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| You are here: Care Centers > Organ Transplantation > Liver > Treatment Options |
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Liver Introduction | Disease Progression/Prognosis | Treatment Options | Liver Issue: Cirrhosis | Alcohol: Can it hurt my Liver? | Videos Treatment Options
Laparoscopic Hepatic Resection (band-aid surgery) During the last six years, the Transplant Team at Jewish Hospital has pioneered the area of minimally invasive (band-aid surgery) hepatic surgery. During the last decade, four groups around the world have developed the methods and techniques to remove benign and cancerous tumors through small incisions. Laparoscopic resection surgery provides the distinct advantage of minimizing pain, decreasing recovery time and often providing superior exposure and visualization of the liver. Our group has removed over 300 liver tumors with these techniques with superior survival rates, low tumor recurrence rates and complication rates equivalent to open hepatic resections. Patients are often discharged within 23 to 72 hours after this major surgery.
Click here for more photos (Warning: Content may be graphic.) Traditionally, hepatic resection for colorectal metastases to the liver provides a five-year survival rate, ranging from 22 percent to 60 percent. Survival tends to be better for patients with disease confined to the liver and with four or fewer lesions. These lesions must be able to be resected with at least a one centimeter tumor-free margin, leaving an adequate amount of healthy liver tissue remaining. Concurrent disease in the liver and lung are also amenable to resection (simultaneously or in sequence), with a five-year survival rate in the range of 20 percent to 30 percent. Current controversy exists over the sequence of chemotherapy administration. Traditionally, chemotherapy has been delivered first, followed by resection for the remaining lesions. Two issues bring this approach into debate—the first is the liver damage seen in patients receiving systemic chemotherapy and the second is the survival advantage seen in radiofrequency ablation (RFA) of colorectal cancer in the presence of extra-hepatic disease. Unfortunately, open hepatic resection carries the complications of a large incision and major surgery. At most centers, it is still preferred as the standard for hepatic resection. Click here for more photos (Warning: Content may be graphic.) Prior to minimally invasive hepatic resection and improvements in anesthesia and critical care, surgeons moved to the technique of ablation. Ablation is the destruction of a tumor through thermal or chemical injury. The first attempt to do so was with a technique to freeze liver tumors (cryoablation). After initial success, widespread use of this technique led to bleeding complications and eventual abandonment of this technique for liver tumors. Click here for more photos (Warning: Content may be graphic.) Laparoscopic Radiofrequency Ablation (RFA) Following the innovation of ablation, surgeons adopted a thermal method to destroy these liver tumors. This technique appears to be safer in normal and cirrhotic (injured) livers. Radiofrequency ablation delivers local energy which thermally destroys the tumor. After treatment, these tumors will increase in size from the local destruction of normal and tumor tissue which will eventually shrink over a period of weeks to months. Radiofrequency ablation can be performed through an open incision or laparoscopically. This procedure, when performed through minimally invasive techniques, can allow the patient to be discharged in 23 to 48 hours. Primary liver tumors (hepatocellular and cholaniocarcinoma) and metastatic tumors are often good candidates for ablation therapy. Our group reserves this technology for unresectable tumors or large tumors in cirrhotic patients. Radiofrequency ablation is an accepted method of bridging hepatocellular cancers to transplantation. Open Radiofrequency Ablation (RFA) During open radiofrequency ablation (RFA), an electrode is placed in the tumor under the guidance of an imaging method, such as an ultrasound or computed tomography (CT) scan. A radiofrequency current is passed through the electrode, heating the tumor tissue near the needle tip. The heat from this radiofrequency energy closes small blood vessels, minimizing the risk of bleeding. In general, radiofrequency ablation causes only minimal discomfort and may be done as an outpatient procedure without general anesthesia. Admission to the hospital is not usually necessary.
Click here for more photos (Warning: Content may be graphic.) Therasphere® is a new technology where small micro beads are placed into liver tumors through a radiologic approach. The micro-beads are composed of Yttrium-90, a radioactive material which has a limited dept of penetration into tumor tissue. This is currently being used to decrease larger hepatocellular cancers to smaller tumors, making the patients a more appropriate candidate for resection or transplantation.
