Name: SCORE School Liver

Description: SCORE School Liver

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Segment:0 .

A. ALFRED CHAHINE: All right, everyone. It's 8 o'clock. So we'll get started. Welcome to SCORE school. My name is Alfred Chahine. I'm the assistant editor of SCORE, and 1 want to welcome you tonight. We encourage you to use the chat box to ask questions and make comments. Everyone has been muted to avoid unnecessary noise.
A. ALFRED CHAHINE: Please use the Click on the Phone icon on top to choose how you want to access the audio. Tonight, we'll be discussing two core modules in detail and one advanced one, and we'll have time for questions and comments after each one. The three modules, we're going to be discussing are primary hepatic neoplasms, benign and malignant by Drs. Makris and [INAUDIBLE],, hepatic biopsy by Drs.
A. ALFRED CHAHINE: [INAUDIBLE] and Myers and, the technical module hepatic ultrasound by Drs. [INAUDIBLE] and [INAUDIBLE]. Our-- excuse me, before we go to the presenter, you will see a QR code for the week displayed after each module and during the discussion. You only need to submit it once if your residency requires it for attendance. Finally, all these sessions would be recorded for later viewing on the SCORE website, and we encourage you to view them as your schedule allows.
A. ALFRED CHAHINE: Allow me to present our faculty presenter tonight, Dr. Alexander Parikh, who is the Robert and Penny Barnhill Distinguished Professor of Oncology in the Department of Surgery and Chief of the Division of Surgical Oncology and Director of Hepatobiliary and Pancreatic Surgery at Brody School of Medicine at East Carolina University and Vidant Health System in Greenville, North Carolina. His areas of expertise include cancers and complex diseases of the pancreas, liver and bile duct, stomach and small intestine, neuroendocrine system, and sarcomas.
A. ALFRED CHAHINE: Dr. Parikh went to undergrad at Johns Hopkins University and got his MBA at University of Pennsylvania with an MPH after that at Vanderbilt. He must have gotten the MPH during when he was faculty at Vanderbilt I assume. He trained for residency a University of Cincinnati and then obtained a fellowship in surgical oncology at the University of Texas MD Anderson Cancer Center. His research interests include comparative effectiveness of multimodality treatment strategies for GI malignancies as well as the investigation of cancer care disparities related to rural living and health insurance.
A. ALFRED CHAHINE: He and his wife, who's also a surgical oncologist, live in Greenville and have two children. His hobbies include woodworking, history, and spending time outdoors. Thank you, Dr. Parikh for joining us, and please go ahead.
ALEXANDER A. PARIKH: Thank you Dr. Chahine and Dr. Joshi and the SCORE organization for the opportunity. Go to the next slide. And Dr. Chahine went over this already, to ask chat, and I'll be answering questions as [INAUDIBLE] So let's start out with a little question, and I like to ask my residents and medical students about how many lobes does the liver actually have. So I'm going to give you a couple seconds here.
A. ALFRED CHAHINE: [INAUDIBLE] already.
ALEXANDER A. PARIKH: We have at least four answers so far. Perfect. So basically I've answers B, C, D, and E, which is exactly my point. Can I have the next slide. So I actually personally a lot of our liver surgeons do not like using the word right lobe and left over the liver, because it is very confusing because no one can really agree how many lobes there are.
ALEXANDER A. PARIKH: If you go by the strict definition of a true fissure defining a lobe, the liver actually has one lobe, i.e. the caudate lobe. That's it. Most of us like calling the liver the right hemiliver, the right liver is shown here, or the left hemiliver, the left liver shown here. And so because of that, I think if you're going to understand liver surgery, you really need to understand both the sectoral divisions of the liver as well as the [? Quino ?] segment.
ALEXANDER A. PARIKH: So for example, in this slide, the right hemiliver is divided really into two sections or sectors, the right interior sections shown near segments 5 and 8 and the right posterior. And then the left hemiliver is divided into two sections, the left medial and the left lateral and then a caudate lobe is segment I shown there posterior. An important thing to, remember and I think it's really important to understand both the sectors as well as the segments, the segments are shown here-- 1 through 8 we'll go over how they're made, really because number one, when you're looking at a radiographic film, whether it's a CT or an ultrasound or an MRI, it's really important to understand where these lesions are.
ALEXANDER A. PARIKH: The other thing that's important and this has changed over the years. When I was a fellow many years ago, we tended to do more of formal right hepatectomies, left hepatectomies, for disease now with multimodality therapy, we are doing more segmental resection. And therefore, it's really important to be able to identify the individual segments in the sectors when you're doing liver surgery.
ALEXANDER A. PARIKH: So again as shown here are the different sectors and segments. As I will discuss again more and more, the sectors are divided by the hepatic veins, the three hepatic veins. So the right hepatic vein, for example, shown there divides the posterior in the anterior sections and the middle hepatic vein divides the right and left hemilivers, but basically the left medial and the right anterior section, and the left hepatic vein divides the left lateral and left medial section.
ALEXANDER A. PARIKH: In terms of the segments, the top half of the liver, everything above where the portal vein comes in or the top segments-- segments 2, segments 4a, 8, and 7 and everything below is segments 3, 4b, 5, and 6. Next slide, please. So in terms of some of the other nuances of liver anatomy, the arterial blood supply is typically to the right and left, and there is a middle hepatic artery, and they do follow the portal vein and the bile duct.
ALEXANDER A. PARIKH: Middle hepatic artery is most commonly a branch of the left that goes to get into the segment 4, and most-- and this is important to remember, when you're treating is most primary and secondary liver tumors are actually supplied by hepatic artery, we'll get into that when it comes to the hepatic artery embolization, et cetera. I mentioned the three hepatic veins-- the left hepatic vein there, which runs in the middle of the left liver dividing the left lateral and left medial segment or sectors.
ALEXANDER A. PARIKH: It drains segments 2, 3, and part of 4. The middle hepatic vein that runs in the middle of the liver, again dividing the left medial sector and the right anterior drains segments 5 and 4, and the right drains 7 and 8. Again, there are some variations in this, but in general, that's what it is. Middle hepatic vein oftentimes about 80% of the time, as you can often see on ultrasound, will join the left hepatic vein, and that's important to know when you're doing a hepatic resection.
ALEXANDER A. PARIKH: There's also about 20% of patients, there's a very large or significant accessory right hepatic vein that actually drains that posterior sector 8 and 7 and that's important, for example, if you're doing an extended left resection, you can rely on that. The other thing to remember the interferior phrenic veins, they drain at the IVC, and they're up near that hepatic veins.
