Preoperative imaging of liver metastases. Comparison of angiography, CT scan, and ultrasonography

Radiologic Diagnosis of Liver Metastases in Colo-Rectal Carcinoma

To evaluate the accuracy of radiologic methods in liver metastases from colo-rectal carcinoma, a prospective investigation of 71 patients was performed. These patients were examined by angiography, ultrasound (US), computed tomography (CT) and computed tomographic angiography (CTA). The primary aim of the investigation was to determine the accuracy of CTA. The results of these examinations were then compared with the results from inspection and palpation of the liver at laparotomy. An analysis of liver tumor distribution, as well as a lesion-by-lesion analysis, was performed. In 20 patients, tumor growth was found in the liver in 36 lobes/segments at laparotomy. Three patients called false positives (angiography 2, US, CT and CTA 3 patients) turned out to be true positives since the lesions were overlooked at operation. The changes in sensitivity obtained when these patients are considered are given in parentheses. Of the lobes/segments affected by tumor growth at surgery, angiography revealed 47 (48) per cent, US 69 (71) per cent, CT 80 (82) per cent and CTA 83 (84) per cent. At a lesion-by-lesion analysis, angiography showed 33 per cent, US 69 per cent, CT 61 per cent and CTA 76 per cent of the lesions. Because of a larger number of false positives recorded with CTA compared with CT the former examination is not suitable as a single method for evaluating resectability of liver metastases.

Sensitivity of magnetic resonance imaging in the detection of colorectal liver metastases

INTRODUCTION

The aim of this study was to evaluate the sensitivity of magnetic resonance imaging (MRI) in the detection of colorectal liver metastases.

PATIENTS AND METHODS

Pre-operative MRI scanning of the liver was performed by a single radiologist and the size and number of definite liver metastases were recorded. Patients then underwent hepatectomy with routine intra-operative ultrasonography (IOUS) and resected specimens were sent for histopathology. Pathology findings were compared with those of MRI scans to determine the sensitivity of this imaging modality. Exclusions were patients undergoing hepatic resection more than 4 weeks after the MRI scan, those undergoing chemotherapy at the time of the scan, and those with conglomerate unilobar metastases.

RESULTS

Complete data were available for 84 patients. There was total agreement between MRI, IOUS and histology in 79 patients (101 metastases). MRI missed 5 metastases in 5 patients that were found on IOUS (or palpation of superficial lesions) and subsequently confirmed by histological examination. These measured 5 mm or less (4 patients) and 7 mm (one patient). The sensitivity of MRI in the detection of colorectal liver metastases was thus 94% for all lesions and 100% for lesions 1 cm or larger in diameter.

CONCLUSIONS

MRI of the liver is a non-invasive technique with an extremely high degree of sensitivity in the detection of colorectal liver metastases and should be considered as the 'gold standard' in the pre-operative imaging of these patients.

Utility of intraoperative liver ultrasound

Intraoperative ultrasound has become an essential tool for the surgeon in the field of hepatobiliary surgery. No preoperative study has been able to duplicate the sensitivity and specificity of IOUS in the identification of occult lesions. With recent improvements in technology, IOUS has now become an indispensable means of defining the extent of disease and respectability, and providing a guide to anatomic and nonanatomic hepatic resections and minimally invasive and percutaneous ablative techniques.

Resection of liver tumors: technical aspects

The resection of primary and secondary liver tumors has become accepted as the only curative therapy that can be offered to patients with these cancers. Technical advances made over the last two decades have improved the ability of the surgeon to perform these procedures with decreased morbidity. This article reviews hepatic anatomy, the preoperative evaluation of patients and various technical aspects involved in liver resections. The latter includes the role of intraoperative ultrasound and techniques of vascular occlusion and hepatic parenchymal dissection.

