In the initial diagnostic of colorectal cancer and single hepatic metastases, we highly recommend active surgical treatment with simultaneous removal of the primary focus and metastases. This allows increasing the five-year survival rate up to 30-40% of all primarily operated patients.
In general, hepatic cancer metastases decrease life expectancy, although they are not necessarily a doom verdict. We believe that it makes sense to keep on fighting using all possible modern methods of treatment. If one does not give up and does one’s best, then there is a chance to live for many years more!
Causes for appearance of hepatic metastases
The liver is one of the most vascularized organs. Every minute, up to 30-40% of the entire blood volume passes through it, on average about 1.5 liters per minute. In this case, approximately 30–35% of the blood enter through hepatic arteries, and the remaining 70–75% through the portal vein from the intestine. After that, both these flows mix and return to the heart through the inferior vena cava.
Due to the special nature of its blood supply, the liver is a place for “entrapment” of tumor cells, which leads to the most frequent localization of hematogenous metastases of tumors therein, regardless of whether the primary tumor is drained by the portal vein system or by other veins of the greater circuit.
At the same time, half of the metastases come from primary tumors localized in the abdominal cavity and small pelvis and draining into the portal vein system. Thus, in case of a colorectal cancer, after radical resection of the affected intestine region without subsequent relapse in the primary operation area, PET-CT shows single hepatic metastases in approximately 50% of cases.
In the absence of radical treatment, the average life expectancy of such patients is less than 2 years.
For other gastrointestinal tumors, including cancer of the stomach, esophagus, pancreas, metastases are detected in approximately 40-50% of patients. With pulmonary, mammary cancer and melanoma, metastases are detected in approximately 30% of patients. Very rarely hepatic metastases occur with cancer of the mouth cavity, pharynx, prostate, urinary bladder. Quite rare are hepatic metastases with cancer of the uterus, ovaries, pharynx, mouth cavity, urinary bladder and kidneys.
It is important to note that approximately 2/3 of metastases histologically and immunohistochemically replicate the “maternal” tumor, and 1/3 morphologically differ from primary tumors by the degree of differentiation of tumor cells, which makes it difficult to establish the organ affiliation of the primary tumor.
Symptoms of hepatic cancer metastases
If a patient has single hepatic metastases, in most cases due to the high regenerative capacity of the liver they do not manifest themselves for a long time until they reach a diameter of 5-7 cm or begin to compress the biliary tract. In the presence of a primary tumor focus (before radical or cytoreductive surgery), the clinical symptoms of metastases are summarized with the symptoms of the primary neoplasm.
Speaking about hepatic metastases, the disease may manifest itself with the following signs. First of all, it is astheno-vegetative syndrome. The patient loses a good deal in body weight while maintaining a normal diet and appetite, complaining of constant fatigue and a feeling of weakness and being unrested at any time of the day. Performance gradually decreases.
Persistent acute paroxysmal or minor pains in the right side appear, sometimes accompanied by an unpleasant sensation of friction in the right hypochondrium. The patient complains of uncontrolled nausea and vomiting, bitter belching, diarrhea or constipation. The skin gets an ashy hue. All manifestations of this syndrome are due to functional impairment of the biliary and detoxifying liver functions, and, in principle, they are reversible in case of elimination of the primary factor, the hepatic cancer metastasis.
The biliary tract obstruction syndrome develops due to compression by the tumor mass of the major bile ducts, first of all, the common and lobar intrahepatic ones. The patient constantly complains about arching pains in the right hypochondrium. The patient also starts to be bothered by itching, the skin and scleras become yellowish. Spontaneous bouts of fever occur. Urine color becomes dark (beer-like).
The inferior vena cava compression syndrome is accompanied by persistent edemas of the lower extremities that remain unchanged during the day, accompanied by accumulation of fluid in the abdominal cavity. The pain becomes diffuse throughout the abdomen.
Gradually, the severity of the astheno-vegetative syndrome together with the biliary tract and inferior vena cava compression syndrome increases. The hepatic function decompensation leads to a weight loss up to cachexia, the extreme degree of exhaustion, while there is a deterioration in appetite up to a complete food rejection.
The portal hypertension syndrome with compression of the portal vein adds to compression of the biliary tract, and as a result, obstructive jaundice develops. Consequently, by the law of communicating vessels there occurs an expansion of veins of the esophagus, rectum and anterior abdominal wall (cirsomphalos), which leads to episodic hemorrhages from the dilated veins. A small ascites enlarges, reaching a maximum of 20-25 liters according to our clinical data.
The most dangerous condition develops closer to the end of the disease, manifesting itself in persistent vomiting lasting up to a day, especially with scarlet blood, black excrements, and a great abdomen enlargement. As a rule, there is gastric or intestinal bleeding that requires urgent surgical assistance.
In order to avoid these complications, we recommend regular control examinations, including liver ultrasound at least once every month, and abdominal MRI with intravenous contrast enhancement at least once every 3 months. Only thus can a life prolongation with a satisfactory general condition be achieved. Late detection results in death of the patient.
Diagnostics of hepatic cancer metastases
In most cases, hepatic cancer metastases are diagnosed during some other examination (for example, in a planned cholecystectomy), less frequently during the examination regarding the lesion nature clarification with the primary cancer of other localization.
As a rule, study includes non-invasive and invasive examination methods. Among the non-invasive ones, the simplest and most accessible is liver ultrasound which mainly performs the screening function. However, its resolution limits make it impossible to detect metastases less than 0.4-0.5 cm in diameter.
Such visualization methods as PET-CT, CT or MRI scan allow to assess their size, number, location, growth pattern, to detect suppuration, disintegration and involvement of neighboring tissues and organs in the tumor process.
However, the diagnostics of micrometastases in the hepatic area is based on portography with contrast enhancement, which allows a detailed study of the state of blood flow in the portal vessels. Micrometastases themselves are detected on portograms on the basis of depletion of the vascular pattern in the area of metastatic lesions. With their help, damage to the vascular bed can be observed, while the procedure is supervised on the CT monitor.
Invasive diagnostics of hepatic cancer metastases involves a liver biopsy, including using a needle (fine-needle aspiration biopsy) or a special instrument called trephine (core needle biopsy, trephine biopsy).
It is necessary to dispel the myth that a liver biopsy leads to growth of the tumor or the appearance of peripheral metastases. It does not - liver biopsy does not increase the risk of metastatic spreading.
The biomaterial is sent to a specialized laboratory for histological and immunohistochemical studies. On the one hand, 2/3 of metastases coincide in their histological portrait with the maternal tumor, however, 1/3 do not.
All of the above diagnostic methods are available for patients of the Clinic Medicine 24/7.