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Metastatic Liver Tumors
Liver tumors often form when cancer from another site (for example, the breast or pancreas) spreads to the liver. When this occurs, the tumors in the liver are referred to as metastatic liver tumors. There are several clear indications to surgically remove cancerous tumors (called resection) that originate from the colon and rectum or directly in the liver. However, the role of liver resection in the treatment of other metastatic liver tumors is less clear.
When making a decision to undergo liver surgery to treat metastases from different types of cancers, you and your surgeon should discuss:
- The Safety of Liver Resection or Ablation
- Whether or Not Tumor(s) are Located Outside the Liver
- Number of Tumors
- Use of Debulking (Cytoreduction) to Treat the Disease
- Use of Minimally Invasive Ablation Techniques
- Type of Cancer that has Spread to the Liver
The Safety of Liver Resection or Ablation
A number of factors have led surgeons to become more aggressive in the surgical removal of liver metastases. One of the primary factors is the improvement in the morbidity and mortality rates of liver resection. Experienced surgeons now can perform liver resection without blood transfusion, leading to fewer complications. The use of new, promising adjuvant chemotherapies after complete removal of cancerous tissue has been shown to be effective in improving outcomes in some patient groups.
Whether or Not Tumor(s) are Located Outside the Liver
Under most circumstances, if a tumor is found outside the liver (usually in the abdomen, lungs, or bone), a physician will not use liver resection or ablation to treat the disease. Outside of a scientific study designed to safely answer a specific question, there are few instances where a major liver operation is warranted when tumor is found elsewhere. There also are certain diseases, such as pancreatic cancer, where surgery for the metastatic tumor is not effective in treating the disease. Therefore it is critical that a patient considering surgical removal of liver metastases undergo a very careful evaluation to rule out the presence of distant metastases. Tests to rule out these sites of distant metastasis include:
- a careful physical examination,
- laboratory tests, and
- a variety of x-rays (chest x-ray, chest CT scan, abdominal CT scan, bone scan and possibly a PET scan).
Undergoing a major liver procedure should be considered only after metastasis outside the liver has been ruled out.
Number of Tumors
The number of tumors found in the liver is also a factor when determining whether or not to undergo surgery. It seems reasonable that the presence of fewer tumors, or the development of disease well after the treatment of the primary tumor, would suggest a more favorable outlook. In this very diverse group of disease processes there is an overall suggestion that this may be true. The presence of a solitary tumor that is readily accessible for safe removal often brings up the question of the appropriateness of resection. Liver resection in such cases may benefit the patient both from relief of any symptoms and an improvement in survival. The same may apply to the development of a liver tumor long after the time of the primary diagnosis. Scientific opinions and data disagree on the significance of these two points, but in general the presence of fewer, or solitary, tumors occurring at a remote time from the primary diagnosis will factor favorably into the decision to offer a liver operation. However, the presence of multiple tumors does not preclude liver resection.
Use of Debulking (Cytoreduction) to Treat the Disease
Debulking, also known as cytoreduction, is a surgical procedure that reduces, but does not completely eliminate, all of the known tumor through resection and/or ablation. The purpose of debulking is to reduce tumor volume in the body to allow radiation or chemotherapy to be more effective in destroying remaining cancerous tissue (because there is less tumor to treat).
Use of Minimally Invasive Ablation Technique
Radiofrequency thermal ablation, and cryosurgery are newer, minimally invasive techniques (see Figure 1) used to treat liver metastases. Once only performed at select medical centers, these techniques are becoming increasingly available throughout the country and the world. However, the long-term outcomes have not been clearly defined in scientific studies.
Figure 1: CT guided percutaneous radiofrequency ablation of a carcinoid metastasis.
Review of Scientific Data
The available data regarding resection of liver metastases of a variety of non-colorectal, non-neuroendocrine, non-renal cell cancers is difficult to interpret. Studies frequently represent retrospective reviews of a single institution's experience, rather than data derived from well-designed studies. Because of this, the information can be misleading and/or difficult to interpret and must be reviewed as such.
The treatment recommendations for each of the following diseases are largely based on studies of resection. Unless otherwise specified, the recommendations are for either resection or ablation. The approach of physicians at the University of Minnesota is to apply similar indications for ablation techniques as well as resection. The decision to apply one approach over another is based on the feasibility of resection, the ability to perform complete tumor ablation and other patient safety-related issues.
Type of Cancer that has Spread to the Liver
Colorectal cancer
See Modern Management of Hepatic Metastases of Colorectal Cancer.
Breast Cancer
Breast cancer has a significant tendency to spread to the lungs, bones, and liver (see Figure 2). Unfortunately, it is often inappropriate to surgically remove cancer that has spread from the breast to the liver due to disease found outside the liver (extrahepatic disease). The median survival of patients with this form of metastatic disease rarely exceeds two years. However, metastatic breast cancer can be a highly variable disease, and all patients should talk with their oncologist about the therapeutic options.