Laparoscopic ultrasound for the detection of hepatic metastases during laparoscopic colorectal cancer surgery

PURPOSE

The search for liver metastases before surgery forms an accepted part of colorectal cancer surgical practice. Intraoperative ultrasound and manual palpation of liver together form the criterion standard as far as screening for metastases is concerned. However, extracorporeal imaging, such as ultrasound and magnetic resonance imaging, are also widely used. The purpose of this study was to demonstrate the efficacy of laparoscopic ultrasound scan in detection of liver metastases during laparoscopic colorectal cancer surgery by comparison with conventional imaging modalities.

METHODS

A prospective, controlled study was undertaken. A total of 76 consecutive patients undergoing laparoscopic colorectal resections for malignancy were recruited. Patients underwent preoperative liver ultrasound scan and intraoperative blinded laparoscopic ultrasound scan examination performed by a single surgeon. Contrast-enhanced magnetic resonance imaging was performed within 30 days of surgery.

RESULTS

Conventional ultrasound scan was negative in all cases. Metastases were identified during simple laparoscopic inspection of the liver in one case. Two cases shown by laparoscopic ultrasound scan to have definite metastases were confirmed by magnetic resonance imaging. In seven further instances laparoscopic ultrasound scan identified suspicious liver masses. In three cases these were confirmed to be metastases at magnetic resonance imaging; one was confirmed as a cyst, and the remaining three suspicious lesions were confirmed at serial magnetic resonance imaging scans to be benign and of no significance.

CONCLUSION

Laparoscopic ultrasound scan with a flexible-tipped probe permits satisfactory hepatic examination. It is superior to conventional ultrasound scan and seems to be as effective as magnetic resonance imaging, although the latter modality is still required to delineate identified lesions.

Experience with staging laparoscopy in pancreatic malignancy

BACKGROUND

The role of diagnostic laparoscopy in the staging of abdominal malignancies is not well defined.

METHODS

We retrospectively reviewed the usefulness of diagnostic laparoscopy as a staging procedure in pancreatic malignancy. This experience between February 1988 and May 1997 involves 109 cases of suspected or proven pancreatic malignancy. All laparoscopies were performed with the patient under conscious sedation and local anesthesia in an endoscopy suite.

RESULTS

Of the 109 patients with pancreatic cancer, 45 (42%) had metastatic disease. The use of computed tomography (CT) alone revealed the existence of liver metastases in 10 of 109 (9%) patients, which were confirmed laparoscopically. The further use of laparoscopy identified metastases in 29 more cases: hepatic, 23; hepatic and peritoneal, 3; peritoneal and mesenteric, 1; and mesenteric, 2. CT in conjunction with laparoscopy therefore revealed metastatic liver, peritoneal, or mesenteric lesions in 39 of 109 (36%) patients with pancreatic cancer. After staging laparoscopy, 67 of 69 patients underwent laparotomy. Metastatic disease was identified at laparotomy in 6 more patients; however, only 4 of these patients had metastases to the liver whereas 2 had metastases to the peripancreatic lymph nodes. Therefore, in patients with pancreatic malignancy, the negative predictive value for the diagnosis of metastases to the liver, peritoneum or mesentery was 94% (61 of 65 patients). The positive predictive value of laparoscopy alone for the detection of metastatic disease to the liver, peritoneum, or mesentery was 88% (29 of 33 patients). Laparoscopy was successfully performed without complications in all patients with pancreatic cancer; however, one had a technically unsatisfactory examination. The overall rate of resectability after staging by imaging studies and laparoscopy was 57% (35 of 61 patients).

CONCLUSIONS

In patients with a negative CT for metastases, laparoscopic identification of metastases avoided unnecessary laparotomy in 29 of 99 (29%) patients with pancreatic cancer. Staging laparoscopy is indicated in all cases of pancreatic malignancy before an attempt at a surgical cure.

Primary and metastatic liver cancer

OBJECTIVES

To review liver physiology, the disease process, diagnostic tests, and current treatment options for primary and metastatic liver cancer.

DATA SOURCES

Research studies, review articles, and textbooks relating to liver cancer.