ALEXANDER A. PARIKH: When you're mobilizing the liver via the left to the right, you have to be careful of these phrenic veins because you can get into them and then have some [INAUDIBLE] the vena cava. The caudate lobe which many of us believe is the only true lobe is right in the middle of the liver posterior, and it gets you drainage and blood supply from both sides. Next slide, please.
ALEXANDER A. PARIKH: So again in summary here, the segments I through 8, and I think it's important that when you're talking about liver to just talk about the segments, because although people don't agree with the left lobe and the right lobe and the hemilivers, everyone understands the segment. So when I do a resection, for example, and I send to pathology, I mention, we respected segments this, this, this, and this, as I'll go into later.
ALEXANDER A. PARIKH: Glisson's capsule, as often people know is a peritoneum that covers the liver. It also covers the portal structures, the portal vein, hepatic artery and the bile duct to differentiate from the hepatic vein, as I'll show you later. There's a bare area of the liver, that's area posterior superior that's not covered by any peritoneum when you mobilize. And there's also the triangular ligaments both in the lateral and medial edge.
ALEXANDER A. PARIKH: When you're mobilizing the liver, be it the left to the right, those are the ligaments you get through. The portal triad enters right in the middle of the liver segments 4 and 5, and the gallbladder as everyone knows also sits right between 4 and 5. So for example, when you tell patients you're going to do a right hepatectomy or a left hepatectomy, you have to do a cholecystectomy with it, and that's the reason.
ALEXANDER A. PARIKH: Next slide. So looking here, and you'll see I'm going to show this over and over again, because I think the liver anatomy is very confusing. I have to admit I was a fellow really before I really understood looking at the liver looking at a CAT scan. So it's really important, all these segments. And that's why I keep showing this.
ALEXANDER A. PARIKH: Here's an anterior view on the left, kind of colored where we're talking again, 2, 3, 4, which is 4a and 4b the segments here, the 4a being in the top, 4b being in the bottom, 8, 5, 7, and 6. And there's the posterior view as well. You can see that caudate lobe segment 1. Next slide, please.
ALEXANDER A. PARIKH: So here's a question here. So 60-year-old female, history of colon cancer undergoes a routine surveillance imaging that reveals a 2.8 centimeter lesion on the anterior surface of the liver as shown in that CT scan posterior to the middle hepatic vein. In which segment is this lesion located? Knowing what you know now. 2, 4, 8, 5, or 7?
ALEXANDER A. PARIKH: So the majority of the answers are segment 8, which is C, which is correct. Next slide, please. And so again, so this is important because the other answer was 5, and this is a very good point.
ALEXANDER A. PARIKH: So shown here on the left is again the different segments of the liver. And this is anterior and is posterior to the middle hepatic vein, which I agree would be 5 and 8. What makes an 8 versus 5 is where in the liver it is, a bit superior to the portal vein. And I specifically did not show you that, but this is a superior toward the lung [INAUDIBLE] posterior. Because it's on the cephalad side of the portal vein, it is segment 8.
ALEXANDER A. PARIKH: If it was lower down in the same anterior of the middle hepatic vein, it would be segment five 5. In this case, the answer is segment 8. Next slide, please. So some other facts of liver. Kupffer cells are liver macrophages. That's very important when we talk about FNH and hepatic adenomas later on.
ALEXANDER A. PARIKH: The portal triad or that hepatoduodenal ligament as everyone understands, it includes three main structures-- the common bile duct, which is typically lateral, the portal vein, which is posterior, and the proper hepatic artery, which is medial, and they [INAUDIBLE].. And so when you're doing the Pringle maneuver, whether it's trauma or elective hepatic surgery, it is where you get into the foramen of Winslow, which is posterior to that above the IVC, that's when you clamp the inflow to the liver, and again, will provide vascular control.
ALEXANDER A. PARIKH: It's important however, and this is oftentimes a question in trauma, is when you get bleeding despite doing a Pringle maneuver. It is because number one, that you actually have a hepatic venous bleeding, because that's, again, back [INAUDIBLE] off the vena cava. In addition, as we'll talk about, there's an aberrant anatomy that you may not catch with a Pringle maneuver.
ALEXANDER A. PARIKH: The portal vein is formed by a confluence of the superior mesenteric vein and the [? splenic ?] vein. The IMV, the inferior [INAUDIBLE] mesentery, typically adds to the [? splenic. ?] The portal vein is, I like to say, is the only vein in the body that actually has branches. Every other vein as a tributary because it's smaller veins into large veins. Think of rivers.
ALEXANDER A. PARIKH: Portal vein is the only vein in the body that actually has a branch, left and right. And it provides, again, about 70% of the hepatic blood flow, [? with ?] only about 30% of the oxygen. The left goes to segments 2, 3, and 4. And the right goes to 5, 6, 7, 8. The caudate lobe or segment one, gets branches from both. Next slide please.
ALEXANDER A. PARIKH: You can see I'm spending a lot of time in anatomy because I think it's really important when you treat anything in the liver. There is some aberrant anatomy. The important thing is to think and to know about. One is the replaced right or an accessory right, which is a right hepatic artery coming off the SMV or SMA, I'm sorry, in about 20%. This runs behind the pancreas and posterior lateral common bile duct.
ALEXANDER A. PARIKH: That's very important because as you dissect out the [? porta, ?] let's say you're getting inflow control, you can oftentimes injure that right hepatic artery if you don't know where it is. The left hepatic artery in about 20% comes off the left gastric. And that's important because that comes to the lesser omentum. So again, if you do a Pringle maneuver, you're not going to get that replaced left of hepatic artery.
ALEXANDER A. PARIKH: So if you get bleeding from the left liver, when you do that, you have to look for a left hepatic artery. A falciform ligament is something that separates the medial and left segments of the left liver. Again, shown, this is again, this is some of the confusion. I copied this from a textbook. Left lobe is actually left liver. And it attaches liver to anterior abdominal wall.
ALEXANDER A. PARIKH: Interestingly enough, the French, if you look at some of the older French literature, they define the left lobe of the liver as, or the division, by the actual falciform. So for them, the left lobe of liver is what we would call the left lateral section. And the rest is the right. Again, that's the reason I really don't like talking about left and right lobes literally, it very confusing.
