Liver tumor removal cuts out cancer or a benign tumor with a margin of healthy liver, by keyhole or open surgery, after a tumor board review.
About This Department
General Surgery
Liver tumor removal cuts out the tumor with a margin of healthy liver, and the liver regrows. For bowel cancer that has spread to the liver, surgery offers a real chance of cure.
In 1,001 patients operated on in New York for bowel cancer spread to the liver, 37 percent lived five years and 22 percent ten years. Surgery also removes primary liver cancer, bile duct cancer and some benign tumors. Whether an operation fits depends on the tumor, the health of the rest of your liver and how much healthy liver stays behind. Send your CT or MRI and blood tests, and our liver surgery team will tell you whether removal is possible and safe.
37%
Five-year survival after removing bowel cancer spread to the liver, 1,001 patients
19% vs 31%
Complications, keyhole against open liver resection
1.3%
Operative mortality in the last two years of a 1,803-patient series
A liver resection, also called a hepatectomy, removes part of the liver together with the tumor inside it. The liver divides into eight segments, each with its own blood supply and bile drainage, so a surgeon can take one segment, several, or a whole half and leave the rest working.
How the liver regrows
A healthy liver rebuilds its lost volume within six to eight weeks. Up to two thirds of a healthy liver can come out. A liver scarred by cirrhosis or damaged by long chemotherapy regrows less, and the surgeon leaves more behind.
Benign tumors that need removal
Most benign liver lumps, such as hemangiomas and focal nodular hyperplasia, stay harmless and need only a scan to confirm them. A hepatocellular adenoma larger than five centimeters, a growing or painful lump, and any tumor whose nature stays unclear after imaging come out.
Four groups of patients come to liver surgery, and the reason for the operation sets how much liver we remove, which technique we use and whether chemotherapy comes first.
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Liver tumors and when surgery fits
Tumor
Where it starts
When we operate
Colorectal liver metastases
Bowel cancer spread to the liver
When all tumors can come out with enough liver left
Hepatocellular carcinoma
Liver cells, often in cirrhosis
Good liver function and normal portal pressure
Cholangiocarcinoma
The bile ducts inside the liver
No spread outside the liver
Benign tumors
Adenoma, large hemangioma, cysts
Size, growth, pain or doubt about the diagnosis
Tumors outside our scope
Cancer spread from the stomach, pancreas or lung rarely benefits from liver surgery, and hepatocellular carcinoma in a failing liver needs a transplant assessment instead. Our pages on liver transplant for hepatocellular carcinoma and on cirrhosis cover those paths.
Predicting the outcome
Fong and colleagues at Memorial Sloan-Kettering studied 1,001 consecutive resections for bowel cancer spread to the liver and found five factors before surgery that predicted relapse. Each scores one point.
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Clinical risk score for colorectal liver metastases, one point each
Factor
Scores a point when
Lymph nodes of the bowel cancer
Cancer cells found in them
Time from bowel cancer to liver spread
Under 12 months
Number of liver tumors
More than one
Largest liver tumor
Over 5 centimeters
CEA blood marker
Above 200 ng/ml
Who can have a liver resection
Enough liver left behind
Every decision rests on the remnant, the liver that stays. A CT volume study measures it before surgery. In a healthy liver we want at least a fifth to a quarter of the total volume left, and in a liver injured by chemotherapy or cirrhosis, more. When the remnant falls short, blocking the portal vein to the diseased side makes the healthy side grow first.
Cirrhosis and portal pressure
Bruix and colleagues measured the pressure in the liver veins of 29 patients with early cirrhosis before removing a liver cancer. Eleven had liver failure that had not resolved three months later, and their pressure gradient averaged 13.9 mmHg against 7.4 mmHg in those who recovered. A high pressure points us to transplant or ablation instead.
Cirrhotics with increased portal pressure are at high risk of hepatic decompensation after resection of hepatocellular carcinoma.
Barcelona study of 29 patients, Gastroenterology, 1996
Chemotherapy around surgery
1
Before surgery
Six cycles of FOLFOX chemotherapy over three months, for bowel cancer spread to the liver.
2
Restaging
A new CT or MRI to confirm the tumors have shrunk or held still.
3
Surgery
The liver resection, four to six weeks after the last cycle.
4
After surgery
Six more cycles once you have recovered.
What the EORTC trial found
Nordlinger and colleagues randomized 364 patients with up to four liver tumors from bowel cancer to surgery alone or surgery with chemotherapy before and after. Three-year survival free of progression rose from 28.1 to 35.4 percent in all patients, a result just short of statistical significance, and from 33.2 to 42.4 percent among those whose tumors came out, which reached it.
The cost of chemotherapy for the liver
Reversible complications after surgery reached 25 percent with chemotherapy against 16 percent without, and deaths after surgery stayed low in both groups. Long courses of chemotherapy damage the liver, so we keep the course before surgery to the planned six cycles.
Whether every tumor can come out with a clear margin.
Whether enough healthy liver will remain.
Whether cancer exists outside the liver.
Whether chemotherapy first helps this patient.
Our tumor board
Liver surgeons, oncologists, radiologists and pathologists review every case together and answer these four questions in a written plan, before you travel.
Perioperative chemotherapy with FOLFOX4 is compatible with major liver surgery and reduces the risk of events of progression-free survival in eligible and resected patients.