CONCLUSIONS

Surgical resection offers the best available treatment modality, but only a small percentage of patients are eligible. However, combined treatment of radiation therapy and chemotherapy (systemic and intra-arterial), as well as chemoembolization, cryosurgery, and transplantation, offers hope of palliation, conversion of unresectable to resectable disease, and prolonged survival.

IMPLICATIONS FOR NURSING PRACTICE

Understanding and knowledge of the disease process and treatment modalities for primary and metastatic liver cancer will assist the oncology nurse in educating patients and families during their diagnostic and treatment phases.

CT during arterial portography

CT during arterial portography (CTAP) is based on portal enhancement of the liver by infusion of contrast material through the superior mesenteric or splenic artery. This technique provides high degrees of enhancement of the portal vein and intrahepatic vessels, allowing reliable segmental localisation of tumours and accurate assessment of relationships between tumours and intrahepatic vessels. Because of its invasiveness, CTAP must be limited to patients for whom non-invasive preoperative imaging suggests resectable tumour. In the majority of cases, CTAP is performed in patients with hepatic metastases from colorectal cancer, but other types of hepatic tumour (either primary or secondary) and pancreatic tumour may be an indication for CTAP. Visualisation of non-tumorous perfusion defects is a limitation of this technique, but such defects have been well described and have characteristic locations and appearance. In difficult cases, correlation with sonographic, CT and MRI findings helps characterise portal perfusion defects. CTAP is the most sensitive technique for the detection of intrahepatic tumours, and the recent use of spiral technology shows promise in the performance of CTAP. CTAP data can be viewed as multiplanar and three-dimensional reconstructions that allow preoperative planning of the extent of resection and determination of the volume of the remaining liver after resection.

Improved survival after resection of colorectal liver metastases

BACKGROUND

The goal of this study was to determine if staging with intraoperative ultrasound (IOUS), assessment of porta hepatis lymph nodes, and evaluation of resection margins can improve selection of patients likely to benefit from resection of colorectal liver metastases.

METHODS

A retrospective evaluation was performed on patients undergoing celiotomy with intent to resect colorectal liver metastases. Patients were considered unresectable if extrahepatic disease was identified by peritoneal exploration or if IOUS demonstrated greater than four lesions or the inability to achieve negative margins. Tumor-negative margins were confirmed by pathologic evaluation. Actuarial 5-year survival was calculated using the method of Kaplan and Meier.

RESULTS

Median follow-up is 25 months. Of the 151 patients undergoing operative exploration, 107 (71.0%) underwent liver resection (all margins tumor negative). Three operative deaths occurred in this group (2.8%). The disease of 30 patients (19.8%) was considered unresectable due to extrahepatic involvement, and that of 14 patients (9.2%) was demonstrated by IOUS to be unresectable. Five-year actuarial survival was 44% for the resected group and 0% for the unresectable patients (p < 0.0001).

CONCLUSIONS

IOUS, portal node assessment, and pathologic margin evaluation improves the selection of patients likely to benefit from resection of colorectal liver metastases.

Intraoperative ultrasonography in detection of hepatic metastases from colorectal cancer

PURPOSE

This study was designed to compare diagnostic accuracies of measuring liver enzymes, preoperative ultrasonography, surgical examination, and intraoperative ultrasonography for detection of liver metastases from colorectal cancer.

METHODS

Blind, prospective comparisons of diagnostic examinations mentioned above were performed in 295 consecutive patients with colorectal cancer. An experienced ultrasonologist performed the preoperative examinations, and results were unknown to the other experienced ultrasonologist who performed the intraoperative examinations. The latter, also was unaware of the findings by the surgeon. The presence of metastases was further assessed by ultrasonography three months postoperatively, as well as additional surgery and liver biopsy in some of the patients.