ALEXANDER A. PARIKH: The ligamentum teres attaches to the falciform. It carries the obliterated umbilical vein. And as many people know when you're cirrhotic, that can be a significant source or a sizable vessel, sometimes the size of the portal vein, that one, so that ligament. The other thing to know is Cantlie's Line. A Cantlie's line is the line that basically divides the right and left hemilivers.
ALEXANDER A. PARIKH: And it essentially goes in the middle of gall bladder fossa to the IVC as shown there. Next slide. So I think that's everything for anatomy. If there's any questions with anatomy, please we'll go back to that at the end when I talk about ultrasound. But if there's any questions, please let me know.
ALEXANDER A. PARIKH: So moving on now to hepatic neoplasms. Being a hepatobiliary surgeon who deals with cancer, I'm going to concentrate on this, both benign and malignant. So the benign, the three most common are adenomas, focal nodular hyperplasia or FNH, and hemangioma. The other common is hepatic cyst, although I don't consider that really as a neoplasm, but we can put it in there.
ALEXANDER A. PARIKH: In terms of malignancy, the two most common by far, in terms of primary liver malignancies, are hepatocellular carcinoma, or HCC, or hepatoma, followed by intrahepatic cholangiocarcinoma. It's important to know, however, that metastatic lesions are even much more common in the liver than the primary, of which the majority is colorectal. In fact, the majority of liver resections may actually do it for colorectal metastasis.
ALEXANDER A. PARIKH: But again, that's another talk. We can certainly, if there's questions about colorectal cancer and metastatic disease, we can talk about them. But I'm going to concentrate really on primary liver neoplasms. Next slide, please. So in terms of the epidemiology of the benign lesions, it's in about 5% of the population.
ALEXANDER A. PARIKH: So it's reasonable. I mean, humans are by far the most common 4%. FNH and adenomas are much less common. Turns out hemangiomas, again, this is a typical incidental finding. Somebody gets a CT scan for some other reason, and they get a liver lesion. And then you get consult with the hepatobiliary surgeon, what to do with this lesion.
ALEXANDER A. PARIKH: Oftentimes it is a hemangioma, typically, in the age 30s to 50s. FNHs are much more common in females, 8 to 1. And again, third and fifth decades of life, similar to hemangiomas. Adenomas-- and we'll talk about some of the differences-- also about 90% females. Reproductive age, 15 to 45. And these are the ones that are estrogen dependent.
ALEXANDER A. PARIKH: So patients that are on oral contraceptive, or hormonal replacement therapy, those are the patients that typically develop these adenomas, although not 100%. Next slide, please. So this is important. I know there's a lot of information on this slide. But really, the important point here is there are CT and MRI and ultrasound characteristics of the three.
ALEXANDER A. PARIKH: So again, hepatic hemangiomas-- and I'll show you some examples-- CT scan, the key thing here is this peripheral enhancement. So again, CT with contrast, peripheral enhancement, and then you get enhanced in the middle, very bright lesion, on [INAUDIBLE] films. On MRI on T2, which also is very bright, persist also very bright for hemangiomas. Adenomas look very even, encapsulated.
ALEXANDER A. PARIKH: With contrast, there's some areas of hemorrhage and necrosis. So it looks a little bit heterogeneous there. And also oftentimes, they will bleed. And if they do, they can show the hyperintensity. Focal nodular hyperplasia, however, is also well circumcised, and typically has a central scar. Well, the central scar is only about 50%. But that's very typical for a focal nodular hyperplasia.
ALEXANDER A. PARIKH: And really, when we're looking at this, it's adenoma versus hyperplasia. Those are the two that are important. And we'll talk about some of the characteristics that differentiate them. Next slide, please. So here is a couple of-- or a few examples. So FNH in the left upper quadrant there, again, bright, and that central scar, as you can see on CT scan.
ALEXANDER A. PARIKH: And adenoma, again, looks a little bit similar, but a little bit heterogeneous. You can see those areas in necrosis, not that central scar. And then hemangioma much brighter. This is a kind of delayed hepatic arterial, or delayed arterial phase. You can see the portal vein there. And that's why it's also bright.
ALEXANDER A. PARIKH: And these are the different characteristics between the three of them on CT scan. And MRI again, is also very helpful. Next slide, please. So in summary of these three, hemangiomas, again, most common. The rupture is very rare. And so these are the ones that you really want to avoid a biopsy.
ALEXANDER A. PARIKH: If you have something that looks like hemangioma, your interventional radiologist, or who's going to do the biopsy, is going to be very-- they want to avoid this because these will bleed. There are times when their giant hemangioma is over 10 centimeters. And therefore, they can rupture and is related somewhat to size. And we'll talk about treatment for that.
ALEXANDER A. PARIKH: Again, MRI and CT scan, as well as the tagged red blood cells scan, we don't use that as much anymore. But the tagged red blood cell scan is a good scan, on nuclear medicine, which will light up these hemangiomas, again, if there's any doubt. You do not want to biopsy these, however. FNH, again the central stellate scar, the important thing here is there's no malignancy risk. So you don't operate on these unless they're symptomatic, which is very rare.
ALEXANDER A. PARIKH: And the old sulfur colloid against nuclear medicine scan is very good. [INAUDIBLE] for cells that we talked about are present in FNH. They're not present in adenoma. And therefore, the sulfur colloid scan, they will light up in FNH. It's a very good differentiating image between that and adenomas.
ALEXANDER A. PARIKH: Adenoma women as in FNH. Again, the key to this is oral contraceptives. Up to 80% can become symptomatic, depending on the size. They do definitely have a risk of malignancy about at 5%, and it's highly dependent on size. So the larger they get, as we'll talk about, the malignancy risk goes up. So those are the ones that we will typically resect depending on size.
ALEXANDER A. PARIKH: And again, if there's any doubt between that and FNH, there's no uptake on sulfur colloid. We'll talk a little bit later about liver biopsy. Liver biopsy for adenoma and FNH is reasonable. If you can't tell, as long as you're confident it's not a hemangioma. Next slide, please. So question.
ALEXANDER A. PARIKH: So we have a 50-year-old woman with a newly diagnosed liver lesion. She's asymptomatic. What imaging finding indicates that the patient should undergo a resection? I'll warn you, some of this we haven't talked about yet, but I kind of did as a pre-discussion question and a post.
ALEXANDER A. PARIKH: All right. So everyone so far is correct, in E. Next slide, please. So it is E. Again, the one we have not talked about, hepatocellular carcinoma.
