Over 20,000 patients per year are diagnosed with primary or secondary liver cancer. The majority of liver cancers are secondary liver cancers occurring from metastatic spread to the liver from other primary sites. Common sources of metastatic liver cancer are colon, breast, pancreas, lung, and stomach. For many years, the prognosis of metastatic liver cancer was extremely poor. Over the last twenty years, with the development of new surgical and nonsurgical techniques, patients with metastatic liver cancer have effective treatment options which can greatly improve survival while preserving a reasonable quality of life.

 

Traditionally, surgical resection of liver metastases was reserved for solitary lesions. Before the development of modern techniques and technologies by liver surgeons, liver resections were considered hazardous operations with high morbidity and mortality rates. An experienced liver surgeon can perform a variety of surgical procedures to simultaneously treat multiple liver cancer lesions, including a right hepatic lobectomy, a left hepatic lobectomy, extended lobectomy, partial hepatic lobectomies, and/or multiple simultaneous wedge resections. Liver resections are performed with low expected mortality rates (1% or less). With successful liver resection, patients with metastatic liver cancer have improved 5-year survival rates (in some studies improving from 13% to 58% at 5 years). Repeat resections are occasionally possible for recurrent metastatic liver cancer, depending on liver anatomy and the regenerative potential of the remnant liver parenchyma.

 

Radiofrequency ablation (RFA) utilizes radio waves to heat the tumor to 90 degrees Celsius, thereby effectively killing metastatic liver cancers of 5 cm in diameter or less. RFA can be performed either percutaneously with radiographic guidance (ultrasound or CT) or surgically with a laparoscopic or open approach. RFA can be repeated or performed in conjunction with surgical resection for multiple metastatic liver cancers residing in both hepatic lobes. Metastatic cancer lesions greater than 5 cm or adjacent to major vascular structures are less effectively treated with RFA. Microwave ablation therapy achieving more effective heating and tumor kill for metastatic liver cancers larger than 5 cm is now available.

 

Systemic chemotherapy has been largely unsuccessful in improving survival in patients with significant metastatic liver cancer. Chemotherapeutic agents are mostly eliminated through hepatic metabolism; attaining effective intrahepatic concentrations are difficult at best. Hepatic arterial chemoembolization (HACE), also called trans-arterial chemoembolization (TACE), utilizes the unique pathophysiology of metastatic liver cancer to provide directed therapy. Metastatic liver cancers derive their blood supply from branches of the hepatic artery, while normal liver parenchyma derives its blood supply primarily from the portal venous system. A hepatic arteriogram is first performed to identify feeding arteries to the metastatic liver cancer. The interventional radiologist then infuses chemotherapeutic agents (doxorubicin, cisplatin, mitomycin, and/or 5-FU) directly into the lesion and embolizes the feeding arteries temporarily with lipiodol or ethiodol. The resulting hypoxemia and high concentrations of chemotherapy within the lesion result in effective tumor kill without significant systemic side effects while minimizing collateral damage to normal liver parenchyma. HACE has already been used with great success in the treatment of hepatocellular carcinoma and metastatic pancreatic neuroendocrine tumors. HACE can be performed safely while continuing systemic chemotherapy treatments, and does not usually require any inpatient hospitalization. HACE can also be repeated, so long as the portal vein and hepatic arteries are patent. Newer liver-directed therapies available at several large cancer centers include hepatic arterial embolization of metastatic liver cancer with Yttrium-90 microspheres.

 

Although radiation therapy has been traditionally used only for the palliation of pain in metastatic liver cancer, computer directed robotic gamma radiotherapy has shown promise in the treatment of inoperable liver cancer. Advances in computer and robotic technology permit extremely precise administration of gamma radiation to liver cancers of various shapes and sizes.

 

Advances in surgical and nonsurgical techniques have greatly improved patient survival and quality of life for patients with metastatic liver cancer. A multidisciplinary approach with an oncologist, liver surgeon, and primary care doctor are essential to effective treatment of metastatic liver cancer. Nearly all of the discussed treatment options are available to patients in East Tennessee. For more information on the management of metastatic liver cancer, contact LeeJR@msha.com or 423-431-1830.

 

 

 

310 N. State of Franklin Road, Suite 105, Johnson City, TN.