RESULTS

The sensitivity of intraoperative ultrasonography (62/64) was significantly superior to that of surgical exploration (54/64) and that of preoperative ultrasonography (45/64). The lowest sensitivity was presented by liver enzymes. Bilobar metastases were detected in 42 of 46 patients by intraoperative ultrasonography but in only 33 patients by the surgeon. Intraoperative ultrasonography demonstrated the highest specificity of all examinations.

CONCLUSIONS

Intraoperative ultrasonography reduces the number of patients with liver metastases from being subjected to superfluous or even harmful liver surgery, and it may increase the number in whom liver surgery will prolong life.

Laparoscopy preferable to imaging procedures in detecting metastases of a pancreas carcinoma to the liver. Report of two cases

In two patients a pancreatic mass, 6 and 4 cm in diameter, respectively, was detected using imaging techniques. Computed tomography, ultrasound, and angiography revealed no evidence of a metastatic lesion in the liver. In the first patient, exploration was done prior to a possible radical operation. Multiple hepatic metastases forming thin, flat lesions on the surface of the liver were present and palliative surgery only was done. In the other patient, laparoscopy was done before surgical exploration and multiple hepatic metastases on the surface of the liver were clearly evident. Laparoscopy can help to avoid unnecessary explorations in patients with large pancreas cancer.

Role of staging laparoscopy in the treatment of hepatic malignancy

Despite current radiologic imaging capabilities, 40% to 70% of patients with primary or metastatic hepatic malignancies are found to have unresectable disease at the time of laparotomy. The present study evaluates the use of laparoscopy in the staging of hepatic malignancy. Twenty-nine patients underwent staging laparoscopy prior to a planned laparotomy for resection of a hepatic malignancy that was deemed resectable by computed axial tomographic scan and ultrasonography. Twelve patients had primary hepatic malignancies, and 17 had metastatic malignancies. Laparoscopy demonstrated evidence of unresectability in 48% (14 of 29) of patients studied. Four patients had unsuspected cirrhosis, and 10 had unresectable or extrahepatic metastatic disease. Patients who underwent laparoscopy alone had shorter mean hospital lengths of stay than historical controls who underwent laparotomy alone. We conclude that diagnostic laparoscopy should precede laparotomy for planned resection of hepatic malignancies.

Intra-operative ultrasound for the detection of hepatic metastases from colorectal cancer

The aim of this study was to compare the accuracy of intra-operative ultrasound (IOUS) with other imaging modalities and with surgical palpation in detecting liver metastases from colorectal cancer (CRC). Intra-operative ultrasound was performed in 100 patients undergoing surgery for CRC. All patients had pre-operative liver function tests, transcutaneous ultrasound and computerized tomography (CT) scan of the liver. The liver was palpated intra-operatively by a surgeon who was unaware of the pre-operative findings. The liver was then assessed by IOUS. Intra-operative ultrasound detected more patients with metastases than either CT scan, transcutaneous ultrasound or surgical palpation. It also detected a greater number of smaller metastases in these patients and allowed better anatomical definition compared with pre-operative investigations.

Comparisons of dynamic infusion and delayed computed tomography, intraoperative ultrasound, and palpation in the diagnosis of liver metastases

The purpose of this study was to determine whether delayed computed tomography (DCT) of the liver would more accurately detect hepatic malignancy when compared with bolus contrast-enhanced dynamic computed tomography (BCDCT). Fifty-one patients who required operation for intra-abdominal malignancy (92% with colorectal cancers) underwent preoperative BCDCT followed by DCT. At operation, palpation and intraoperative ultrasound (IOUS) examination of the liver were performed for localization and biopsy of tumor nodules. The standard for diagnosis was defined for this study as the combined results of IOUS, palpation, and biopsy. The sensitivities of BCDCT and DCT for hepatic metastases were 50% and 54%, respectively, with a corresponding specificity of 72% for each. DCT demonstrated no significant improvement over BCDCT in the detection of individual hepatic lesions. The sensitivity of palpation for the detection of metastases was 82%, equal to that of IOUS. Both palpation and IOUS were significantly superior to BCDCT or DCT in excluding false-positive and false-negative results (p < 0.001). IOUS failed to identify surface lesions less than 1.0 cm in diameter (sensitivity: 40%). Conversely, palpation was limited in the detection of subsurface tumors less than 1.0 cm in diameter (sensitivity: 33%). Combined IOUS and palpation were significantly more accurate in the detection of hepatic metastases than any single modality that was evaluated (p < 0.001).