ALEXANDER A. PARIKH: This is kind of process of elimination. We talked about the other one. So an HCC does enhance in the arterial phase and has washout of contrast in the portal venous phase as shown here. This lesion should undergo resection. Again, we'll talk more about this if there's no other contraindications. Next slide, please.
ALEXANDER A. PARIKH: Just to go over some of the other ones. So focal nodular hyperplasia was choice A. Again, if you look at that, has bright, again, homogeneous enhancement on anterior phase with that central scar. Hepatic adenomas are heterogeneous appearing on CT, has smooth surfaces. Again, that's the one, it's sometimes difficult to differentiate versus hepatocellular cancer. Hemangiomas or cavernous hemangiomas have that centripetal enhancement on liver protocol CT.
ALEXANDER A. PARIKH: And then simple cyst. We didn't talk about cysts, but cysts are also very common in the liver. They are fluid filled. They do not require a resection if they are asymptomatic. There are things called biliary cyst, adenoma cyst, adenocarcinomas that are very rare. But simple cyst in the liver did not require any treatment. The best way to diagnose that, again, ultrasound is very good at looking at cysts as well as MRI, which is also very good looking at cysts.
ALEXANDER A. PARIKH: Next slide, please. So in terms of treatment, again, hemangiomas. Resection, rarely indicated. These are the ones that are-- the only time you're going to really resect are if they're symptomatic, which they can be. And this one's going to get six, seven, eight, nine, 10, 14 centimeters large.
ALEXANDER A. PARIKH: When they stretch that liver capsule, they can become symptomatic. If they are growing, oftentimes, you will resect in a healthy person as well as rupture. If they rupture, these patients can bleed. And again, rupture's really related to size. One of the other tools that we could use for this is arterial embolization. So basically, if the lesion is very large and certainly, if it's ruptured, let's say as an emergency, we can embolize.
ALEXANDER A. PARIKH: Your radiology colleagues can get into the aorta and embolize the artery that supplies hemangioma to stop the bleeding. It oftentimes will shrink that tumor just a little bit, or that lesion, a little bit, if we can actually resect it. So again, this is something else that we use as a tool. FNH, again--
A. ALFRED CHAHINE: Alex?
ALEXANDER A. PARIKH: Yeah.
A. ALFRED CHAHINE: Sorry to interrupt you. What size do you start worrying about for hemangiomas for rupture? What's the threshold?
ALEXANDER A. PARIKH: Usually, about 8 to 10 centimeters is the time when we'll oftentimes, we'll do it. I mean, a lot of patients to be totally honest, by the time they're that big, they're usually symptomatic. But the giant hemangiomas are over 10 centimeters, anywhere from 8 to 10. In the right, young healthy patient, we'll talk about resecting those. It's a good question.
A. ALFRED CHAHINE: Thank you.
ALEXANDER A. PARIKH: So FNH, again, as long as you're confident with the diagnosis, resection's rarely indicated, only if they're symptomatic. And even that, you really have to make sure. A lot of times, they'll have gallstones or other causes for resection. But if they're large, sometimes we'll resect them. Adenomas, these are the ones that are little more controversial. Typically, if they're 5 centimeters or less, the first thing you will do is you'll stop the oral contraceptives or estrogen replacement if they have that.
ALEXANDER A. PARIKH: These are also the ones that when patients are pregnant, will get larger because of the estrogen surge. And a lot of times they're asymptomatic. They're less than 5 centimeters. You try that. They go away. And you leave them alone. Because they can also be multifocal. If they are larger than the 5 centimeters, they're symptomatic, or they're growing, these are the ones that you can consider resecting.
ALEXANDER A. PARIKH: Again, typically, they're younger women so they're healthier. And these are the ones that we'll consider resection. Because there is a risk of malignancy, particularly with size. So the greater than 5 centimeters, their increase of malignancy is there. And then the other thing is sometimes it can be very difficult to distinguish from a very well different in a hepatocellular cancer.
ALEXANDER A. PARIKH: So that's the threshold to do that in terms of resection versus that. The other thing to think about is that they can be multifocal. So if they are multifocal we'll, typically treat each lesion separately. So in other words, one lesion's greater than 6 or 5 centimeters, and the other ones are tiny, they're in the same area, we can do that. So the question here from the audience, would arterial embolization [INAUDIBLE] be efficient for management?
ALEXANDER A. PARIKH: So it depends. So for hemangiomas, oftentimes, yes. Particularly if they've ruptured or they're bleeding, you can just embolize them, and they may be enough. Most of us, though, right-- and again, I think I use that for patients that are just not healthy candidates. If there's a large hemangioma, they have to get a large liver resection, they're not the healthiest patients, I think arterial embolization is not.
ALEXANDER A. PARIKH: For the other two, no. The other question is, if the lesion were borderline with [INAUDIBLE] adenoma, would you proceed with the biopsy first? And that is, the answer to that is yes. We'll talk a little bit about biopsy later. Adenoma versus a [? TCF ?] is a very good. If you think, if there's any question between the two, I think a biopsy is reasonable.
ALEXANDER A. PARIKH: We'll talk about some of the other characteristics about HCC versus, adenoma like history. That may also help you. But good questions. Next slide, please
A. ALFRED CHAHINE: Very good. If you haven't scanned your code, this is an opportunity to do that. And ask any other questions to Dr. Parikh if you have them. Take a little bit of time before we proceed to the malignant ones. All right. Sounds like you covered it. OK.
A. ALFRED CHAHINE:
ALEXANDER A. PARIKH: So in terms of the malignant primary liver lesions, again, these are primary. These are by far the two most common. Hepatocellular cancer, HCC, hepatomas, those are the other terms that we use. 75% of the primary liver cancers are going to be hepatocellular cancer. It is the number one most common cancer in the world. And as I'm sure most people know, cirrhosis, particularly viral hepatitis, is the number one risk factor for developing hepatocellular cancer.
ALEXANDER A. PARIKH: In the United States, for example, 16% are related to hepatitis B and 48% are hepatitis C. In fact, as I'll show you, in patients that have hep C cirrhosis, it is recommended they undergo surveillance scans, because again, 100-fold increase in the incident of the hepatocellular cancer. So other causes, aflatoxin, which is more common in Southeast Asia, alcoholic cirrhosis, which also can be as risk factor although not as much as hepatitis C. Oftentimes, you'll have both.
ALEXANDER A. PARIKH: You have patients that are alcoholic and hepatitis C as well as diabetes, obesity. Again, a lot of times, you have multiple combinations of this. In terms of the pathologic types, fibrolamellar is the best. And those are the ones that can be difficult even on biopsy, to tell an adenoma versus the fibrolamellar hepatocellular cancer. If there's any question, you typically remove those.
