Liver Tumor Surgery

CAMILOT DaVinci surgery

Surgery is the most time-tested, gold standard therapy that provides long-term survival or cure in select patients with hepatobiliary malignancies. The surgeons of CAMILOT have been pioneers in applying state-of-the-art minimally invasive approaches developed for hepatobiliary surgery, and were the first in the Northwest to offer the minimally invasive treatments of thermal tumor ablation, irreversible electroporation, and robotic hepatectomy for liver and bile duct cancers. CAMILOT surgeons continue to be the highest volume providers in the Northwest of these techniques, and as such have outcome data ranked significantly higher than the national average. Each patient seen in the Liver Tumor Clinic will be evaluated for a minimally invasive treatment by one of the surgeons, or other CAMILOT team provider.

Meet our Team

Surgery

Raymond S.W. Yeung, M.D.
James O. Park, M.D.

Robotic/Laparoscopic Hepatectomy – Liver resection or hepatectomy is an operation to remove part of the liver or bile duct where the tumor is located, with an additional rim or margin of tissue with the goal of leaving no cancer cells behind. Depending on the location of the tumors and their relationship to the surrounding vasculature, a minimally invasive approach may be an option. These procedures are performed through small abdominal incisions, and have been demonstrated to result in less blood loss, less pain concomitant with decreased narcotic use, and a shorter hospitalization and recovery time. Robotic hepatectomy differs from laparoscopic surgery in that it uses a robotic platform to assist with the procedure, allowing the surgeon increased dexterity and stereotactic visualization.

Laparoscopic/Thoracoscopic Thermal Ablation – Radiofrequency ablation (RFA) and microwave ablation (MWA) are techniques that use electrical currents or electromagnetic waves, respectively, to create heat around the tumor to destroy the cancer cells. These dead tumor cells are slowly replaced with scar tissue that shrinks over time. The CAMILOT liver surgeons perform RFA or MWA using a scope inserted through small abdominal (laparoscopic) or chest (thoracoscopic) incisions to locate the liver cancer and ablate it under ultrasound guidance. RFA and MWA is applied when hepatectomy is not an option, and our CAMILOT surgeons perform the RFA/MWA when the interventional radiologists cannot provide a percutaneous approach due to the tumor’s proximity to vital organs, e.g. the heart.

Irreversible Electroporation (NanoKnife) – NanoKnife is a novel ablative technique similar to RFA in that it uses electrical currents to treat the liver cancer cells, however, it differs from RFA in that NanoKnife does not use heat. The strong, ultra-short electrical currents generated by NanoKnife punch minute pores in the cell membranes of the cancer cells to destroy them. The electrical currents are able to do so without harming the surrounding vasculature or bile ducts because these tissues can repair these small pores whereas the cancer cells cannot. As such, NanoKnife provides a treatment option for patients with tumors close to large blood vessels that create a heat sink, leading to an inadequate ablation. CAMILOT surgeons perform NanoKnife in a minimally invasive fashion, passing the electrical probes through small incisions in the abdomen or chest.

Minimally invasive robotic liver surgery with a da Vinci Surgical System at UW Medical Center.

​​Minimally Invasive Hepatectomy

As a high volume center for liver resection, the surgeons at University of Washington Medical Center (UWMC) offer robotic and laparoscopic approaches to a large number of patients. The main advantage of minimally invasive surgery is to hasten recovery and to lessen patients' discomfort. Patients often experience less pain, less bleeding at the time of surgery, reduced length of stay in the hospital, and faster resumption of daily activities.

Enhanced Recovery After Surgery (ERAS) Pathway

To improve patient care and comfort following liver surgery, we developed standard guidelines following established ERAS principles of minimizing intravenous fluids and narcotic use, along with early mobilization free from tubes and catheters. Whereas epidural catheters are used routinely for major liver surgeries at most high-volume centers, we have adopted a much more effective and efficient method of pain control using a long-acting local anesthetic injected into the transverse abdominis plane (TAP) as a temporary nerve block. Since the implementation of our ERAS pathway, our average hospital length of stay (LOS) following open liver resection has dropped to 3-5 days, which is substantially shorter than the national average of 7-9 days. All patients are followed closely after discharge to ensure a smooth transition to recovery at home. 2 (Figure 1 – NSQIP)

Thorascopic Liver Ablation

Ablation aims to destroy tissues such as cancer without the need to remove them. This approach has been reserved for tumors that cannot be resected safely via surgery. The UWMC team has offered liver tumor ablation for almost 20 years and delivers one of the highest volume centers on the West Coast. In certain situations where tumors are located next to the lung in a location difficult to access, we offer a thoracoscopic approach to reach the tumors using small openings through the chest. This provides an alternative for the hard-to-reach lesions.

