Where is the liver located?
The liver is the largest organ in the abdomen and is located beneath the diaphragm in the uppermost part of the abdomen.

What does the liver do?
The liver performs numerous vital functions, among them being the filtration of the blood as it passes from the intestinal tract into the main circulation. A variety of toxic substances that are absorbed by the intestine and must be chemically changed by the liver to avoid harmful effects on the rest of the body.

Why does cancer spread to the liver?
The liver is filled with many vessels, so it is fairly common for tumor cells that manage to get into the blood stream to be captured and grow within the liver. Since all blood coming from the intestinal tract passes first through the liver, cancer cells that escape from tumors in the intestinal tract often spread to the liver. Malignant tumors that have spread from other organs into the liver are called hepatic metastases. Intestinal cancers are the most common source of liver metastases, but virtually any type of cancer has the potential to spread to the liver.

Are all liver cancers the result of tumors that spread into the liver?
A significant proportion of liver cancers are tumors that have spread there through the blood stream. However, malignant tumors can actually begin within the liver itself. Primary cancers of the liver occur much more frequently in people who have other underlying liver diseases, such as cirrhosis. These cancers typically arise either from the bile duct cells, called cholangiocarcinomas, or from the liver cells, called hepatocellular carcinomas.

Is liver cancer treatable?
Malignant tumors within the liver are among the most difficult problems that physicians treat. There is no single treatment that is always effective. Depending on the kind of tumor, treatment may involve either surgery or chemotherapy, and in some cases both. Primary liver cancers are occasionally also treated with liver transplant, but this is fairly uncommon and is dependent on a great many factors.

What types of surgery can be used to treat liver cancer?
For primary liver cancer the total removal of the tumor offers the best hope for a successful outcome. Frequently this is not feasible, either because of the size and total number of tumors, or because of the patient's overall poor health. While it is possible to survive after removal of as much as two-thirds of the liver, patients who have cirrhosis have far less reserve. They are at higher risk of liver failure following surgical removal of any significant portion of the liver.

Patients with metastatic cancer in the liver may also benefit from surgical removal of the tumors. Generally, if only one or two tumors are present, it may be reasonable to remove that part of the liver. However, metastatic tumors are frequently present throughout the liver, making surgical removal impractical if not impossible. Even when metastatic tumors can be removed, it is common for additional tumors to show up within the liver at a later time.

Another method for surgically treating liver tumors involves killing the cancerous cells within the liver without actually removing them. This type of treatment is called ablation therapy. Specialized needles designed to generate heat within the tumor are used to literally cook the cancer cells, along with a small area of the surrounding normal liver. This technique is called Radio-Frequency Ablation or RFA. It can be performed either during an open incision operation or as a laparoscopic procedure. Laparoscopic RFA eliminates the need for a large incision and offers a more rapid recovery.

Are all liver tumors treatable with laparoscopic RFA?
Laparoscopic RFA can potentially be used in a wide variety of circumstances, and for most types of cancer in the liver. For this reason it can potentially be used to treat many more patients than would be possible with conventional surgical resection. The goal of laparoscopic RFA is to destroy all the tumor tissue that is found within the liver. However, laparoscopic RFA has its limitations as well. Typically, tumors must be smaller than 8 centimeters in diameter (3 inches across) and fewer than 10 to 12 in number to be considered treatable. The total amount of liver occupied by tumor should also be less than 20%. The cancer should also be confined to the liver only. Once the tumor has spread outside the liver into other areas of the body, it is unlikely that laparoscopic RFA of the liver tumors would be of any benefit.

What is laparoscopic RFA surgery done?
The patient is first placed under general anesthesia in the operating room. A small incision, less than an inch long, is made above the belly button, and a special tube, called a canula, is inserted into the abdomen through this small incision. The abdominal cavity is then filled with carbon dioxide gas, much like inflating a balloon. The gas separates the internal organs from the abdominal wall and allows the surgeon to look inside the abdomen using a small, lighted tube called a laparoscope. Attached to the laparoscope is a miniature television camera, which displays a clear picture of the interior of the abdomen on a high-resolution video monitor. Additional canulas are then placed through small incisions in the abdomen, which serve as passages for other surgical instruments.

Scar tissue is frequently found between the internal organs due to previous surgery. This type of scarring, referred to as adhesions, can present a major obstacle when performing laparoscopic surgery. These adhesions must be carefully separated to allow for a complete visual examination of the abdomen. Any areas that are suspicious for cancer are tested immediately, since finding cancer outside the liver would likely change the planned operation. If the cancer has spread outside the liver there would be little or no advantage to performing RFA of the liver tumors.

