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Hepatobiliary Carcinoma and Pancreatic Surgery
Our Extraordinary Program…
Hepatobiliary and pancreatic surgery has been a part of the Transplantation Center since its inception and is under the leadership of Jean Botha, MD. Liver cancers are some of the most common cancers worldwide and along with biliary and pancreatic cancers are amongst the most challenging to treat.
Nowhere in the Midwest will you find a more experienced team of physicians and health care professionals dedicated to treating these cancers than at The Nebraska Medical Center. Our ground-breaking surgeries and innovative treatment options provide early staging and the most positive outcomes for patients with both primary and metastatic cancers. The use of laparoscopic surgery offers patients a less-invasive approach for many of these operations and our world renowned liver transplant team is available for patients who are candidates for transplantation.
Our Patient Care…
Our program draws on the expertise of an array of experts so that each case can be treated individually and with a customized treatment plan to achieve optimal outcomes for each patient. A multi-disciplinary patient centered plan is developed for each patient involving surgeons, hepatologists, radiologists, oncologists, and pathologists. Patients, families and primary physicians are all viewed as partners in care. Our team provides continued communication and support throughout the entire treatment process.
Diagnosis
Liver cancer develops when some cells begin to grow abnormally. While it's not clear why this occurs, it is believed that cancer occurs when there has been damage to the DNA, which is the substance that stores the instructions for every chemical process in your body, including the rate of cellular growth. When damage occurs to your DNA, cells may grow out of control and eventually form a tumor.
Damage to DNA in the liver cells can be caused by Cirrhosis, or excessive use of alcohol, Hepatitis B and C, or inflammation of the bile ducts. Long-term exposure to aflatoxins found in corn products, peanut products, cottonseed, milk, Brazil nuts, pecans, pistachios and walnuts can also cause cancer in the liver. Exposure to vinyl chloride, the chemical used to manufacture plastic or arsenic can also damage the DNA in liver cells. Ulcerative colitis is an inflammatory condition of the colon and digestive tract which can cause changes within the bile ducts and increase the risk of cholangiocarcinoma, a type of primary liver cancer.
Types of Liver Cancers
Primary Liver Cancer
Primary liver cancer is one of the most common cancers worldwide and is among the most challenging cancers to treat. While many cancers are declining in the United States, new cases of primary liver cancer are on the rise and are expected to continue to increase over the next two decades. Primary liver cancer starts in the hepatocytes, the main liver cells and often spreads as a single tumor that slowly infects the rest of the liver or as a cancer that quickly spreads throughout the entire organ. There are several types of primary liver cancer.
Hepatocellular carcinoma (HCC)
This is the most common type of primary liver cancer among children and adults. This type begins in the hepatocytes, the main type of liver cell, but can spread in different ways. Some liver cancers begin as a single tumor that slowly spreads throughout the rest of the liver. Other tumors are more aggressive and immediately begin spreading throughout the entire organ. The primary causes of HCC include hepatitis B or C infection, cirrhosis, and ingestion of aflatoxin-contaminated food.
Cholangiocarcinoma
This form of primary liver cancer starts in the small bile ducts within the liver. Individuals at increased risk for developing this type include those with gallstones or ulcerative colitis. Certain liver parasites commonly found in parts of Southeast Asia also may be associated with this type of cancer.
Hepatoblastoma
This is a rare form of primary liver cancer that primarily affects children younger than four years of age. Its cause appears to be related to an abnormal gene. Most cases can be treated successfully.
Angiosarcoma or hemangiosarcoma
These are rare forms of liver cancer that originate in the blood vessels of the liver and are associated with exposure to industrial chemicals such as vinyl chloride or the drug thorium dioxide. Because workers are better protected from exposure to carcinogenic chemicals and use of thorium dioxide has been continued for some time, these cancers are not commonly seen today.
Metastatic Liver Cancer
In the United States, even more common than primary liver cancer is metastatic cancer, with the colon and rectum being one of the more common primary origins. Because the liver is close to a number of significant organs such as the pancreas, gallbladder, stomach, colon, breasts and lungs and because it is fed from several blood supplies, it is especially vulnerable to metastatic tumors. Metastatic cancers develop when malignant cells spread from the primary cancer and travel through the body in the circulatory or lymphatic system. These cancers are typically named after the organ from which it originated, thus the name metastatic. For instance, cancer that has spread to the liver from the colon is referred to as metastatic colon cancer.
Carcinoid and Neuroendocrine Tumors
Neuroendocrine tumors are mostly very slow growing and it is often difficult to diagnose. They can originate almost anywhere in the body but are mostly found in the gastrointestinal tract, pancreas and lungs. The patient may present with vague symptoms such as flushing, diarrhea, palpitations, cardiac disease or wheezing as a result of hormone production by the tumor. Because of the delay in diagnosing these tumors many patients have metastatic disease to the liver at the time of diagnosis.
There are many types of neuroendocrine tumors. The most common are those arising from the gastrointestinal tract such as carcinoid or those arising from the pancreas such as gastrinoma or insulinoma
Treatment Options
Management of carcinoid and other neuroendocrine tumors require a multidisciplinary approach. For this reason, at The Nebraska Medical Center we have a specialized program that combines the expertise of medical oncologists, interventional radiologists, hepatobiliary and transplant surgeons, to offer the most effective therapy for these unique tumors. Combined modalities are often most effective in treating Neuroendocrine tumors.
