Surgical Options for Primary Hepatic Malignancy

by Boris Kuvshinoff II, MD, MBA

The two most common malignancies originating within the liver are hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). HCCs are one of the most common solid tumors seen worldwide, typically arising in the setting of hepatitis B and C. In the United States, 33,000 new cases of HCC and ICC were estimated for 2014. For a variety of reasons these cancers are difficult to diagnose and treat at an early stage. This may be related to advanced disease or underlying cirrhosis, both making surgical resection problematic. Liver transplant is recommended for patients with localized disease and cirrhosis, but organ availability continues to be limited, especially in New York State.

Liver Transplant and Surgical Resection

In well-selected patients, liver transplant has been associated with five-year survival as high as 70 percent. When localized HCC occurs in the setting of very early cirrhosis (Child’s A) or in an otherwise-healthy liver, surgical resection is recommended. This can be done laparoscopically or using conventional open surgery, depending on the location and extent of the tumor. Following liver resection, five-year survival has been reported up to 50 percent. For patients with marginal liver function, portal vein embolization can be used to "pre-regenerate" the future liver remnant and expand the number of patients who can undergo hepatic resection. Both liver transplant and surgical resection are the mainstays of curative treatment for HCC. Intrahepatic cholangiocarcinoma is treated with liver resection when it is localized within the liver and there is enough healthy noncancerous liver remaining.

Roswell Park is a high-volume center for both liver and pancreas surgery, and over the last seven years, the 30-day and in-hospital mortality for both liver and pancreas resection has been less than 3 percent — better than the national average for this important quality measure.

Thermal Ablation

When liver transplant or surgical resection is not feasible, thermal ablation with microwave or radiofrequency is considered. Microwave ablation has become popular because of its ease of applicability and efficacy. Microwave ablation can be done using a single probe inserted directly into the tumor, using minimally invasive laparoscopic approaches or at the time of open surgery. Tumors 4 cm or less can be directly treated with microwave while larger tumors may benefit from preoperative embolization.

NanoKnife Ablation

Smaller tumors near such critical structures as bile ducts or critical blood vessels can be approached with NanoKnife ablation. This technique uses high-voltage electrical energy, rather than heat, to destroy the tumor cells without harming the bile ducts or vessels. In some cases, a combination of resection and ablation is necessary to completely treat the hepatic tumors. You can learn more about our NanoKnife capabilities here.

Importance of Multidisciplinary Care

In situations where a tumor may be too large or extensive for surgical resection—which is often the case with ICC—neoadjuvant chemotherapy may downsize the tumor to allow resection or ablation. Multidisciplinary treatment planning is critical in the treatment of patients with primary hepatic malignancies.