Functional Assessment of Liver Reserve

Liver failure after surgery is one of the most feared complications following liver resection, especially in patients with underlying chronic liver diseases. Ways of predicting how well the liver will function remain very much an art rather than a science. We are currently exploring a new method to map out the health of the liver by repurposing a form of liver imaging that gives us regional information regarding which part of the liver functions well or poorly.2 Armed with this knowledge, we can be more accurate in determining the risk of liver failure following liver resection.

References

  1. Sham JG, Richards MK, Seo YD, Pillarisetty VG, Yeung RS, Park JO. Efficacy and cost of robotic hepatectomy: is the robot cost-prohibitive? Journal of robotic surgery. 2016. doi: 10.1007/s11701-016-0598-4. PubMed PMID: 27153838.
  2. Bowen SR, Chapman TR, Borgman J, Miyaoka RS, Kinahan PE, Liou IW, et al. Measuring total liver function on sulfur colloid SPECT/CT for improved risk stratification and outcome prediction of hepatocellular carcinoma patients. EJNMMI research. 2016;6(1):57. doi: 10.1186/s13550-016-0212-9. PubMed PMID: 27349530; PubMed Central PMCID: PMC4923007.
  3. Sham JG, Kievit FM, Grierson JR, Miyaoka RS, Yeh MM, Zhang M, et al. Glypican-3-targeted 89Zr PET imaging of hepatocellular carcinoma.​ J Nucl Med. 2014;55(5):799-804. doi: 10.2967/j​numed.113.132118. PubMed PMID: 24627434; PubMed Central PMCID: PMC4116087.
  4. Sham JG, Kievit FM, Grierson JR, Chiarelli PA, Miyaoka RS, Zhang M, et al. Glypican-3-targeting F(ab')2 for 89Zr PET of hepatocellular carcinoma.​ J Nucl Med. 2014;55(12):2032-7. doi: 10.2967/jnumed.114.145102. PubMed PMID: 25359880; PubMed Central PMCID: PMC4259878.
  5. Christofides D, Leen E, Averkiou M. Automatic respiratory gating for contrast ultrasound evaluation of liver lesions. IEEE transactions on ultrasonics, ferroelectrics, and frequency control.​ 2014;61(1):25-32. doi: 10.1109/TUFFC.2014.6689773. PubMed PMID: 24402893.
  6. Riggle KM, Riehle KJ, Kenerson HL, Turnham R, Homma MK, Kazami M, et al. Enhanced cAMP-stimulated protein kinase A activity in human fibrolamellar hepatocellular carcinoma. Pediatr Res. 2016;80(1):110-8. doi: 10.1038/pr.2016.36. PubMed PMID: 27027723.
  7. Riggle KM, Turnham R, Scott JD, Yeung RS, Riehle KJ. Fibrolamellar Hepatocellular Carcinoma: Mechanistic Distinction From Adult Hepatocellular Carcinoma. Pediatric blood & cancer. 2016;63(7):1163-7. doi: 10.1002/pbc.25970. PubMed PMID: 26990031; PubMed Central PMCID: PMC4877189.
CAMILOT DaVinci surgery - research

Our Northwest Liver Research Program provides cutting-edge technology and science to address the most pressing needs of our patients with liver cancer. Here are some examples of our ‘Team Science’:

  1. Precision Oncology

    The notion that a physician can tailor drugs that are most effective for a specific cancer is becoming a reality. In an age where many cancer therapies have high toxicity profiles and are extraordinarily expensive, it makes sense to individualize treatment to maximize benefit and minimize side effects. The current strategy of delivering 'personalized' oncologic treatment options is largely based on the detection of a handful of 'actionable' genomic (DNA) alterations found in the patient’s tumors. Due to the complexity of human cancers, an isolated finding of a mutation does not always translate to a 'cause-and-effect' relationship. In fact, many gene variations found in cancers have no or unknown consequence. The lack of a functional assay to address the biologic significance of a mutation found on sequencing represents a critical gap in clinical oncology.

    Surgeons and basic scientists at UWMC have developed a new platform to evaluate the response of a patient’s cancer to various drugs. To do this, we place small pieces of the actual patient’s tumor in a special culture system and expose them to drugs that are relevant to the case and determine their response. Our system differs from most others because it takes the whole tumor into consideration and not just certain cancer cells. Other advantages include an efficient turnaround time and its relative low cost. Ongoing trials are addressing the clinical utility of our platform in delivering accurate information to guide treatments.

