Surgical Aspects in the Imaging of Focal Hepatic Lesions

Abstract

The particular surgical interest with regard to focal lesions of the liver is directed towards three main areas which will be discussed subsequently in this article: diagnostic tools, differential diagnosis and indication for surgery; surgical therapy and modalities; patient survival and prognosis. First of all, there are two crucial questions to be asked by the surgeon (Figure 6.1): 1. Is there any indication at all for surgery? The answer clearly depends on the aetiology and character of the lesion. As a principle, tumours can be differentiated into benign or malignant types. Fairly common and well-known benign solid tumours are cavernous haemangioma, focal nodular hyperplasia (FNH), and hepatocellular adenoma. While, in haemangioma and FNH, spontaneous rupture and intraperitoneal bleeding are extremely rare, and also malignant transformation is still in discussion in only very few cases of FNH, these particular complications have been reported to occur in adenoma1, 2, 3, 4, 5, 6. Therefore, it is our own strategy in patients with the clearly established diagnosis of haemangioma or FNH to recommend surgical resection only in cases of symptomatic disease and/or tumour growth. In contrast, due to the risks as described above, surgery for cure should always be performed not only in suspected but also in clearly diagnosed cases of adenoma 2, 4, 5, 6, 7, 8, 9, 10. The question of indication for treatment is somewhat easier in primary or malignant hepatic tumours. Since the spontaneous prognosis is usually fatal within a limited period of time, and currently no alternative effective therapy is available, radical surgery with the aim of potentially curative tumour removal is undoubtedly the treatment of first choice whenever possible. 2. Is the hepatic lesion resectable? In order to answer this very important question before operation most precisely, all information available about the anatomy of the lesion must be taken together: exact localization, size and number of the tumours within and outside the liver, as well as involvement of vascular or biliary structures, regional lymph nodes, neighbouring and distant other organs. These data are a prerequisite, not only to decide about the surgical resectability, but also to have an accurate tumour classification and staging which has significant implications for the overall prognosis, especially of patients with malignancies. There are different staging systems in use for primary and also secondary malignant tumours of the hepatobiliary system. At present, most suitable for clinical application seems to be the TNM classification of the International Union against Cancer11. Of course, apart from anatomic resectability, the functional capacity of the liver (e.g. in cirrhosis) and the patient’s clinical condition must be taken into consideration before surgery.