Liver

Hepatobiliary Carcinoma and Pancreatic Surgery

Our Extraordinary Program

Liver cancers are some of the most common cancers worldwide and, along with biliary and pancreatic cancers, are among the most challenging cancers to treat. Nowhere in the Midwest will you find a more experienced team of physicians and health-care professionals dedicated to treating these cancers than at Nebraska Medicine. Our groundbreaking surgeries and innovative treatment options provide early staging and the most positive outcomes for patients with both primary and metastatic cancers. The use of laparoscopic surgery offers patients a less-invasive approach for many of these operations, and our world-renowned liver transplant team is available for patients who are candidates for transplantation.

Our Patient Care

Numerous physicians and medical professionals work together to ensure patients receive the most comprehensive and innovative treatments possible. Our multidisciplinary transplant team includes transplant surgeons, hepatologists, gastroenterologists, nursing staff, clinical nurse coordinators, social workers, child life specialists, psychologists, psychiatrists, pharmacologists, financial counselors, pastoral services, patient relations coordinators and others dedicated to providing extraordinary care to patients and their families.

The liver is the largest organ inside the body and is located just below the ribs on the right side. The liver has many functions: it filters waste and other harmful materials from the blood, it produces enzymes and bile that help with digestion and it produces chemicals and hormones necessary for regulating many body functions. Liver cells are called hepatocytes.

Liver cancer is classified as either primary (starting in the liver) or secondary (spreading to the liver from cancer in another part of body). Hepatocellular carcinoma is the most common form of primary liver cancer.

It develops in the liver cells and damages other healthy liver cells. Continuous growth of cancerous hepatocytes can cause malignant, or cancerous, tumors to form.

In its early stages, liver cancer does not produce many symptoms and is hard to detect. As the cancer grows, symptoms such as abdominal pain and bloating, weight loss, nausea, vomiting, fatigue and jaundice (yellowing of the skin and eyes) may appear. While doctors do not know exactly what causes liver cancer, chronic liver infections, such as viral hepatitis B and C, and cirrhosis of the liver can increase a person's risk for developing the disease. Men are more likely to develop liver cancer, as are people over the age of 60.

There are different treatment options available, depending on the type and stage of the cancer. Surgery or a liver transplant are options only if the tumor is small and contained within the liver. If the tumor is very large or has spread beyond the liver, chemotherapy or radiation may relieve symptoms and prolong life, but this is not a cure.

Liver Cancer


Primary Liver Cancer

Primary liver cancer is one of the most common cancers worldwide and is among the most challenging cancers to treat. While many cancers are declining in the United States, new cases of primary liver cancer are on the rise and are expected to continue to increase over the next two decades. Primary liver cancer starts in the hepatocytes (the main liver cells) and often spreads as a single tumor that slowly infects the rest of the liver. It can, however, spread quickly throughout the entire organ. There are several types of primary liver cancer.

  • Hepatocellular Carcinoma (HCC)
    This is the most common type of primary liver cancer among children and adults. This type begins in the hepatocytes (the main liver cells), but the cancer can spread in different ways. Some liver cancers begin as single tumors that slowly spread throughout the rest of the liver. Other tumors are more aggressive and immediately begin spreading throughout the entire organ. The primary causes of HCC include hepatitis B or C infection, cirrhosis and ingestion of aflatoxin-contaminated food.
  • Cholangiocarcinoma
    This form of primary liver cancer starts in the small bile ducts within the liver. Individuals at increased risk for developing this type of cancer include those with gallstones or ulcerative colitis. Certain liver parasites commonly found in parts of Southeast Asia also may be associated with this type of cancer.
  • Hepatoblastoma
    This is a rare form of primary liver cancer that primarily affects children younger than 4 years old. Its cause appears to be related to an abnormal gene. Most cases can be treated successfully.
  • Angiosarcoma or Hemangiosarcoma
    These are rare forms of liver cancer that originate in the blood vessels of the liver and are associated with exposure to industrial chemicals such as vinyl chloride or the drug thorium dioxide. Because workers are better protected from exposure to carcinogenic chemicals and the use of thorium dioxide has been discontinued for some time, these cancers are not commonly seen today.

Metastatic Liver Cancer

In the United States, even more common than primary liver cancer is metastatic cancer, with the colon and rectum being more common primary origins. Because the liver is close to a number of significant organs such as the pancreas, gallbladder, stomach, colon, breasts and lungs, and because it is fed from several blood supplies, it is especially vulnerable to metastatic tumors. Metastatic cancers develop when malignant cells spread from the primary cancer and travel throughout the body in the circulatory or lymphatic system. These cancers are typically named after the organ from which it originated, thus the name metastatic. For instance, cancer that has spread to the liver from the colon is referred to as metastatic colon cancer.