Surgery
We have taken the approach of being surgically aggressive towards these tumors sometimes employing radical surgical procedures to treat metastatic neuroendocrine tumors. More specifically we utilize staged hepatectomy, portal vein embolization and radiofrequency or microwave ablation.
Transplantation
Liver transplantation may be an option for some patients with slow-growing tumors confined to the liver particularly patients who have debilitating symptoms due to hormone production.
Trans Arterial Chemoembolization (TACE)
This is a procedure where high doses of chemotherapy are delivered directly to tumors within the liver. The blood supply to that part of the liver is also blocked off so that the chemotherapy drug does not spread to the rest of the body.
Selective Internal Radiation
This procedure involves the delivery of small glass beads loaded with a radioactive compound being delivered to the liver. Because the blood vessels supplying the tumor are of a different size than those supplying the uninvolved liver, the radiation is delivered directly to the tumor without damaging the surrounding liver.
Benign tumors
A number of noncancerous or benign tumors also may develop in the liver.
Hemangioma
The most common type of benign liver tumor, this type affects the liver's blood vessels and typically occurs as a result of a malformation of tissue during fetal development. The majority of hemangiomas do not cause symptoms and do not require treatment.
Hepatic Adenoma
This type of tumor begins in the main liver cells called the hepatocytes. Usually, hepatic adenomas don't cause signs or symptoms. However, occasionally, you may experience abdominal pain, a mass in the abdomen or blood loss. Individuals who use birth control pills are more prone to developing this form of tumor. Halting use of birth control pills often causes the tumor to shrink.
Focal nodular hyperplasia
This tumor is made up of a combination of several types of cells including hepatocytes, bile duct cells and connective tissue. It is more common in women than men and usually doesn't cause signs or symptoms.
Treatment
The Nebraska Medical Center offers patients the full realm of treatment options to provide the most positive outcomes for patients with both primary and metastatic liver cancer. Resection and liver transplantation, when possible, provide the most favorable outcomes for primary liver cancer patients. In the past, patients with liver cancer were not eligible for liver transplantation, but today, new treatments to control and shrink the tumor have allowed some of these patients to become candidates. What makes liver cancer particularly difficult to treat is the fact that many patients don't discover they have the disease until they are in more advanced stages of the disease.
Resection
If the tumor has not spread outside the liver and it is localized, surgery may be recommended and is referred to as surgical resection. The liver is unique in that it can regenerate damaged or resected tissue as long as there is not cirrhosis or hepatitis present. In some cases, up to 75 percent of the part of the liver affected by cancer can be completely removed. Today, the five-year survival rate after resection often exceeds 50 percent. The strongest predictors of recurrence are the presence of involvement of the small blood vessels and/or additional tumor sites besides the primary lesion. We are continually pushing the limits of resectability and routinely utilize novel techniques such as portal vein embolization, bilobar resections and staged resections to achieve complete removal of tumors that are often considered unresectable by conventional means.
Laparoscopic Surgery
Laparoscopic liver resection is a minimally invasive technique to remove diseased parts of the liver. When possible, laparoscopic surgery is the procedure of choice over open surgery because it is so much less demanding on the patient. A traditional liver resection can be a complicated operation because there is so much blood flowing through the liver and it requires a very large incision. Laparoscopic surgery is usually an outpatient procedure, and compared to traditional surgery, results in less pain and discomfort following surgery, shorter recuperation time and a quicker return to normal activities.
Liver transplantation
The Nebraska Medical Center is home to one of the most active and prominent liver transplant centers in the world. Established in 1985, the liver transplant program consistently achieves better outcomes than the national average and performs more successful high-risk liver transplants than almost any other program in the nation. This procedure involves removing and replacing a diseased liver with a healthy, donated organ. Read more about our Liver Transplant Program.
Learn more about our Liver Transplant Program.
Who is a candidate?
Liver transplantation is normally an option for people with small, early-stage liver tumor or for certain cases that involve bile duct tumors. In the past, individuals with cancer were not eligible for transplantation. However, new treatment options that can reduce the size of the tumor have helped increase the eligibility of many patients. Eligibility is based on the number of tumor nodules, the size of the tumors, how much the tumor has spread, the age and overall health of the patient.
Pancreatic Surgery
We provide a multidisciplinary approach to a wide variety of pancreatic diseases including acute and chronic pancreatitis, benign and malignant pancreatic tumors. We partner with gastroenterologists who are able to perform advanced diagnostic and interventional procedures such as endoscopic ultrasound and spyglass endoscopy. Our surgeons perform a wide range of pancreatic procedures including the Whipple procedure, total pancreatectomy with auto-islet transplantation and laparoscopic pancreatic surgery.
Cancer of the pancreas is the fifth-deadliest form of cancer in the United States. It often carries a high mortality because it usually presents late in the course of the disease. We work closely with our medical oncology colleagues combining, surgery, chemotherapy and radiation therapy for the treatment of this cancer.
