Minimally Invasive Liver Resection and Ablation For Malignancy Advances in Oncology Dorothy E. Schneider Cancer Center Mills-Peninsula Health Services March 16, 2013 Kimberly Moore Dalal, MD, FACS Medical Director, Surgical Oncology Peninsula Medical Clinic Burlingame, CA
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Minimally Invasive Liver Resection and Ablation For Malignancy
Mills-Peninsula Health Services Cancer Symposium - Kimberly Moore Dalal, MD, FACS Medical Director, Surgical Oncology Peninsula Medical Clinic Burlingame, CA
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Minimally Invasive Liver Resection and Ablation For Malignancy
Advances in OncologyDorothy E. Schneider Cancer Center
Mills-Peninsula Health ServicesMarch 16, 2013
Kimberly Moore Dalal, MD, FACSMedical Director, Surgical Oncology
Peninsula Medical ClinicBurlingame, CA
Historical Perspective
“…the liver is so friable, so full of gaping
vessels and so evidently incapable of
being sutured that it seems impossible to
successfully manage large wounds of its
substance.” JW Elliot 1897
Liver cancer
Historical Perspective
“…20% of patients died in the operating room
because of exsanguinating hemorrhage…
Another 14% died post-operatively as a
direct consequence of enormous blood loss
during operation…15% died of liver failure
caused by technical factors other than
hemostasis, including 3 bile duct injuries…”
Foster JH, Berman MM. Major Problems in Clinical Surgery 1977;1-342.
Liver cancer
OR Team, Bagram, Afghanistan 2007
Liver cancer
Liver Resection TodayAuthor N Operative Mortality (%)
Laparoscopic liver resections for benign and malignant tumors– Benign lesions– Hepatocellular carcinoma– Colorectal cancer metastases
Ablation for patients who are not operative candidates– Tumor size and function– Liver function– Comorbidities
Liver cancer
Radiofrequency Ablation
High-frequency alternating current flows from electrical probe through tissue to ground– Ionic agitation results in frictional heating and
coagulation of surrounding tissue
Probe insertion
Extension of prongs
RF current application
Liver cancer
Radiofrequency Ablation
Advantages– Performed
percutaneously, laparoscopically, or at laparotomy
– Low complication rateMay be related to size of ablation (<3 cm)
Disadvantages– Poor performance
near blood vessels– One probe
Many tumors require multiple, overlapping ablations
– Slow
Liver cancer
Microwave Ablation
Theoretical advantages over RFA– Larger zone of active
heatingPossibly better performance near blood vessels
– Hotter temperature– Use of multiple probes
Liver cancer
Lubner M, et al.,J Vasc Interv Radiol. 2010 Aug;21(8Suppl):S192-S203.
Liver cancer
Case 5: Segment IV B 2.6 cm mass, Cirrhosis
77 year old womanChild’s Pugh Class A cirrhosis due to autoimmune hepatitisAFP: 23CT: 2.6x2.6 cm heterogeneously enhancing nodule segment IVB of liverFNA: HCC
Liver cancer
Microwave Ablation
Preop; AFP 23 1 month postop; AFP 7
10 months postopAFP 24
1 months postop repeatAFP 6
Liver cancer
Microwave Ablation
Cirrhotic liver and gallbladder Adhesion to recurrent tumor
Intraoperative ultrasound Post-ablation
Summary
Laparoscopic liver resections are safe and oncologically sound in highly selected patients in the hands of surgeons with a laparoscopic skill set.
Patients with malignant liver tumors can be considered for resection based on tumor characteristics, future liver remnant size and function, and patient comorbidities.
Radiofrequency and microwave ablations are alternative ways to treat small liver tumors which are not amenable to resection.