearance • Combination of surgery + other ablative techniques • Neoadjuvant treatment to improve resectability www.medicalppt.blogspot.com

  13. Palliative intent Decision tree for patients with hepatic metastases. Beginning with treatment of the primary tumor, optimal management depends on careful weighing of multiple factors and making the best individual treatment choice. www.medicalppt.blogspot.com

  14. Surgical resection 80%-90% of resections of hepatic metastasis are for colorectal cancers. First hepatic resection for hepatic metastasis-by Garre in 1988. 1949 total right lobotomy by Wangensteen. 1959-hepatic artery infusion. 1972 implantable pump. www.medicalppt.blogspot.com

  15. Functional anatomy It is composed of eight segments each of which is supplied by a single portal triad composed of a portal vein hepatic artery & bile duct. Segmental anatomy of the liver as seen at laparotomy in the anatomic position (Surgical and radiologic anatomy of the liver and biliary tract) www.medicalppt.blogspot.com

  16. Anatomical Resections They follow the liver segmentation principles described by Couinaud. They are considered as minor, when less than 3 segments are resected, or major, when resection includes more than 3 segments. Nomenclature for Most Common Major Anatomic Hepatic Resections www.medicalppt.blogspot.com

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  18. The most common approach to a anatomic resection in most common order, • Mobilization of liver • Dissection of inflow and outflow structure • Division of inflow • Division of outflow • Parenchymal transection • Non-Anatomical Resections • They include the resection of a portion of the liver independently of the liver scissors and glissonian pedicles. They refer mainly to metastasectomies. The liver resection depends on the size of the tumor. www.medicalppt.blogspot.com

  19. Rules to Respect During Hepatectomy • Independently of the type of liver resection, one must follow these rules in order to avoid postoperative complications: • Functional liver parenchyma preservation of at least 30% of the total liver mass, to avoid hepatic insufficiency. • Limit blood loss, in order to avoid transfusions, because it is a known risk factor that favors recurrence. • Resect the 1 mm margin, to reduce the risk of recurrence. • Resect glissonian pedicles destined to the remaining segments, to avoid segmental exclusion, ischemia and necrosis, and biliary fistulas. www.medicalppt.blogspot.com

  20. ABLATION • 1. Cryotherapy • Destruction of tumor cells by freez thraw. • Probe positioned over tumor • Liquid nitrogen is circulated through tip of probe • Temp lowered to -100° C • 1-3 cycles of freezing for 15 mins with spontaneous periods of thraw • Lethal temp -20° C • Intracellular or extra cellular ice forms • Ice ball of ~3-6cm Complications - biliary, abscess, myoglobinuria, haemorrhage, coagulopathy, cryoshok www.medicalppt.blogspot.com

  21. 2. Radiofrequency ablation • Radiofrequency waves (high frequency alternating current - 460khz) are converted into thermal energy • Friction from rapidly moving ions results in heat • Temp of ~60°C • Coagulative necrosis • Open/laparoscopic or percutaneous technique • Effective with tumors upto 5 cm • Complications - bilioma’s, biliary fistula’s, stricture’s abscess www.medicalppt.blogspot.com

  22. 3. Laser interstitial thermal therapy (LITT) • Placement of laser fiber or fibers directly into the tissue to be treated. • Infrared laser producing lethal thermal injury to tumor cells • LITT utilizes diod laser or more frequently Nd-YAG laser • Coagulative necrosis • Procedure is usually performed under MRI. • Extensive use if MRI is its major drawback. www.medicalppt.blogspot.com

  23. 4. Microwave coagulation therapy • Uses microwave of frequency 2450 Mhz • Produces heat by stimulation of water molecule • Produces rapid frictional heating and coagulative necrosis • 5. Intratumoral alcohol injection • Causes denaturation of protein leading to cell death.. • Can be used for tumors <3cm. www.medicalppt.blogspot.com

  24. RADIOTHERAPY • 1. Stereo tactic body radiation • Tolerance of liver to radiation is poor. • Conformational radiation therapy using multiple field & beam angles is used to deliver large doses to a target sparing surrounding normal tissues. • 2. Selective interstitial radiation therapy • Micro spheres containing yttrium 90 (sir spheres) • Injected via hepatic artery www.medicalppt.blogspot.com

  25. Tumor cells receive a higher proportion of there blood supply via hepatic artery. • 200-300 Gy to tumor ,15-50 Gy to liver • B radiation with a penetrance of 2-3 mm • Half life of 64 hours. • Percutaneous cannulation of hepatic artery • Administration of spheres • Spheres selectively lodge into tumor cells www.medicalppt.blogspot.com

