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Microwave ablation and irreversible electroporation of liver tumors

Overview Each year nearly 1 million liver cancers are diagnosed across the world, making liver cancer the fifth most common cancer in men and ninth in women , (see Chapter 89 ). Liver cancer is one of the most fatal cancers, being the second leading cause of cancer death in men and sixth leading cause of cancer death in women. The most common liver cancer remains…

Radiofrequency ablation of liver tumors

Resection for curative intent is the gold standard for metastatic and primary hepatic tumors where feasible. Resectability, as previously discussed in other chapters, is the result of a coalescence of factors: technical/anatomic feasibility, adequacy of the predicted future liver remnant, and appropriate patient performance status to tolerate major surgery (see Chapter 101A ). Liver resections range widely in terms of technical difficulty and risks posed to…

Ablative treatment of liver tumors: Overview

Image-guided ablation techniques have evolved considerably during the past 25 years and are increasingly used in the definitive treatment of small primary and secondary liver tumors. Image-guided ablation is recommended as the best therapeutic choice for patients with early-stage hepatocellular carcinoma (HCC)—defined as either a single tumor smaller than 5 cm or as many as three nodules smaller than 3 cm—when surgical options are precluded and…

External beam radiotherapy for liver tumors

Historical context and whole-liver radiation therapy The efficacy of radiation therapy (RT) is predicated on the ability to deliver the tumoricidal RT dose while keeping the dose to the surrounding normal tissues the same. The balance between the probability of tumor control and the risk of normal tissue complications is a measure of the therapeutic ratio of the treatment. Irradiation of tumors using external beam RT…

Radioembolization for liver tumors

Overview Interventional oncology is a rapidly growing branch of interventional radiology that is a vital part of multidisciplinary oncologic care. In the management of patients with liver tumors, the minimally invasive nature of its procedures allows targeted delivery of oncologic treatments, maximizing their local effects while minimizing the systemic exposure to such treatments. In this chapter we discuss the general concepts of transarterial radioembolization with yttrium-90…

Hepatic artery embolization and chemoembolization of liver tumors

Hepatocellular carcinoma (HCC) is the most common primary liver cancer worldwide (see Chapter 89 ). Despite the widespread implementation of surveillance programs of high-risk populations, only 20% to 30% of HCC patients are candidates for potentially curative surgical treatment, including hepatic resection (see Chapter 101 ) and liver transplantation (see Chapters 105 and 108 ) due to poor liver function, underlying portal hypertension, tumor extent, comorbidities,…

Hepatic tumors in childhood

Overview An appreciation of hepatic segmental anatomy (see Chapter 2 ) has led to major advances in hepatic surgery, especially for tumors. In addition, the well-known but still somewhat mysterious stimulus to hepatic regeneration has allowed larger and more extensive resections. In small infants, 70% to 80% of the liver can be removed safely, greatly increasing the scope for cure. This may be aided by portal…

Hepatic metastasis from noncolorectal nonneuroendocrine tumors

Overview Only 10% of malignant liver tumors are primary liver or bile duct cancers. The vast majority of cancerous hepatic lesions are metastatic lesions originating from extrahepatic primary tumors (see Chapters 90 and 91 ). The only potentially curative approach for most malignant liver tumors is surgical resection. This procedure can be performed safely with an acceptable risk of perioperative mortality and morbidity (see Chapters 101…

Hepatic metastasis from neuroendocrine cancers

Overview The liver is the most common site of metastasis for all neuroendocrine neoplasms and second only to regional lymph nodes as the dominant site of metastases from all gastrointestinal (GI) tract malignancies. In patients with neuroendocrine liver metastases (NELMs) the cause of death is from local progression in the liver resulting in liver failure. The progress made and the accumulated experience documenting the survival potential…

Hepatic metastasis from colorectal cancer

Colorectal cancer (CRC) is the third leading cause of cancer-related mortality worldwide. CRC spreads via two main mechanisms: cancer cells can metastasize to regional lymph nodes and then through central lymphatics into the systemic circulation, or cancer cells can spread directly to the liver via portal venous drainage. The likelihood of presenting with or developing metastases is associated with primary tumor T and N stage and…