Colorectal cancer. Principles of postoperative follow-up

Monitoring patients after primary large bowel surgery for malignancy is predicated on the concept that early detection of recurrence may provide salvage treatment for cure. Knowledge of the pathologic site and stage provides important information as to the probability of recurrence and the patterns of failure that are likely to occur. Available methods to detect recurrence include clinical, roentgenographic, and serum tests that are done more frequently during the first 2 years after surgery. Monitoring plasma carcinoembryonic antigen levels can lead to identification of asymptomatic recurrences, but there is controversy about the curability of recurrences outside the liver. Newer techniques (such as computed tomographic portography, intraoperative ultrasonography, and radioimmunoguided surgery) provide greater diagnostic accuracy and lead to more appropriate procedures during "second-look" operations. For example, hepatic resection in properly selected patients offers up to a 30% chance of cure and should be pursued aggressively. A search for metachronous cancers by endoscopy also should be done. Knowledge of the potential and patterns of failure can provide a useful guide during the postoperative follow-up care of the patient with large bowel cancer.

Diagnosis of liver metastases from malignant gastrointestinal neoplasms: results of pre- and intraoperative ultrasound examinations

In this prospective study, 108 patients presenting with gastrointestinal cancer were examined for liver metastasis before and during surgery. The investigations emphasized a comparison of pre- and intraoperative ultrasound (US) examinations. The results of intraoperative liver inspection and palpation served as control parameters. In addition, an exact description and characterization of the liver metastases was attempted. Liver metastases were found in 30 of the 108 patients (28%). They could be identified in 17 subjects by preoperative US (57% sensitivity), in 21 patients by intraoperative palpation and inspection (70% sensitivity), and in 27 cases by intraoperative US (90% sensitivity). We concluded that 7%-34% of patients with liver metastases can be identified with 95% reliability using intraoperative US alone or in combination with palpation and inspection.

Initial staging of non-small cell lung cancer: value of routine radioisotope bone scanning

The exclusion of bone metastases is important in the initial staging of non-small cell lung cancer, though there is debate about whether bone scans should be performed routinely or restricted to patients who present with clinical or laboratory indicators suggesting skeletal metastases. In a prospective study of 110 consecutive patients referred for initial staging of non-small cell lung cancer, we assessed the sensitivity of a group of clinical indicators (chest pain, skeletal pain, bone tenderness on physical examination, serum alkaline phosphatase, and serum calcium) for the presence of skeletal metastases as determined by bone scanning. The final staging result was validated with follow up data over at least three years. At the initial staging 37 of 110 bone scans (34%) showed areas of increased uptake, of which only nine were confirmed to be metastases (by tomography, computed tomography, or biopsy). Half the patients (55) had at least one clinical indicator suggesting skeletal metastases, including all patients with proved skeletal metastases. Thus the sensitivity of these clinical indicators was 100% and the specificity 54%. Within one year three of 27 patients with non-confirmed positive bone scans had skeletal metastases, one of which was in the area that had shown increased uptake initially. All these patients had clinical indicators for skeletal metastases and all had inoperable advanced tumours. Four of 69 patients with an initially negative bone scan developed skeletal metastases within one year. It is concluded that in non-small cell lung cancer bone scanning can be restricted to patients with clinical indicators for skeletal metastases. This approach reduces the number of bone scans and consecutive investigations without loss of sensitivity in the detection of skeletal metastases.