  26. CHEMOTHERAPY • 1. Neoadjuvant • Patients at high risk of recurrence should receive neoadjuvant chemotherapy. • Drugs include oxaliplatin, irinotecan, 5fu, leucovorin. • 20-30 % of patients who were unrespectable will be rendered potentially respectable. www.medicalppt.blogspot.com

  27. 2. Hepatic artery infusion therapy (implantable pump) • Rationale is that hepatic metasis is perfused almost exclusively by hepatic artery. • Injection of floxuridine into hepatic artery demonstrates mean tumor fudr levels are significantly increased • Can be administered by implantable pumps • Most common problems with hai are hepatic toxicity & ulceration of stomach & duodenum. • Addition of dexamethasone in hai has resulted in decreased toxicity. www.medicalppt.blogspot.com

  28. This schematic shows the catheter inserted into the gastroduodenal artery for hepatic infusion www.medicalppt.blogspot.com

  29. 3. Systemic • Does not improve survival following resection or ablation. • Leads to systemic & hepatic toxicity. • Usually not tolerated by the patients. • 4. Chemoembolization • Administration of intra-arterial chemotherapy f/b infusion of one of a number of embolic agents such as degradable starch, gelatin powder pvc, • Best accepted use is for patients with unrespectable metasteses from characinoid or islet cell tumors. • 5. Targeted therapy • Cetuximab (monoclonal antibody to egf. • Bevacizumab (monoclonal antibody to vegf) www.medicalppt.blogspot.com

  30. PORTAL VEIN EMBOLIZATION • If portal vein branch of particular segment is blocked it leads to ipsilateral lobe atrophy & contralateral lobe hypertrophy . • Lead to the concept initiating hypertrophy of segment of liver that would remain following a major liver resection. • Percutaneous approach is the standard technique for portal vein embolization. • Studies shown that future liver volume increased from 19%-36% of total liver volume pre embolization to 31-59% postembolization. www.medicalppt.blogspot.com

  31. LIVER TRANSPLANTATION Which could an option when resection could not be tolerated owing to inadequate liver reserve, rarely is performed for metastatic disease because of high risk of recurrence related to immunosuppressant. Valid Indications and New Operative Strategies A patient with liver metastases limited to one segment without extrahepatic dissemination is always a candidate for liver resection. The challenge for hepatobiliary surgeons is to achieve the necessary resources and strategies that allow the patients’ benefit. www.medicalppt.blogspot.com

  32. Patients can be divided into four groups • Patients with a voluminous hepatic metastases in which resection leaves an insufficient amount of functional liver parenchyma. • Patients with bilobar metastases. • Patients with recurrence after resection. • Patients with a primary colorectal tumor and synchronous liver metastases. • Patients with a Voluminous Liver Metastases • Two alternative may be offered:Tumor downsizing with systemic or local chemotherapy, and hypertrophy of the future remaining liver (non-tumoral) by portal embolization. www.medicalppt.blogspot.com

  33. Downsizing: the use of neoadjuvant chemotherapy with 5-fluorouracyl, folinic acid and oxalyplatin, achieved an adequate tumoral downsizing, with similar results as those patients initially resectable. Liver parenchyma (usually left lobe), surgeons look for hypertrophy of the non-tumoral liver. • Portal Embolization: When resection is not viable due to insufficient functional nce embolization is performed, hypertrophy is evaluated 5-6 weeks after the procedure. If the future remaining liver is >30%, then hepatectomy can be performed. www.medicalppt.blogspot.com

  34. Hepatectomy associated to resection and tumoral destruction by local treatment:Here, the greater lesions are resected and the lesser ones are destroyed locally by either RFA or cryotherapy. • Two-stage Hepatectomy after neoadjuvant chemotherapy: The goal is to achieve an adequate downsizing of the tumor that allows for a resection in a one-stage or two-stage procedure. www.medicalppt.blogspot.com

  35. Patients with Recurrence after Resection Surgery is the only curative option for these patients. It has been shown that patients with a liver recurrence isolated or associated with a resectable extrahepatic metastases, resection of all the tumoral tissue achieves an overall survival similar to patients without recurrence. Patients with a Primary Colorectal Tumor and Synchronous Metastases Surgical strategies remain controversial. Those who favor simultaneous resection, and those who oppose it, differ in terms of oncological basis, immunological techniques and patient comfort. www.medicalppt.blogspot.com

  36. PUBLISHED BY www.medicalppt.blogspot.com Thank You www.medicalppt.blogspot.com

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