SIR-Spheres® are micro polymer beads that have radioactive material inside. The micro-beads are delivered to the tumor through a catheter placed into the artery that supplies blood to the liver. By using micro-beads, treatment can be sent directly to the tumor without affecting the entire body. Usually, there will be two infusions—one each to the right and left lobes of the liver. There is a minimum four week wait between infusions. Chemoembolization (liver-directed chemotherapy) Chemoembolization is a method typically used to destroy hepatic tumors in high risk patients. This technique is performed by radiology staff members. The patient has a catheter placed in their leg artery, which runs up to the hepatic (liver) artery. At that point, chemotherapy is selectively placed into the tumor or the side of the liver with the tumor. Once in the liver, the artery is clotted off with metal coils or glue.
Radiation therapy uses high-energy rays to kill cancer cells. External-beam radiation therapy focuses radiation delivered from outside the body on the cancer. This type of radiation therapy can be used to shrink the cancer to palliate symptoms such as pain. Although liver cancer cells are sensitive to the radiation, this treatment cannot be used at very high doses, because normal liver tissue is also easily damaged by radiation. Another kind of radiation therapy is three-dimensional conformal radiation therapy (3DCRT), the latest form of external-beam radiation therapy that uses sophisticated computers to precisely map the location of a tumor. The patient is fitted with a plastic mold resembling a body cast to keep the body still, allowing the radiation to be aimed more accurately. Radiation beams are aimed at the tumor from several directions, allowing doctors to reduce radiation damage to normal liver tissue and direct higher doses of radiation at tumors. When available, conformal radiation therapy is usually preferred over standard radiation therapy. Currently, colorectal cancer can be treated by numerous therapies. Traditionally, systemic chemotherapy had dismal response rates, which was improved by regional administration, namely hepatic perfusion (local delivery to the liver from a pump device). In recent years, new chemotherapeutic agents have been used, increasing the response rate for this cancer from 15 percent to 60 percent, which are extraordinary advances. These agents are FOFOX™ and Avastatin™. The first is a combination of traditionally used chemotherapy 5-FU and a new, platinum-based agent oxaloplatin. The later is an antibody used to treat replicating tumors. Despite these monumental improvements in response rates, the term “partial response” is defined as 50 percent of the tumor shrinking. In layman’s terms, this means a softball tumor will shrink down to the size of a lemon. Additionally, these agents have been associated with the development of a fatty liver. Some studies have described a hepatitis (liver inflammation), while others a vascular (blood supply) injury. This damage often precludes resection. Robotic surgery was first designed by the United States military to treat soldiers on the front battle lines while the doctors treating them could remain in the rear. With added interest in mars exploration, the technology has been further developed. Currently the robot is used for prostate, kidney, adrenal, gynecologic and liver surgery. Our group is one of three in the world with experience in robotic hepatic resection.
Cyberknife treatment is radiation therapy that is delivered through a targeting system that can accurately deliver high energy x-rays, usually in one or two sessions, to tumors located within the body. To improve targeting, several small gold markers (fiducials) are injected into areas around the tumor that allow for pinpoint targeting of the cancer by the x-ray beams. After the fiducials are placed, a computed tomography (CT) scan is obtained to identify the tumor and map the x-ray field. Finally, the radiation treatment is delivered. The patients are awake during the treatment, as it is usually painless. Liver transplantation was pioneered by Tom Starzl, M.D. in the mid-1960s at the University of Colorado and then at the University of Pittsburgh. Since that time, liver transplantation has been a long established method to treat specific hepatocellular cancers. These are designated by the Milan Criteria. This includes a single tumor, less than five or less than three tumors, with the largest being three centimeters. Several methods of down-staging (shrinking) tumors are used to achieve these criteria including radiofrequency, chemoembolization and Therasphere®. Other uses of liver transplantation are to treat rare tumors such as carcinoids, hemangioendotheliomas and other neuroendocrine tumors.
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