Hepatocellular carcinoma

Overview Hepatocellular carcinoma (HCC) is the most common primary liver tumor and results in approximately 800,000 deaths globally per year. Worldwide, liver tumors represent the fourth leading cause of cancer death and the sixth most common neoplasia. Its incidence presents marked geographic differences, therein Asia and sub-Saharan Africa constitute high-risk areas with yearly incidence exceeding 20 cases per 100,000 population. Incidence rates and mortality are increasing…

Cystic hepatobiliary neoplasia

Overview The vast majority of nonparasitic cystic lesions of the liver are simple cysts. They are unilocular, do not communicate with the biliary tree, have a serous content, and although the epithelium does divide to account for volume expansion, they are not considered tumors and have no malignant potential. Furthermore, they do not tend to recur after partial resection. These lesions are described in detail in…

Benign liver lesions

The widespread use of medical imaging (see Chapter 14 ), such as hepatic ultrasonography (US), computed tomography (CT) scan, and magnetic resonance imaging (MRI), has led to the increased detection of asymptomatic tumors. In the absence of underlying chronic liver disease, the vast majority of these lesions correspond to benign liver tumors, including cystic and solid lesions. Cystic tumors will be discussed in Chapter 88B .…

Tumors of the liver: Pathologic aspects

Liver tumors encompass a large spectrum of benign and malignant neoplasms, both primary and metastatic. In addition, a variety of nonneoplastic tumor-like masses deserve attention because they can simulate neoplasms. Despite the major advances in imaging procedures, the definitive diagnosis of a liver tumor continues to be based primarily on accurate examination and interpretation of histologic material. The roles of the pathologist are to establish the…

Budd-Chiari syndrome and veno-occlusive disease

Among the etiologies of portal hypertension, those caused by postsinusoidal obstruction are seen infrequently by most clinicians. Nonetheless, these disease processes represent complex clinical challenges and require a thorough knowledge of the available diagnostic and treatment modalities. Included in this group are Budd-Chiari syndrome and veno-occlusive disease. The latter condition is also referred to as sinusoidal obstruction syndrome and is most often seen after myeloablation with…

Transjugular portosystemic shunting (TIPS): Indications and technique

Introduction Besides the well-established role of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of portal hypertension, additional indications in noncirrhotic, presurgical, and oncologic patients, as well as portal vein thrombosis, have evolved over the past several years. In presurgical patients, TIPS has been used before major interventions such as colectomy in efforts to reduce the risk of intraoperative bleeding. In anticipation of liver or multivisceral…

Techniques of portasystemic shunting: Selective and nonselective shunts

Introduction Surgical shunts for portal hypertension and variceal bleeding are rarely undertaken today, making this chapter either irrelevant or more important than ever. I believe the latter. The decline in surgical shunting is generally a consequence of the perceived outcomes with transjugular intrahepatic portosystemic shunt (TIPS) and the concept of TIPS as a bridge to transplantation (see Chapter 85 ). The results with TIPS have been…

Portal hypertensive bleeding: The role of portosystemic shunting

Overview Esophageal varices develop in patients with portal hypertension, most commonly secondary to hepatic cirrhosis (see Chapters 74 , 76 , and 80 ). They occur most frequently in the distal esophagus, although they may be accompanied by gastric varices. Rupture of varices is associated with massive upper gastrointestinal (GI) bleeding with an attendant high mortality rate. Therapy aimed at the prevention and treatment of bleeding…

Portal hypertensive bleeding: Operative devascularization

Treatment of esophagogastric varices This chapter addresses the role of devascularization procedures in the management of portal hypertensive bleeding. The management of variceal bleeding is based on the underlying cause, liver function, presentation, and the patient’s clinical condition. Several nonsurgical therapeutic options are available to manage an acute bleeding episode and prevent subsequent episodes (see Chapters 80 , 81 , and 84 ). The roles of…

Portal hypertensive bleeding: Acute management

Overview The most important aspect of care in patients with suspected variceal or other portal hypertensive hemorrhage is adequate resuscitation and stabilization while directed diagnostic maneuvers and therapies are being coordinated (see Chapters 26 and 80 ). Although this chapter focuses on acute esophageal variceal bleeding, many of the principles and therapies may apply to other sources of portal hypertensive bleeding. Acute variceal hemorrhage is associated…