  2. Advances in detection and treatment of hepatocellular carcinoma

    1. Antibody-mediated radionuclide

      Early detection of liver cancer increases the likelihood of treatment success and long-term outcome. Current imaging technology utilizes recognition of contrast-enhancement patterns, which are limited by the size of the tumor. Even the most advanced, high-quality, multiphase computed tomography (CT) or magnetic resonance (MR) imaging can only detect tumors within the liver when the tumor is approximately one centimeter in size, which translates to approximately billions of cancer cells. Investigators at UWMC have developed a novel strategy to detect much smaller liver cancers using an antibody-based positron emission tomography (immunoPET) scan that can recognize a protein expressed on the cancer cell surface, not expressed on normal liver cells. When conjugated to a radionuclide, it gives highly specific signals even in minute tumors 3, 4. Furthermore, this approach can be modified to deliver strong radiation particles as a non-invasive form of therapy.

      Thumbnail from a rotating PET image of mouse with a liver tumor 'lit up'

      A PET image of mouse with a liver tumor "lit up" using this innovative technology. The radioactive antibody creates colorful PET images, forming a "hot spot" where tumors are located.

    2. Contrast ultrasound

      Ultrasound is the only imaging modality that provides real-time monitoring, and when combined with a contrast agent (e.g. microbubbles), it gives unprecedented appreciation of tumor blood flow dynamics. We can exploit the added imaging details to better inform us of the nature or behavior of the tumor, e.g. aggressive versus indolent. Further, ultrasound energy can be used to facilitate drug delivery within the tumor. These and other innovations are being studied by a team of bioengineers and clinicians at UWMC​5.

    3. Fibrolamellar Hepatocellular Carcinoma

      Some liver cancers affect young healthy children and young adults in their prime. As such, they often present late with only vague symptoms, and their prognosis is poor. One such cancer is that of fibrolamellar hepatocellular carcinoma, which until now has had no effective systemic treatment. Recent scientific discoveries have uncovered the underlying genetic mutation, thus bringing us new insights to its cause and fresh ideas for a remedy.

      With a dedicated team of clinicians and scientists at Children’s, UW Medicine and Seattle Cancer Care Alliance, we have engaged in a multi-prong investigation to find a cure through studying the basic biochemistry and biology of the disease 6, 7.

References

  1. Sham JG, Richards MK, Seo YD, Pillarisetty VG, Yeung RS, Park JO. Efficacy and cost of robotic hepatectomy: is the robot cost-prohibitive? Journal of robotic surgery. 2016. doi: 10.1007/s11701-016-0598-4. PubMed PMID: 27153838.
  2. Bowen SR, Chapman TR, Borgman J, Miyaoka RS, Kinahan PE, Liou IW, et al. Measuring total liver function on sulfur colloid SPECT/CT for improved risk stratification and outcome prediction of hepatocellular carcinoma patients. EJNMMI research. 2016;6(1):57. doi: 10.1186/s13550-016-0212-9. PubMed PMID: 27349530; PubMed Central PMCID: PMC4923007.
  3. Sham JG, Kievit FM, Grierson JR, Miyaoka RS, Yeh MM, Zhang M, et al. Glypican-3-targeted 89Zr PET imaging of hepatocellular carcinoma. J Nucl Med. 2014;55(5):799-804. doi: 10.2967/jnumed.113.132118. PubMed PMID: 24627434; PubMed Central PMCID: PMC4116087.
  4. Sham JG, Kievit FM, Grierson JR, Chiarelli PA, Miyaoka RS, Zhang M, et al. Glypican-3-targeting F(ab')2 for 89Zr PET of hepatocellular carcinoma.​ J Nucl Med. 2014;55(12):2032-7. doi: 10.2967/jnumed.114.145102. PubMed PMID: 25359880; PubMed Central PMCID: PMC4259878.
  5. Christofides D, Leen E, Averkiou M. Automatic respiratory gating for contrast ultrasound evaluation of liver lesions. IEEE transactions on ultrasonics, ferroelectrics, and frequency control. 2014;61(1):25-32. doi: 10.1109/TUFFC.2014.6689773. PubMed PMID: 24402893.
  6. Riggle KM, Riehle KJ, Kenerson HL, Turnham R, Homma MK, Kazami M, et al. Enhanced cAMP-stimulated protein kinase A activity in human fibrolamellar hepatocellular carcinoma. Pediatr Res. 2016;80(1):110-8. doi: 10.1038/pr.2016.36. PubMed PMID: 27027723.
  7. Riggle KM, Turnham R, Scott JD, Yeung RS, Riehle KJ. Fibrolamellar Hepatocellular Carcinoma: Mechanistic Distinction From Adult Hepatocellular Carcinoma. Pediatric blood & cancer. 2016;63(7):1163-7. doi: 10.1002/pbc.25970. PubMed PMID: 26990031; PubMed Central PMCID: PMC4877189.​​​​​​​​