Figure 2: Common sites of spread from breast cancer.
In liver metastases from breast cancer, factors that indicate possible positive effects of resection include:
- the liver being the first and only site to which the cancer has spread,
- the absence of tumor(s) in the lymph nodes around the liver (diseased portal lymph nodes)
- and curative resection (no tumor left in the liver).
Previous studies indicate that if these factors occur, liver resection results in a significant improvement in overall patient survival. One study from France reported a five-year survival of 60 percent in a retrospective analysis of 21 patients who underwent liver resection. However, it is important to note that these patients had a form of Stage IV breast cancer (the most advanced type) that probably behaves differently from patients with disease in and outside the liver.
As part of a treatment plan for breast cancer that has spread to the liver, one should consider using chemotherapy before and/or after liver resection. Since liver resection only reduces the amount of tumor in the body and not necessarily microscopic cancer cells, additional therapy should be considered to potentially cure the disease. Discuss the possible benefits of this therapy with your physician.
Patients who tend to benefit most from liver resection for metastatic breast cancer are those in which the liver is the first and only site of metastasis. Patients who have disease regression outside the liver on systemic chemotherapy with residual liver disease may also benefit from liver resection. Although patients with this pattern of disease will be rare, aggressive therapy is appropriate and should be pursued.
Sarcoma (extremity, retroperitoneal, bowel)
The general treatment of all forms of metastatic sarcoma involves liver resection and adjuvant chemotherapy. However, recurrence of the cancer does occur in most patients who have undergone liver resection.
Conventional chemotherapy has not been very successful in treating hepatic metastases of soft-tissue sarcomas. However, chemotherapy can be beneficial for patients after undergoing a complete resection of all identifiable gross tumor. Patients who experience symptoms of hepatic metastasis sarcoma may be offered chemoembolization, tumor resection or ablation in order to control symptoms. It should be understood that patients with liver metastases of sarcoma do not have a favorable five-year survival and the approach of repeated resection taken for extrahepatic disease is not supported in the scientific literature for liver metastases.
Figure 3: Harvest of an isolated melanoma metastatic to the liver for autologous tumor vaccine production.
Melanoma
Malignant melanoma is a unique tumor that may be regulated and controlled by the body's own cancer-fighting system. For this reason, physicians now use a new, very aggressive approach to treat these types of tumors that can be surgically removed. This approach may be further supported by the promising, newly emerging adjuvant therapies being studied for melanoma treatment.
Recent scientific data on the resection of isolated liver metastases of melanoma indicate a five-year survival benefit of between 25 to 35 percent when compared to historical Stage IV melanoma controls.
The University of Minnesota hepatobiliary team regularly performs complete hepatic tumor resection (see Figure 3). Patients who cannot be rendered free of gross tumor undergo the least invasive procedure that allows acquisition of a sufficient tumor volume.
Noncolorectal adenocarcinomas of the gastrointestinal tract (pancreas, stomach, small intestine)
The presence of a liver metastasis (white arrow) from pancreatic cancer indicates that resection will not be an effective treatment.
Previous clinical experience indicates that resection of liver metastases of noncolorectal gastrointestinal (GI) tract adenocarcinomas is not effective in treating the disease. If cancer of the GI tract has spread to the liver, it is very common that the disease is also elsewhere in the liver, in the peritoneum or lungs. A physician may consider liver resection if primary tumor is growing into the liver directly, not if has spread through the blood or lymph systems. Combined liver and pancreas resection (called a "Whipple operation") also may be considered for locally advanced bile duct or gallbladder cancers.
Lung
Lung cancers (small cell or non-small cell) very rarely metastasize to the liver in a way that makes liver surgery an effective treatment for the disease. There has been no research that indicates treating hepatic metastases from the lung is beneficial.
Ovarian Cancer
Gynecologic oncologists have long debated the role of tumor debulking (also known as cytoreduction, see above) in advanced (Stage IV) ovarian carcinoma. The basis for this debate comes from the apparent increased sensitivity of smaller volumes of ovarian cancer to chemotherapy. Cytoreduction can be accomplished by surgically removing or minimizing peritoneal nodules, the omentum and other sites of tumor deposits (including the liver).
Inadequate tumor debulking is clearly of no benefit, i.e. when significant residual disease remains after operation. Physicians at the University of Minnesota use a combined approach to treat hepatic metastases of ovarian cancer, involving careful, detailed abdominal exploration to search for any other spread or residual disease in the peritoneal or pelvic area. If no significant disease remains, then an ultrasound is performed and the resection/ablation is planned. The liver procedure will be performed only if a complete resection/ablation of all liver disease can be achieved. A combination of surgery and chemotherapy also has been beneficial for some patients.