ALEXANDER A. PARIKH: Diffuse nodular, however, is the worst in terms of the pathology. The other common cancer is intrahepatic cholangiocarcinoma, so IHCC. Again, there are three when we talk about cholangiocarcinoma or tumors of the bile duct. The more commonly distal cholangiocarcinoma, so near the pancreas. Hilar cholangiocarcinoma which is the classic in these tumors.
ALEXANDER A. PARIKH: But there's also a third subset, the intrahepatic, the least common of the three, which is actually a primary bile duct in the liver itself. So it's actually a parenchymal lesion in the liver. Most commonly in the 70s in terms of age. Men are more common than women. And again, also Southeast Asia. The incidence actually is on the rise in the United States. And the difficult part here is that you oftentimes have to differentiate this from metastatic disease.
ALEXANDER A. PARIKH: So as we'll talk about, if you do have an intrahepatic cholangiocarcinoma, it comes as an adenocarcinoma. And again adenocarcinoma is a glandular cancer. So oftentimes we'll talk about, you need to do the work up to make sure it's not a metastatic lesion. Next slide, please.
ALEXANDER A. PARIKH: Terms of the diagnosis. Again, hepatocellular cancer. This goes back to that former question, adenoma or HCC. The history is key. Cirrhosis, you can get hepatocellular cancer particularly in the degenerate adenoma in a patient with a normal liver. But by far, the most common cause is cirrhosis. So if you have a patient that's cirrhotic, who then has a lesion, and it's unclear if it's adenoma or HCC, HCC should be much higher on the list.
ALEXANDER A. PARIKH: Again, surveillance with ultrasound and AFPs are recommended every six months in patients with cirrhosis, typically, especially with hepatitis C. Elevated AFP, so Alpha Fetoprotein, is very helpful. It's not 100%, but it's very helpful in hepatocellular cancer as well as imaging characteristics. Because of that, and there's actually just like bio-rads for breast, there's a LI-RADS L-I RADS, for liver.
ALEXANDER A. PARIKH: And that helps differentiate the hepatocellular cancer. So for example, if you have a highly suspicious LI-RADS, five lesion with an elevated AFP, that is enough. In fact, we'll talk about it. That's enough for transplant. You don't even need a biopsy. That's enough to be [INAUDIBLE] for HCC. Again, hyperenhancing arterial phase with rapid washout, a very ugly looking tumor.
ALEXANDER A. PARIKH: Intrahepatic cholangiocarcinoma, the liver functions are often normal except for bilirubin. Because again, this is a [INAUDIBLE] and oftentimes, they get very large. And they can cause biliary obstruction as well as pain. CA 19-9, so that's a carbohydrate antigen, also elevated in pancreatic cancer although hepatobiliary cancers, not super specific, but associated with a liver lesion.
ALEXANDER A. PARIKH: Certainly, that could be indicative of a cholangiocarcinoma. Again, imaging characteristic, we'll talk about it. Looks more like a hypodense lesion. The biopsy comes back adenocarcinoma. So this is complicated because colon cancer is adenocarcinoma, small bowel cancer is adenocarcinoma, stomach cancer, really, breast cancer. I mean, a lot of cancers are adenocarcinoma, particularly ones that can metastasize to the liver like colon, like pancreas, like stomach.
ALEXANDER A. PARIKH: So it's sometimes difficult. So if you have a lesion in the liver and biopsy comes back out adenocarcinoma, one of the recommendations is you want to rule out metastatic disease because that's more common. Get an upper endoscopy. Get a lower endoscopy. And make sure there's no colon cancer, stomach. Look at the pancreas.
ALEXANDER A. PARIKH: Is there any pancreas lesions, et cetera, before you assume it's cholangiocarcinoma. There are stains that can help. But oftentimes, all they can tell you is it's some sort of hepatobiliary pancreas origin. So you can potentially rule out colon but not so many others. Next slide, please. So in terms of imaging, shown here on the left is hepatocellular cancer.
ALEXANDER A. PARIKH: Again, very nodular looking liver. This liver is actually not super cirrhotic. But you can see the brightness on the edges enhancing. In the cholangiocarcinoma on the left has that necrosis. So again not as nodulous as hepatocellular cancer, more hypodense area, not as bright. But often, can look like metastatic pancreas right there. Next slide please.
ALEXANDER A. PARIKH: So in the terms of the treatment. So hepatocellular cancer, there's really three-- resections, so transplant, and the liver-directed therapy. When we talk about liver-- I'm going to talk about all three-- but when we talk about liver-directed therapy because that's what's really come into both certainly, since I was a fellow, There's different strategies.
ALEXANDER A. PARIKH: The most, the well-known, the oldest is ablation. So whether it's microwave ablation or RF ablation, if you have lesions, typically, 5 centimeters or less, either in the OR, laparoscopically, or open. Or more common in a percutaneous radiology, you can actually burn these tumors. And a very good local recurrence rate, and certainly very good for patients with not the healthiest liver. TACE, which is Transarterial Chemoembolization,.
ALEXANDER A. PARIKH: Because again, most of these tumors are supplied by the artery, we can either do bland, meaning radiology, interventional, can do the bland or chemotherapy. We're again [INAUDIBLE] and get into the hepatic artery that actually supplies this tumor and either bland embolize or cut off the blood supply or give chemotherapy. Y-90, which has gotten very popular in the last several years, Yttrium-90 is actually using radiation.
ALEXANDER A. PARIKH: And this is portal vein based. So even though it's not [INAUDIBLE] they can actually appear large tumors that involve, let's say, an entire sector or the liver or hemiliver. Y-90 can be given. For example, you can give Y-90 to the right portal vein and basically treat the entire right liver with radiation. Also very good in terms of hepatocellular cancer. And then something that's also stereotactic radiation.
ALEXANDER A. PARIKH: So not quite as good in terms of their recurrence or the treatment. However, very good at difficult to reach locations. So locations that are really hard to get to in terms of why nine year arterial bays are very good to radiate. So again, when you're thinking about what to do-- do you resect, do you transplant, liver-directed therapy-- number one is the condition of the liver.
ALEXANDER A. PARIKH: Again, most of these patients are cirrhotic. And so whether it's Child-Pugh classification, Milan criteria, and MELD score, I should put on there as well, if you have a cirrhotic liver you probably don't want to resect unless, again, it's a very early Childs A cirrhotic, and it's a small resection, I tend not to want to do a formal right hepatectomy in a patient with cirrhosis. The size, number, and location.