Accuracy of intraoperative ultrasonography in diagnosing liver metastasis from colorectal cancer: evaluation with postoperative follow-up results

The accuracy of intraoperative ultrasonography in diagnosing liver metastasis was evaluated at the time of surgery and at follow-up in 189 patients with colorectal cancers. Evaluation at the time of operation revealed that the sensitivity of intraoperative ultrasonography (93.3%) was significantly (p less than 0.0001) higher than that of preoperative ultrasonography (41.3%), conventional computed tomography (47.1%), and surgical exploration (66.3%). Twenty-two of 104 metastatic liver tumors were detected solely by intraoperative ultrasonography in 18 patients (9.5% of total patients). These 22 tumors were small in size (4 x 4 mm to 15 x 18 mm) and nonpalpable during operation. During the postoperative follow-up period of 18 months or more (mean 35.6 months, median 37.1 months) after colorectal surgery, liver metastases that were unrecognized during surgery appeared in 13 (6.9%) patients. Re-evaluation based on these follow-up results indicated that the sensitivity of intraoperative ultrasonography decreased to 82.3%, which was still significantly (p less than 0.0005) better than that of other methods. Intraoperative ultrasonography was capable of identifying 18 of 31 (58.1%) patients in whom liver metastases were otherwise unrecognized at the time of operation. Intraoperative ultrasonography is more accurate in diagnosing liver metastasis than traditional screening methods, and may have a beneficial impact on the management of colorectal cancer.

Detection by CT during arterial portography of colorectal cancer metastases to liver

A prospective evaluation of the accuracy of real-time ultrasonography (US), computed tomography (CT), infusion hepatic angiography (IHA), and computed tomography during arterial portography (CT-AP) was performed on 65 resected liver metastases of colorectal cancers. The total detection rate was 58.5 percent for US, 56.3 percent for CT, 55.4 percent for IHA, and 86.2 percent for CT-AP. The sensitivity of 29 lesions with diameters of smaller than 1 cm was 65.5 percent for CT-AP, CT found only two, and both US and IHA localized no more than three. The smallest lesions detectable by CT-AP were as small as 0.4 cm in diameter. CT-AP proved most useful in detecting the liver metastases, and the use of this technique is recommended for preoperative planning of hepatectomy on patients with liver metastases.

Detection of colorectal liver metastases using intraoperative ultrasonography

Intraoperative ultrasonography of the liver has been carried out in 99 patients undergoing surgery for colorectal cancer. Palpation of the liver, preoperative abdominal ultrasonography and computed tomography scanning were also performed in all patients. Metastases were identified in 26 of the 99 patients (26 per cent). Intraoperative ultrasonography diagnosed more metastases than palpation, abdominal ultrasonography or CT scanning, identifying metastases in 24 of the 26 patients, including six patients in whom the metastases were not detected by any other technique. Identification and localization of impalpable liver metastases is therefore possible using intraoperative ultrasonography.

Preoperative assessment of malignant hepatic tumors

Over a 31-month period, 100 patients with malignant hepatic tumors were preoperatively evaluated with three imaging techniques. The results of intravenously enhanced computed tomography (CT) scan, selective hepatic arterial contrast CT, and magnetic resonance imaging (MRI) were compared with operative findings. A total of 227 lesions were identified, with the sensitivity for tumor detection being arteriographically enhanced CT 94% (p less than 0.01), MRI 70%, and CT 66%. This advantage for arteriographically enhanced CT was most marked for lesions less than 1 cm in diameter (82% versus 20% for MRI and 5% for CT; p less than 0.01). Arteriographically enhanced CT was also most sensitive in assessing tumor margins. MRI was clearly superior to arteriographically enhanced CT or CT in detecting vascular involvement (85% versus 30% and 8%, respectively; p less than 0.01). No imaging technique was sensitive in determining extrahepatic involvement. Arteriographically enhanced CT was also best at predicting the operative procedure. The combination of arteriographically enhanced CT and MRI was the best predictor of true disease. We conclude that both arteriographically enhanced CT and MRI should be used for preoperative assessment of hepatic malignancies.