Carcinoid and Neuroendocrine Tumors

Neuroendocrine tumors are mostly very slow growing and often difficult to diagnose. They can originate almost anywhere in the body but are mostly found in the gastrointestinal tract, pancreas and lungs. The patient may have vague symptoms such as flushing, diarrhea, palpitations, cardiac disease or wheezing as a result of hormone production by the tumor. Because of the delay in diagnosing these tumors, many patients have metastatic disease to the liver at the time of diagnosis. There are many types of neuroendocrine tumors. The most common are those arising from the gastrointestinal tract (such as carcinoid) or those arising from the pancreas (such as gastrinoma or insulinoma).

Benign tumors

A number of noncancerous or benign tumors also may develop in the liver.

  • Hemangioma
    The most common type of benign liver tumor, this type affects the liver's blood vessels and typically occurs as a result of a malformation of tissue during fetal development. The majority of hemangiomas do not cause symptoms and do not require treatment.
  • Hepatic Adenoma
    This type of tumor begins in the main liver cells called the hepatocytes. Usually, hepatic adenomas don't cause signs or symptoms. However, occasionally, you may experience abdominal pain, a mass in the abdomen or blood loss. Individuals who use birth control pills are more prone to developing this form of tumor. Halting use of birth control pills often causes the tumor to shrink.
  • Focal nodular hyperplasia
    This tumor is made up of a combination of several types of cells including hepatocytes, bile duct cells and connective tissue. It is more common in women than men and usually doesn't cause signs or symptoms.

Management of carcinoid and other neuroendocrine tumors requires a multidisciplinary approach. For this reason, at Nebraska Medicine we have a specialized program that combines the expertise of medical oncologists, interventional radiologists, hepatobiliary and transplant surgeons to offer the most effective therapy for these unique tumors. Combined modalities are often most effective in treating neuroendocrine tumors.

Surgery

We have taken the approach of being surgically aggressive towards these tumors, sometimes employing radical surgical procedures to treat metastatic neuroendocrine tumors. More specifically, we utilize staged hepatectomy, portal vein embolization and radiofrequency or microwave ablation.

Transplantation

Liver transplantation may be an option for some patients with slow-growing tumors confined to the liver, particularly patients who have debilitating symptoms due to hormone production.

Trans Arterial Chemoembolization (TACE)

This is a procedure where high doses of chemotherapy are delivered directly to tumors within the liver. The blood supply to that part of the liver is also blocked off so that the chemotherapy drug does not spread to the rest of the body.

Selective Internal Radiation

This procedure involves the delivery of small glass beads loaded with a radioactive compound being delivered to the liver. Because the blood vessels supplying the tumor are of a different size than those supplying the uninvolved liver, the radiation is delivered directly to the tumor without damaging the surrounding liver.

Treatment

Nebraska Medicine offers patients the full realm of treatment options to provide the most positive outcomes for patients with both primary and metastatic liver cancer. Resection and liver transplantation, when possible, provide the most favorable outcomes for primary liver cancer patients. What makes liver cancer particularly difficult to treat is the fact that many patients don't discover they have the disease until they are in more advanced stages of the disease.

Resection

If the tumor has not spread outside the liver and it is localized, surgery may be recommended and is referred to as surgical resection. The liver is unique in that it can regenerate damaged or resected tissue as long as there is not cirrhosis or hepatitis present. In some cases, up to 75 percent of the part of the liver affected by cancer can be completely removed. Today, the five-year survival rate after resection often exceeds 50 percent. The strongest predictors of recurrence are the presence of involvement of the small blood vessels and/or additional tumor sites besides the primary lesion. We are continually pushing the limits of respectability. We also routinely utilize novel techniques such as portal vein embolization, bilobar resections and staged resections to achieve complete removal of tumors that are often considered unresectable by conventional means.

Laparoscopic Surgery

Laparoscopic liver resection is a minimally invasive technique to remove diseased parts of the liver. When possible, laparoscopic surgery is the procedure of choice over open surgery because it is so much less demanding on the patient. A traditional liver resection can be a complicated operation because there is so much blood flowing through the liver, and it requires a very large incision. Laparoscopic surgery is usually an outpatient procedure and, compared to traditional surgery, results in less pain and discomfort following surgery, shorter recuperation time and a quicker return to normal activities.

Liver transplantation

Nebraska Medicine is home to one of the most active and prominent liver transplant centers in the world. Liver transplantation is normally an option for people with a small, early-stage liver tumor or for certain cases that involve bile duct tumors. In the past, individuals with cancer were not eligible for transplantation. However, new treatment options that can reduce the size of the tumor have helped increase the eligibility of many patients. Eligibility is based on the number of tumor nodules, the size of the tumors, how much the tumor has spread, the age and overall health of the patient.

Learn more about our Liver Transplant Program.

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