ALEXANDER A. PARIKH: Again, if there's one lesion and if it's small, that may be amenable to resection or transplants we'll go over, as well as location. If there's multifocal lesions and if they're all the lesions, in one hemiliver, for example, the right, and it's good preserved function, maybe you'll go ahead and resect that, or certainly, a segmental resection. Again, if there's multiple lesions or large lesion in the right, maybe Y-90 is a good idea because you can knock out the entire right liver.
ALEXANDER A. PARIKH: If however, there's a smaller lesion, and you don't want to hurt the entire right side or left side, maybe arterial based or TACE should be the example. So there's, again, different criteria. Because usuallly, you have a multi scenario, HPV tumor board with radiology, and hepatobiliary surgery to figure out what the best thing is. The other thing that's important is no extrahepatic disease because, again, this can metastasize.
ALEXANDER A. PARIKH: If you do have extrahepatic disease, we tend not to do liver-directed therapy unless the patient is just symptomatic, in which case we do. One thing I also want to mention is systemic therapy, is you've seen a lot of the older textbooks, sorafenib, which is a tyrosine kinase inhibitor, has been used. However, within the last year-- and again, this is why it hasn't made the [INAUDIBLE]---- there's a combination of atezolizumab which is a immunotherapy.
ALEXANDER A. PARIKH: Again, they're going to go into cancer, and they got the money in the therapy. Bevacizumab, which is an antiangiogenic agent, in combination is superior. So for systemic therapy, so again, these are for patients that may not be a resection candidate, or even if resected, in terms of coming back, consideration of these. Now I only bring that up because in case you see that in the literature, you may hear more about that.
ALEXANDER A. PARIKH: So that's the multimodality treatment of the HCC. Next slide, please. And again, please ask questions. I know that's somewhat confusing. So in terms of transplant, most commonly, it's the Milan criteria. So these are patients that are transplant cancer, hepatocellular cancer. Again, cirrhosis, but also single tumor less than or equal to 5 centimeters, or up to three tumors none larger than three.
ALEXANDER A. PARIKH: And again, no significant vascular invasion in the main portal vein, for example, or anything outside the liver. That's the typical Milan criteria. If the patients have cirrhosis, and they meet that criteria, the number one consideration or treatment option would be transplant. If they're otherwise, good candidates because that does have the best success.
ALEXANDER A. PARIKH: There's also a little bit more liberal criteria called the UCSF criteria. And it's not just used by UCSF but other places, for example, Mayo Clinic. Again, get up to a 6 and 1/2 centimeter single tumor, or the two to three lesions not exceeding 4 and 1/2 with a combination total that are less than that. Again, a little bit more liberal.
ALEXANDER A. PARIKH: But again, nothing outside liver. So most patients that have hepatocellular cancer with cirrhosis should at least be evaluated by transplant, just to make sure they're not a transplant candidate. If they are, there's also bridge to transplant. Next slide, please. So before we get to IHCC. So there are bridges to transplants.
ALEXANDER A. PARIKH: For example, we have someone that's listed for a transplant that has a tumor, we may ablate those tumors, [INAUDIBLE] get microwave ablation or chemoembolization that does not preclude a liver transplant. They're on the list but before, let's say, we don't want the tumor to get large or out of control, we will oftentimes do that as a bridge to transplant until a liver becomes available.
ALEXANDER A. PARIKH: So again, that-- [AUDIO OUT] In terms of intrahepatic cholangiocarcinoma again, no one thing, nothing [AUDIO OUT].. So if there's any one match prepared, that's [? neo ?] match, et cetera, regional lymph node involvement is OK. So if you have some periportal nodes that line up, that's OK. You do not want para-aortic nodes, retroperitoneal nodes, all that stuff is considered metastatic disease.
ALEXANDER A. PARIKH: And again, those patients are not resectable candidates. They will oftentimes need, as I showed you there, a major liver resection. These are pretty large by the time they present. So a formal right, formal left extended resection, we'll go over that, they do often have vascular involvement. So that's very important. When you're staging these patients, you want to make sure that you can get clear margins on the vasculature.
ALEXANDER A. PARIKH: For example, if you have a right-sided cholangiocarcinoma in the liver, you have to make sure the left vasculature is not involved. The other thing is conditional liver. Although these patients are not cirrhotic, they can be. And oftentimes, these patients could have fatty liver disease, whether it's from obesity, diabetes, NASH, et cetera, you want to make sure that the liver can tolerate this kind of reception.
ALEXANDER A. PARIKH: The other thing we'll talk about is the volume. So anyway, the Greeks and Prometheus knew the liver is the only one that can hypertrophy not really regenerate, but hypertrophy. But we know that you can take up to 70 80% of a liver, of a normal liver, and be OK. The 20% to 30% will grow. However, the complications definitely go up if you're taking over 70% or above.
ALEXANDER A. PARIKH: So those of us that do this, we oftentimes look at what we call them-- I'll go over this in detail-- this functional liver reserve to see what kind of volume we're talking about. And there's tricks that we can use with the cholangiocarcinomas or portal vein embolization, which I'll get into. So the question is the use of Milan versus UCSF, that's [? surge ?] independent.
ALEXANDER A. PARIKH: I would say yes, it's more institution dependent. So again, for transplant, it's not just necessarily the surgeon transplant, the centers have a hepatologist that's actively involved as well as the liver transplant surgeon. So it's really more of a institutional dependency. I would say the majority of the institutions use the Milan criteria. But there are some centers that go ahead and use the UCSF criteria as well.
ALEXANDER A. PARIKH: Next slide, please. So I want to get into operative terminology. Because I mean, again, this is very confusing. People here, left or right trisegmentectomy, which is a misnomer, et cetera. So we're talking the anatomical, right hemiliver or right liver, not right lobe, right liver, and hemiliver. When I dictate a case, I say right liver or right hemiliver.
ALEXANDER A. PARIKH: The [INAUDIBLE] segments, 5, 6, 7, 8, shown there in pink, plus or minus segment 1. We'll talk about that. The term is a right hepatectomy, right hemihepatectomy. And you can add segment 1, et cetera. When I dictate a case, if I do a right hepatotectomy, I will say, procedure right hepatectomy, parentheses, segments 5, 6, 7, 8, that's what I'd say. Same with the left here, left hemiliver, or left liver are segments 2, 3, and 4.