Prospective comparison of preoperative imaging and intraoperative ultrasonography in the detection of liver tumors

A prospective evaluation of the accuracy of preoperative computed tomography (CT), ultrasonography (US), and angiography was performed in 54 patients undergoing resection of hepatic neoplasms. The results were compared with surgical findings and intraoperative ultrasonography (IOUS). A total of 167 lesions was seen by means of IOUS, of which preoperative US enabled detection of 127 (76%). In 48 patients CT allowed detection of 91 of 150 lesions (61%), and in 35 patients angiography showed 56 of 107 lesions (52%). When the detection rate is analyzed according to hepatic segment, the greater overall accuracy of preoperative US may be attributed to a markedly better detection rate in lateral segment of the left lobe of the liver. Lesion size also represented a factor, with preoperative US allowing detection of a greater number of small (less than 2 cm) lesions compared with CT. In patients studied with both CT and US, the combined lesion-detection rate increased to 81% in the right lobe and 76% in the left lobe. Because of this we recommend that preoperative assessment include both CT and US evaluation of the liver. IOUS showed 25% to 35% additional lesions compared with preoperative US and CT. More importantly, 40% of the lesions demonstrated by IOUS were neither visible nor palpable at surgery. We recommend that IOUS be considered in all patients in whom resection of hepatic neoplasm is planned.

Liver function tests in patients with computed tomography demonstrated hepatic metastases

One hundred patients with computed tomographic (CT) evidence of liver metastases (and confirmation by biopsy or progression of disease) had serum levels of alkaline phosphatase, serum glutamic oxaloacetic transaminase, and serum glutamic pyruvic transaminase measured within two weeks of scanning. All three enzymes were within the normal range in 33% of patients. Even with advanced involvement (defined as three or more metastatic lesions over 3 cm in diameter), 20% of patients had normal levels of all three liver enzymes. Although liver function tests (LFTs) (enzyme levels) are inexpensive and simple to perform, they failed to detect a significant number of patients with liver metastases.

Central bisegmentectomy of the liver: experience in 16 patients

Fourteen patients with hepatocellular carcinoma and mild to moderate liver dysfunction and 2 with metachronous liver metastases from rectal cancers underwent central bisegmentectomy of the liver, i.e., en bloc removal of the left medial and right anterior segments. One patient who had undergone preoperative liver artery embolization died in the hospital. Four patients survived without relapse 60-135 months postoperatively. Eleven patients had recurrent tumors, all in the liver remnant, and 2 also had recurrent tumors in the lungs. Six patients who relapsed died 28-93 months postoperatively. Four were alive with disease at 7-89 months, 1 after a second liver resection 54 months after central bisegmentectomy. Six of the 16 patients survived for 5 years or more. The results are favorable for these advanced tumors, often in the presence of liver dysfunction. The indications, technique, and results are discussed.

Operative ultrasound establishes resectability of metastases by major hepatic resection

In this study, the utility of intraoperative ultrasound in the surgical management of hepatic colorectal metastases requiring hepatic resection has been demonstrated. The intraoperative ultrasound technique has been described as a method to accurately monitor curative resection of large colorectal metastases requiring anatomical procedures such as right hepatic trisegmentectomy, bisegmentectomy, and hepatic lobectomy. Preoperative analysis of the patients reported utilizing either computed tomography, ultrasound, or magnetic resonance imaging demonstrated very well the extent of tumor but could not define a major anatomical resection along normal tissue planes. In the 3 patients demonstrated, intraoperative ultrasound was able to confirm a normal hepatic parenchymal dissection overlying the extensive tumors and enabled completion of the curative resections. Furthermore, we have described the intraoperative ultrasound criteria for assessment of resectability. These included a definition of the proximity of the major portal and hepatic venous structures, exclusion of simultaneous minimal metastatic disease in the remaining parenchyma, and the distinction between marginal resectability and resectability for cure along the proposed parenchymal dissection plane. We conclude that intraoperative ultrasound is important in the surgical management of metastatic colorectal cancer and can provide for a more complete clinical staging and appropriate selection of patients for curative major hepatic resection.

