Hepatic Tumor, Metastatic

• • Most common tumors of liver

  • 90% with extrahepatic metastases

  • 20% of patients with metastatic colon cancer have metastasis isolated to liver

  • Common site of metastasis for multiple tumor types; most common candidates for resection include colon, endocrine, melanoma, breast, sarcoma, lung, renal, and other GI tumors

Symptoms and Signs

• • Weight loss

  • Fatigue

  • Fevers

  • Right upper quadrant pain

  • Ascites

  • Jaundice

  • Hepatomegaly

  • Portal hypertension

Laboratory Findings

• • Anemia

  • Hyperbilirubinemia

  • Elevated alkaline phosphatase

Imaging Findings

• • Masses in liver sometimes better visualized with CT by portography or use of MRI

• • Site of primary tumor

  • Time since resection of primary tumor

Rule Out

• • Extrahepatic disease before consideration of resection

• • History and physical exam

  • Liver function tests

  • CBC

  • CT with portography

  • MRI if CT is nondiagnostic

  • Mesenteric angiogram if considering hepatic artery pump for metastatic colon cancer

  • Bone scan if markedly elevated alkaline phosphatase

  • Carcinoembryonic antigen (CEA), CA 125, CA 19-9, and alpha-fetoprotein (AFP) which aid in distinguishing primary from metastatic tumors

  • Intraoperative US if resection is planned

Surgery

• • Resection

  • Hepatic artery chemotherapy pump (for metastatic colon cancer only)

  • Radiofrequency ablation (RFA) or cryotherapy for unresectable lesions

Indications

• • No extrahepatic disease

  • Disease-free interval of 1 year or more for primary tumors, such as gastric and breast

  • Colon cancer metastasis not amenable to resection and no extrahepatic disease (hepatic artery chemotherapy pump)

  • Most common resectable tumors:

  • -Colon

    -Neuroendocrine

    -Melanoma

    -Breast

    -Sarcoma

    -Lung

    -Prostate

    -Renal

    -Other GI tumors (rarely)

Contraindications

• • Extrahepatic disease

  • Minimal planned residual liver function

  • Multiple bilobar metastasis

  • Metastasis involving bilateral portal branches

Medications

• • 5-fluorouracil for colon cancer

  • Other chemotherapy for specific tumor types

Treatment Monitoring

• • CEA levels for colon cancer

  • CT scanning

  • Hormonal markers, eg, gastrin for metastatic endocrine tumors

Complications

• • Liver failure

  • Hemorrhage

  • Recurrent disease

  • Biliary leak

  • Gastroduodenitis (hepatic artery pump)

  • Hepatic artery or pump thrombosis (hepatic artery pump)

  • Sclerosing cholangitis (hepatic artery pump)

  • Perihepatic abscess

Prognosis

• • Colon cancer: 25% 5-year survival with resection

  • Other metastatic disease: 10-20% 5-year survival possible

  • Marked palliation for metastatic endocrine tumors

  • Hepatic artery chemotherapy (colon) increases 2-year survival when compared with systemic therapy

References