ALEXANDER A. PARIKH: Again, 4 is 4a and 4b. Left hepatectomy, left hemihepatectomy, that's what it includes. Again, and I will stipulate the segments 2, 3, and 4. Next slide, please. Let's distinguish this versus that right trisection. So you'll hear this right trisect, the right trisegmentectomy. Well, if you think about it, that's really a misnomer.
ALEXANDER A. PARIKH: Because that's only really taken up three segments, right? So a true right trisection is five segments. So a 5, 6, 7, 8 plus 4. The other thing we oftentimes use is extended right hepatectomy So anything above 5, 6, 7, 8, you know, whether you take part of 4, is an extended right, or extended right hemihepatectomy. And again, the easiest thing to do is just when you dictate an off note, or you look at just what segments did you take out, everyone understands that.
ALEXANDER A. PARIKH: Same with the left, the left trisection, which is probably the hardest liver resection there is because you're going to need a liver, 2, 3, 4, 5, and 8 for an extended left or an extended left hemihepatectomy. Next slide, please. And then now we have a different segmental resection. So you can just resect the segment, or as shown here, is a sectoral section.
ALEXANDER A. PARIKH: So the right anterior sectionectomy, which I don't think anyone does. It's very, very difficult. It's right smack in the middle liver, segments 5 and 8, a right posterior sectionectomy which is pretty common. So you take out that posterior sector. Again, everything behind the right portal vein, 6 and 7, left medial section, you will sometimes do. What's more common is what we call a central hepatectomy, part of 4b and 5.
ALEXANDER A. PARIKH: For example, for gallbladder cancer. And then the left lateral, again, you'll hear left lateral segmentectomy, well, it's really a sectionectomy, right, 2 and 3. If it's only one segment, we will call it. But again, some of the misnomers. But this is very important to understand when we're talking about liver terminology, when you try to figure out what operations you're going to do.
ALEXANDER A. PARIKH: And as I said, more and more, we are doing many more of these segmental resections now as opposed to the entire liver. I don't get into colorectal mets per se. But we know now that as long as we get negative margins, it's the same really thing for cholangiocarcinoma, or hepatocellular cancer. If you get negative margins, there's no reason to take out more of the liver than you have to.
ALEXANDER A. PARIKH: But that requires understanding the interparenchymal anatomy of the liver in order to get a safe resection. Any questions in accordance to liver terminology or resection terminology here? As you can tell-- [INTERPOSING VOICES]
A. ALFRED CHAHINE: This is extremely helpful, Dr. Parikh. Thank you so much. This is wonderful. Yeah.
ALEXANDER A. PARIKH: Well and good. OK. Next slide, please. So I mentioned portal vein embolization. And this is really exciting. This is something that we-- so as we know, we know that if you take out part of the liver, particularly a portal left or right, the other liver or the hemiliver that's left, will grow up to 90% of its original size, which is a great thing.
ALEXANDER A. PARIKH: That is the only organ in that'll do this. So one strategy is well, how about if we jumpstart? So in other words, let's say you're going to take out the right liver or an extended right, or right trisection, and the liver left behind is not very big. It's less than 30%. Maybe, it's a fatty liver. So it's not even that functional.
ALEXANDER A. PARIKH: Is there something you can do that can jumpstart this? It's what we call portal vein embolization. So what we do there is we basically hypertrophy the future liver remnant. And we shrink the side coming out. Next slide, please. So this is what we do. And this is going to be done by CT or MRI. The first thing we do is we look at the total volume of the liver.
ALEXANDER A. PARIKH: So for example, this patient that need to extend it right, and you can tell just from here the left liver is not very big, we do a 3D imaging. Again, this is done here by CT but it's also done by MRI. Total volume is 1700 cc. Next slide, please. And then we can map out. In this case, there's other lesions here. But the patient needed a right-- a little extended right.
ALEXANDER A. PARIKH: And you can see what's left behind is in the blue, and that's the 3D image. So then we can look at what's left. It's 345 cc, or mls. So the volume there is 345, over 1770 cc of the total. So our future reserve, future remnant liver volume, is only about 20%, not enough. Or certainly, a lot of you would be nervous resecting over 80% of a liver.
ALEXANDER A. PARIKH: Next slide. So then what can be done is right portal vein embolization. It's shown here on the left. This is, again, done by interventional [INAUDIBLE].. You know something about liver surgery, if you're going to do liver surgery, you really have to be-- you have to have a great team and interventional radiology is really critical to have if you're going to do any liver operation.
ALEXANDER A. PARIKH: So there's a percutaneous going into the liver. Typically, on the right side, you can see that wire going in. And then what you can see on the right side is it's been coiled. So the right anterior and posterior portal vein have been closed. So basically, the blood supply, that has been knocked out. And what that will do is it'll shift blood flow to the left liver as opposed to the right. Next slide, please.
A. ALFRED CHAHINE: There was a question, Dr. Parikh.
ALEXANDER A. PARIKH: Yeah. OK. Yeah. So there's a question about differential response. And the answer is yes. So healthier livers do have a better response. The other thing is, before you look at this, you have to look at, for example, cholangiocarcinoma as, if let's say you have a right sided intrahepatic cholangio, and the right portal vein is already affected, you may have already had hypertrophy of the left side, in which case doing a portal vein embolization will not help.
ALEXANDER A. PARIKH: The ironic thing in all this is the patients that are cirrhotic are the ones who really need this hypertrophy in the portal vein. But you are right. They oftentimes do not get that robust hypertrophy as a normal liver. So again, we oftentimes will do it. But I can tell you if the residual volume in a cirrhotic is only 19 and 1/2%, it's going to be very difficult to get to the point with a resectable.
ALEXANDER A. PARIKH: Our threshold for patients that are cirrhotic are definitely less. If you only have 30% or 40% even the cirrhotics, a lot of us will go ahead and embolize to get that close to 50%, if at all possible. So shown here on the top line is a patient of mine that had to undergo an extended right hepatectomy. You can see that liver lesions there. And then after portal embolization, vein embolization, you can see the coils on CT.
ALEXANDER A. PARIKH: The bottom two are the CT scan after. You can see that left liver, how much larger, particularly in the right lower, how much larger that liver. So really, I went into this operation only taking out about 30% of liver as opposed to 75% of that liver, or 80% initially. So again, a very, very important tool for us in liver surgery. Next slide, please.