Liver resection. Preoperative and postoperative care

Liver resection is an increasingly common procedure. Despite a wide variety of indications, the preoperative and postoperative care required is similar. Experience with liver resection and transplantation has brought to light the significant alterations in fluid and electrolytes, hemostasis, metabolism, and pulmonary function that may result. A thorough understanding of these changes is required to minimize the morbidity and mortality rates of these procedures. Postoperative hepatic failure is a devastating complication, and careful patient selection is required to avoid this. More work is needed to identify better methods of evaluating functional hepatic reserve.

Computed tomography of the brain, chest, and abdomen in the preoperative assessment of non-small cell lung cancer

The benefit to be gained from carrying out computed tomography of brain and abdomen in addition to the chest has been evaluated retrospectively in 114 consecutive patients with non-small cell lung cancer who, on the basis of history, clinical examination, chest radiography, and bronchoscopy had been considered potentially operable. Computed tomography of the chest showed potentially inoperable tumour in 37 patients, of whom 25 had tumour confined to the chest. Three patients were shown to have malignant disease within the mediastinum and abdomen; five within the mediastinum and brain; and four within the mediastinum, abdomen, and brain. Computed tomography of the abdomen disclosed deposits in nine patients, but in only two were the abnormalities restricted to the abdomen. Computed tomography of the brain showed metastases in 10 patients, of whom only one had metastatic disease confined to the brain. Thus three patients had isolated deposits in the abdomen and brain. In 12 patients the identification of metastases in the abdomen and brain removed the need for mediastinoscopy. Preoperative computed tomography of the abdomen and brain detected occult metastases in 15 patients (13%) in this study. In three patients the extrathoracic abnormality proved the only contraindication to surgery, but in the other 12 it provided valuable corroborative evidence of incurability and facilitated the assessment of the mediastinal abnormality.

Hepatic ultrasonography in the terminally ill patient

In 53 patients comparison was made between findings at autopsy and findings at ultrasound (US) examination performed shortly before death as the only morphologic diagnostic procedure of the liver during the patient's last year. US was found to be highly accurate. The non-invasiveness and the possibility of examining the patient in bed make US examination in experienced hands the ideal initial diagnostic procedure, especially in terminally ill patients.

Malignant tumors of the liver

HCC occurs infrequently in Western countries, with recent increases being reported in California and parts of Europe. Southeast Asia, Japan, and South Africa continue to have a high incidence of this tumor with HBV, cirrhosis, and the ingestion of aflatoxins being identified as probable risk factors. Although the majority of patients present with abdominal pain or mass indicative of extensive tumor, asymptomatic, small HCCs are being detected with increasing frequency. Early detection in high-risk individuals is best accomplished by screening with serum AFP determinations and liver ultrasonography. CT and arteriography are valuable preoperatively in defining anatomy and determining resectability. Five-year survival following resection for cure of HCC ranges from 20 to 40 per cent, with improved survival reported for small asymptomatic tumors. Resection of metastatic liver tumors from colorectal primaries results in 48 per cent 2-year and 24 per cent 5-year survivals, with an additional 5 per cent dying of recurrent cancer after 5 years. Although patients with simultaneous and metachronous metastases do equally well after resection, the presence of four or more individual deposits adversely affects survival. Hepatic artery ligation or embolization can produce a significant palliative reduction in total tumor mass in patients with unresectable liver metastases. Regional chemotherapy using implantable hepatic artery drug infusion pumps is promising, with reports of prolonged survival compared with historical controls. Regional hyperthermia, laser vaporization of tumor, and cryosurgical techniques may prove to have useful roles in the selective treatment of liver cancer in the future. Orthotopic liver transplantation has been successful primarily in those in whom the malignancy is found incidentally in the chronically diseased liver.