Once the liver has been completely exposed, an ultrasound probe designed specifically for use in laparoscopic surgery is used to examine the entire liver. In the same way that ultrasound is used to examine a baby while it is still in the womb, laparoscopic ultrasound is capable of looking beneath the surface of the liver. The ultrasound image can show the precise location of any tumors within the liver. This technique is much more sensitive than other methods used to examine the liver, such as CT scan or MRI. Tumors as small as 2 or 3 millimeters (BB size) can usually be seen with laparoscopic ultrasound. The examination of the interior of the liver with ultrasound establishes the extent of tumor within the liver and ultimately determines whether or not RFA is likely to be of benefit.

When the decision is made to proceed with laparoscopic RFA, the ultrasound image is used by the surgeon to accurately guide the RF needle into the tumors. The needle is designed to emit low frequency electrical energy that gradually heats an area of tissue. This process literally cooks the tumor as well as a small amount of the normal liver tissue immediately next to the tumor.

Once the procedure has been completed the carbon dioxide gas is allowed to escape from the abdomen and the small incisions are closed with sutures. Most patients are able to be discharged from the hospital the following day.

How do you know whether the treatment was successful?
A repeat CT scan is obtained a week after laparoscopic RFA and is compared with the pre-operative test. The scan will show the areas that were successfully destroyed by the heating process. Most of the time RFA is capable of reliably destroying tumors that are as large as 4 to 5 centimeters in diameter (up to two inches). Occasionally larger tumors, up to 8 centimeters, can sometimes be successfully treated. However, the larger the tumor, the more difficult it is to destroy completely. CT scans of the liver are performed every three months to look for any evidence of tumor recurrence or the appearance of any new tumors. If new tumors appear on subsequent CT scans it may be possible to repeat the laparoscopic RFA procedure.

Is chemotherapy necessary after laparoscopic RFA?
Since microscopic amounts of cancer may still be present in the liver or in other parts of the body, chemotherapy is usually recommended following laparoscopic RFA. Each case should be evaluated individually and the final decision regarding chemotherapy is between the patient and their Medical Oncologist.

What are the chabces that laparoscopic RFA will cure the cancer?
It is impossible to predict the ultimate behavior of any given cancer. Obviously the best chance for curing cancer is to find it early and treat it aggressively. The fact that cancer has spread into the liver certainly reduces the possibility of cure no matter what treatments are used. While laparoscopic RFA may help reduce the amount of cancer in the liver, there is simply not enough long-term information to say which patients, if any might be cured. At this time, the role of laparoscopic RFA is to eliminate cancer from within the liver, while causing as little injury as possible.

What are the risks of laparoscopic RFA surgery?
The risk of laparoscopic RFA of liver tumors is dependent on several factors including the overall health of the patient, the total number, size and location of the tumors being treated, and the experience of the operating team. Obviously, the risk is somewhat higher for patients who are older and for those who have other major medical problems such as hepatic cirrhosis, diabetes, heart disease or respiratory problems.

Since a general anesthetic is used (the patient is completely asleep), there are some risks associated with this type of anesthesia. These risks will vary from patient to patient, and will be discussed by the Anesthesiologist with each patient during a pre-operative visit.

All operations have some risk of infection and laparoscopic RFA is no exception. The majority of infections are relatively minor, occurring just beneath the skin, and can often be treated by simply opening the skin incision to allow the infection to drain out. More serious infections inside the abdomen may require re-operation to provide adequate drainage.

Infections are infrequent following laparoscopic surgery, but they can occur. Most often they occur just beneath the skin and are treated by simply opening the skin incision, allowing the wound to drain. More serious infections inside the abdomen may require re-operation to provide adequate drainage.

During laparoscopic surgery it is possible for injuries to occur to the intestine, the urinary bladder and even major blood vessels. Such injuries can happen despite the surgeon's best efforts, especially if previous operations have been performed in the area. In the event of an injury, more extensive surgery would likely be required.

Procedures that involve the liver such as laparoscopic RFA carry an additional risk of injury to the major blood vessels or bile ducts within the liver itself. Although such injuries are uncommon, any major vessel or bile duct injury could lead to very serious complications, including death.

After laparoscopic RFA it is possible for the cancer to come back, either within the liver or in some other location. It is important to recognize that laparoscopic RFA is not considered to be a cure for liver cancer. It should be thought of as a minimally invasive treatment that is designed to reduce the total amount of tumor in the liver with the hope of potentially extending the patient's life. Any recurrence of the cancer could require additional ablation or even other types of surgery, along with aggressive chemotherapy.