LIVER cancer affects tens of thousands of people in the UK each year and has a mortality rate that can be up to 27%, with 50% of cases also resulting in major hepatectomies – a serious operation.
Hepatocellular carcinomas, a particular type of liver cancer, are the sixth most-common form of cancer in the world, with more than 3,400 people in the UK diagnosed with this primary liver cancer each year, and many more diagnosed with secondary liver cancers – metastatic tumours from the colon, for example.
Without ultrasound guidance we would never have been able to give these patients such a good chance of overcoming the cancer and retaining good liver function
In addition to these two types, a third type – cholangiocarcinomas – affects two in every 100,000 people. All three can be treated with operations to remove the tumours, and, at least for metastatic cancers from colon cancer and cholangiocarcinomas, it is the only treatment which affords a chance of a cure. Chemotherapy, radiotherapy and other treatments can sometimes keep the cancer under control, but only the combination of these with surgical intervention offers the potential of a complete cure.
Following major hepatectomies, a patient’s quality of life and independence are both often vastly reduced, emphasising the great importance to patients and surgeons alike of avoiding this adverse outcome.
By operating conservatively in the first instance, as ultrasound-guided techniques allow you to, a second round of surgery becomes a viable option as less tissue needs removing, meaning liver function can still be retained
A further consideration is that, due to the metastatic properties of liver cancers, relapses and new tumour growth can often be inoperable since there may not be enough tissue for a second operation as a considerable amount of healthy tissue is often removed during these operations. Thus, although the liver has a remarkable ability to regenerate itself, it is important to try and remove as little healthy liver tissue as possible during the operation while still ensuring all the tumour is removed to reduce the chance of further growth and relapses.
New ultrasound-guided technique
Using ultrasound as a navigational tool, surgeons have revolutionised hepatic tumour surgery by optimising the compromise between removing enough tumour and leaving enough healthy liver tissue. Thus, by operating conservatively in the first instance, as ultrasound-guided techniques allow you to, a second round of surgery becomes a viable option as less tissue needs removing, meaning liver function can still be retained. This technique was developed by Professor Torzilli, associate professor of surgery with the School of Medicine at the University of Milan and director of liver surgery at Istituto Clinico Humanitas in Italy, in collaboration with ALOKA. Professor Torzilli’s early findings include:
- After using the ultrasound-guided technique, only 4% of surgical cases now require a major hepatectomy, down from 35-50% with traditional approaches
- Mortality rates are up to five times lower using ultrasound guided techniques than with traditional techniques
- As a navigational tool, ultrasound has one enormous advantage over traditional techniques, such as MRI and CT, since it can be used intra-operatively
Benefits will be passed on the primary care trusts, since post-operative demands of patients will be greatly reduced
Professor Torzilli said: “Making the need for major hepatectomies around 10 times less likely is a massive and positive step forward in the care of hepatic cancer patients.”
Ultrasound is allowing previously unfeasible operations to go ahead, and this is saving lives. Using a range of probes, Professor Torzilli is able to give himself the best view at each stage. A convex probe allows him a wide view field to initially explore the area; while a T-shaped probe provides resolution for superficial structures; and a Micro-Convex probe is used for guiding surgical manoeuvres.
Professor Torzilli said: “Without ultrasound guidance we would never have been able to give these patients such a good chance of overcoming the cancer and retaining good liver function.”
A surgical breakthrough
This technique is now being built back into accepted practice with the training of the new generation of surgeons, and Professor Torzilli strongly recommends that ‘all surgeons train in the intra-operative use of ultrasound for hepatectomies’.
However, the adoption of this technique across the UK requires further approval from the NICE Interventional Procedure Programme and support from the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland. The treatment will also have to be compared with alternative techniques and the efficacy, resource requirements and general safety considerations of the procedure will need to be evaluated, alongside a literature review. Discussion in the scientific meetings of the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland will also help establish the technique in the UK, and to further improve it, with input from more surgeons leading to more innovations and developments.
Making the need for major hepatectomies around 10 times less likely is a massive and positive step forward in the care of hepatic cancer patients
Professor Torzilli has already indicated to the favourable comparison against traditional techniques, and the efficacy of the technique, so it should not be too long before this technique is widely adopted across the UK and hepatic cancer patients can benefit from the lower mortality rates and less demanding surgical procedures. Additionally, benefits will be passed on the primary care trusts, since post-operative demands of patients will be greatly reduced.