Management Of Liver Tumours:

Mohamed Reda Mahmoud Sanad

Tumours of the liver may be classified according to different points of view as:1-Primary or metastatic.2-Benign or malignant.3-Of epithelial or mesenchymal nature.4-Derived from liver cell or bile ducts.5-Frequent or rare.Different forms of benign tumours can arise in the liver. Hemangioma is the most common benign hepatic tumour of mesenchemal origin. Occasionally it grows large enough to form a clinically apparent mass. When this is the case, complications such as spontaneous rupture may develop resulting in intraperitoneal haemorrhage and need to be surgically excised. Infantile haemangioendothelioma is a rare benign tumour occuring almost exclusively in children. 87% of the cases were diagnosed prior to the age of months. This tumour is associated with high mortality rate, largely as a result of hepatic failure and C.H.F. treatment of such tumour includes radiation therapy, steroid and surgical excision depending on the size and clinical manifestations.Hepatocellular adenomas are very rare, they have an association with sex hormone therapy and with pregnancy. The adenomas are often symptomatic and can lead to severe and even fatal intraperitoneal haemorrage. Most of the patients are in the third to fifth decades of life. Clinically presented by acute abdominal pain or abdominal mass and treated by surgical resection.Liver cell carcinoma (Hepatocellular carcinoma) is very common in Africa and Asia. Most cases are seen in patients over the age of 50 years but this tumour can also occur in younger individuals and even in children.It usually presents with abdominal pain, ascites, liver enlargement, and obustructive jaundice that may result from tumour invasion into C.B.D. It may be associated with systemic manifestations such as hypoglycemia, hypercholesterolemia, erythrocytosis, hypercalcemia and there is elevation of alpha-fetoprotein occurs in a large percentage of cases. The most effective treatment of hepatocellular carcinoma is complete resection. Lately, an increasing number of tumours have been treated with liver transplantationSystemic or arterial chemotherapy and hepatic occlusion therapy can offer a modest degree of palliation in inoperable or recurrent tumours.Hepatoblastoma occurs exclusively in infants. This tumor has been seen in association with a variety of congenital abnormalities especially her.iihyperti ophy, Wilm’s and glycogen storage disease. Hepatic angiography and C.T scans provide the most valuable preoperative assessment of the tumour location and extent. The treatment of choice of hepatoblastoma is surgical excision with adjuvant chemotherapy and liver transplantation is being increasingly used. Bile duct carcinoma ”cholangiocarcinoma” commonly occurs after the age of 60 years. Abdominal pain and weight loss are the common presenting features. The treatment of bile duct carcinoma is surgical in the form of partial or total hepatic resection, the latter followed by liver transplantation. Sometimes by pass procedures are of palliative value. The liver is a common site for metastasis from many primary sites especially lung, breast and the gastrointestinal tract. Palliative hepatic resection and chemotherapy is used for metastatic tumours. A few patients with metastatic neuroendocrine tumours have been treated by orthotopic liver transplantation. The ability to safely resect liver tissue is based on understanding of anatomy and physiology of the liver. Resection of up to 80 to 90 per cent of the liver can be performed safely, with compensatory hypertrophy and hyperplasia occuring within 3 to 6 weeks resulting in a regenerated liver of approximately normal size. Thorough understanding of the anatomy of the liver also has contributed to the increasing safety of liver resection. This understanding of the intrahepatic anatomic division allows for safer dissection and resection of tumours, minimizing blood loss and maximizing preservation of viable, functional liver parenchyma.At present surgical resection is clearly the treatment of choice for primary tumours of the liver and biliary tree. For these diseases surgical resection represents the only chance of cure, producing long—term survival in a significant number of patients whose tumours are completely resected. For certain metastatic tumours to the liver, surgical resection also represents possible curative therapy. The best documented of these is metastatic colorectal carcinoma. For other tumours, particularly functional neuroendocrine tumours, surgical excision, even when noncurative, may produce good palliation by relieving incapacitating symptoms such as diarrhea or hypertension. The development of liver transplantation as a therapeutic procedure and its subsequent application to large numbers of patients, who without such therapy have little or no hope of survival, has been one of the true medical advances of the last quarter century. The results with liver transplantation are best in children with survival rates being as high as 80-85% for certain highly selected indications. In general, the results obtained with liver transplantation in adults have been less favorable. Survival rates for adults range from 30 to 85%. The clinical status of the individual at the time of transplantation and the specific liver disease for which it is being applied, as well as the presence or absence of portal hypertension and coagulopathy, are each important variables in determining the precise prognosis for a given individual being considered for the procedure. In conclusion, early diagnosis of the tumours, mainly by routine periodic examination of high-risk groups of individuals, and the use of liver function, tumors markers, computed tomography, scintigraphy, nuclear magnetic resonance imaging, angiography, intraoperative ultrasound, ultrasonic doppler studies, doppler flow imaging of hepatic tumours and needle biopsy, can facilitate early intervention. Surgical treatment is the only curative procedure. However, in cases of inoperable malignant tumours, various types of palliative therapy have been tried. These include chemotherapy, hepatic occlusion therapy e.g. hepatic dearterialization and transcathter embolization. Radiation therapy, alcohol injection in small tumours, hyperthermic liver perfusion and immunotherapy.