EORTC trial of 364 patients, Lancet, 2008
The operation
Anatomical or tissue-sparing resection
An anatomical resection removes whole segments along their blood supply, the standard for primary liver cancer. A tissue-sparing resection cuts out the tumor with a one-centimeter margin and keeps as much liver as possible, the preferred approach for bowel cancer spread, since a second operation stays possible if new tumors appear.
Keyhole or open liver surgery
The OSLO-COMET trial
Fretland and colleagues randomized 280 patients having tissue-sparing resection for bowel cancer spread to keyhole or open surgery. Complications within 30 days fell from 31 to 19 percent with keyhole surgery, the hospital stay dropped from 96 to 53 hours, and clear margins, blood loss and operating time matched.
In patients undergoing parenchyma-sparing liver resection for colorectal metastases, laparoscopic surgery was associated with significantly less postoperative complications compared to open surgery.
Norwegian OSLO-COMET trial, Annals of Surgery, 2018
Ultrasound on the liver surface during surgery, to find small tumors the scans missed.
Low pressure in the main vein during the cut, to reduce bleeding.
Clamping of the blood inflow for short periods when needed.
Sealing devices for vessels and bile ducts.
How the operation runs
Before surgery
Tests in Istanbul
Blood tests of liver function, a CT or MRI with liver volume, a heart and lung check, and an anesthesia review, all within two to three days of arrival. With cirrhosis we add a measurement of the pressure in the liver veins, or an elastography scan that grades the scarring, before we decide on the size of the resection.
Keyhole against open results
Same margins, fewer complications.
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OSLO-COMET, keyhole against open liver resection, 280 patients
Outcome
Keyhole
Open
Complications within 30 days
19 percent
31 percent
Hospital stay after surgery
53 hours
96 hours
Clear resection margins
Same
Same
Deaths within 90 days
None
One
Risks and recovery
1
Days one to two
A night in intensive care or a high-dependency bed after major resections, walking the next day.
2
Days three to seven
Eating normally, liver blood tests every day, and discharge between day three and day eight depending on the size of the resection.
3
Weeks two to four
Tiredness as the liver regrows, short walks, no heavy lifting.
4
Six to eight weeks
Normal activity, and the start of any chemotherapy planned after surgery.
Safety over a decade
What drives the risk
Jarnagin and colleagues reviewed 1,803 liver resections at one New York center over ten years. Complications of any grade followed 45 percent of operations, and operative mortality fell from close to 4 percent in the first five years to 1.3 percent in the last two, with no deaths in the final 184 patients, as surgeons removed fewer segments and lost less blood. Bile leaks, bleeding, fluid collections, chest infection and, after large resections, temporary liver failure make up the main risks.
The stay in Istanbul
Plan ten to fourteen days in Istanbul for a keyhole resection and two to three weeks for a major open one. Our surgeon confirms fitness to fly before you leave. Bring a companion, who can sleep in your room. Our coordinators speak English, Arabic, French, Russian, Serbian, Romanian and Spanish, and follow-up after you return home runs through them, with the pathology report, the tumor board plan and scan dates sent to your oncologist. The cost depends on the size of the resection, keyhole or open surgery and any chemotherapy given here, and the estimate after the free review lists each.
The number of hepatic segments resected and operative blood loss were the only predictors of both perioperative morbidity and mortality.
Memorial Sloan-Kettering series of 1,803 resections, Annals of Surgery, 2002
Liver tumor removal FAQ
Can you live with part of your liver removed?
Yes. A healthy liver regrows to near its full volume within two months, and up to two thirds can come out.
Is liver tumor removal a cure for cancer spread from the bowel?
For some patients. In 1,001 patients, 22 percent lived ten years after surgery, and the risk score above helps predict who gains most.
Can liver tumors be removed by keyhole surgery?
Many can. A randomized trial found fewer complications and a shorter stay with the same margins.
How long does liver surgery take?
Two to six hours, depending on the number and position of the tumors.
Do benign liver tumors need surgery?
Rarely. Large adenomas, growing or painful lumps and tumors of unclear nature come out.
References
Fong Y, Fortner J, Sun RL, Brennan MF, Blumgart LH. Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer: analysis of 1001 consecutive cases. Annals of Surgery. 1999;230(3):309-318.
Nordlinger B, Sorbye H, Glimelius B, et al. Perioperative chemotherapy with FOLFOX4 and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC Intergroup trial 40983): a randomised controlled trial. Lancet. 2008;371(9617):1007-1016.
Jarnagin WR, Gonen M, Fong Y, et al. Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Annals of Surgery. 2002;236(4):397-406.
Fretland AA, Dagenborg VJ, Bjornelv GMW, et al. Laparoscopic versus open resection for colorectal liver metastases: the OSLO-COMET randomized controlled trial. Annals of Surgery. 2018;267(2):199-207.
Bruix J, Castells A, Bosch J, et al. Surgical resection of hepatocellular carcinoma in cirrhotic patients: prognostic value of preoperative portal pressure. Gastroenterology. 1996;111(4):1018-1022.
Editor's note
Written by the Biruni Hospital medical editorial team. Reviewed by Prof. Dr. Mustafa Teoman YANMAZ, Medical Oncology.