ALEXANDER A. PARIKH: So in terms of the summary of the malignancy. So again, metastatic disease, we didn't talk a lot about that colorectal, by far the most common, 20 to 1 over primary liver tumors. Of the primary liver tumors, hepatocellular cancer, the most common cancer worldwide is to the stomach, hepatocellular cancer. Fibrolamellar is the best overall diagnosis, very well differentiated, diffuse nodular worse.
ALEXANDER A. PARIKH: Remember AFP is a very sensitive and specific marker for hepatocellular cancer. Almost all these patients have cirrhosis. There are some systemic therapy options, which can be used now for hepatocellular cancer. But again, they're not as curative. So transplant resection, liver-directed therapy are still number one on your list over the systemic therapy. In terms of intrahepatic cholangiocarcinoma, again, tumor of the bile duct, the intrahepatic bile ducts.
ALEXANDER A. PARIKH: Therefore, it is an adenocarcinoma. It's a glandular tumor. Ca 19-9 is very helpful, ruling out metastatic disease. The third one that comes up every once in a while is hepatic sarcoma, very rare, I can tell you. I would say less than 1% of liver resections I've done in my career had been for hepatic sarcoma. So not very common. But certainly, it gets mentioned in textbooks, which is why I mentioned that there.
ALEXANDER A. PARIKH: Next slide, please. So a couple of questions. So here's a question here. 62-year-old male, history of hepatitis C, Childs A cirrhosis, has a 3-centimeter lesion in segment 4, 2.3 centimeters in the segment 6, and a 1.5-centimeter lesion in segment two, all consists of hepatocellular cancer, elevated AFP, et cetera, nothing outside the liver.
ALEXANDER A. PARIKH: What would your step be in management? OK.
ALEXANDER A. PARIKH: Most everyone is saying E. I agree with that. Next slide, please Actually, you may have to go back. Go back, I'm sorry. I had a little circle. So I do agree with E. I think C and D, as we talked about, are not unreasonable. For example, if this patient is not a transplant candidate, I agree that they should be referred for a transplant liver-directed therapy.
ALEXANDER A. PARIKH: Again, we have multiple lesions here. But for example, ablation could be very helpful, because you have multiple segments. Three separate segments, you can certainly ablate those. They are all reasonable in size, again, under 5 centimeters. Multiple segmental resections, I think are reasonable, again, depending on where it is. They're all, 4, 6, and 2 are fairly peripheral, Childs A cirrhotic.
ALEXANDER A. PARIKH: It's kind of borderline. If they're otherwise healthy, let's say they are not a transplant candidate for whatever reason, it's not totally unreasonable to do segmental resections. They are a little bit of higher risk of complications, certainly, not totally out of realm. But I agree. Liver transplant is something I would do first. I think that extended left, I would not do to get them all.
ALEXANDER A. PARIKH: I think that's way too much in the cirrhotic. I think oncology for systemic therapy as we talked about is not primary. They may need that as well. But certainly not the primary treatment regimen or the choice of treatment. Next slide, please. I'll let you guys answer this in terms of the SCORE School but [INAUDIBLE] OK.
A. ALFRED CHAHINE: Apparently, we're getting an error message on the QR codes. And so we'll look into it afterwards. Yeah. Thank you sorry about that.
ALEXANDER A. PARIKH: Any other questions when it comes to malignant and benign? OK. So I'm going to give to back-to-back questions here. So now you're in the operating room, and you're undergoing a cholecystectomy. And you notice a liver lesion in segment 6, what are you going to do? Right hepatectomy with the cholecystectomy, ultrasound the liver, core biopsy if needed, biopsy it, or just leave it alone and do a cholecystectomy.
ALEXANDER A. PARIKH:
A. ALFRED CHAHINE: All right.
ALEXANDER A. PARIKH: All right. Yeah. A lot of B A lot of D. Good point brought up. I know [INAUDIBLE] in the cholecystectomy. So that's also good. So I agree. A is not right. I would not do a right hepatectomy. You probably don't have a consent for that, well, with the cholecystectomy.
ALEXANDER A. PARIKH: I think B, if you're hepatobiliary surgeon, and you're comfortable with ultrasound, I personally would do B. I would ultrasound the lesion into liver. And if this is a solid lesion, I think a biopsy is reasonable. Typically, on a consent, we have other indicated procedures. If there's something large, then you can oftentimes go talk to the family. And as shown here, yes, we have a case for possible liver biopsy.
ALEXANDER A. PARIKH: And the chole consent if I just put other indicated procedures, and I tell my patients, if I see anything, you know we'll go ahead and do that. But I would prefer the ultrasound. If there's a specific lesion, you would do anything. You also want to look at the rest of the liver. Oftentimes, patients undergoing a cholecystectomy probably did not get a CT of the liver. They may have only had an ultrasound.
ALEXANDER A. PARIKH: And so you have an early stage. This patient, I mean, you know, we don't know really what's going on. So I would not really resect it. Biopsy the lesion itself, it kind of goes along with B. If you really want to know what it is, you want to know if it's there's multi [INAUDIBLE] or can the ultrasound give you an idea of what it is. You can oftentimes tell a hemangioma by ultrasound, which we don't want a biopsy, that lesion.
ALEXANDER A. PARIKH: So I would definitely not biopsy it without ultrasounding. And leaving lesion alone and performing the chole, that's not unreasonable. Certainly, if you saw that. But you know, while you're in the operating room, if you have ultrasound available, I think that's certainly some option if you do it. And yes, you can do an ultrasound laparoscopic, again, if you're available, if you have a hepatobiliary surgeon that can do that.
ALEXANDER A. PARIKH: And I'll show you some pictures of that. Next slide, please. So in terms of liver biopsy, you know, why do it? Do we do it? And I think that as hepatobiliary surgeons, we don't do them as often. Number one, and I think we all have to think about that, is it going to affect what you're going to do?
ALEXANDER A. PARIKH: If the results of the biopsy are not going to make a difference, then don't do it. There's always risk to this. As I showed you, our imaging characteristics in lab is enough. If you have a patient who has cirrhosis with elevated AFP, and it looks like hepatocellular cancer, you don't need that. You have a patient who had a history of colon cancer, got it resected, has a liver lesion and elevated CEA that lights up on PET, it's probably metastatic colorectal cancer.
ALEXANDER A. PARIKH: You probably don't need to biopsy that. Other associated medical history, again, cirrhosis is the big one. History of other cancers, particularly colon or another one. Is that a routine scan or do you see it intraoperatively? If you see it on a CT scan preoperatively, it's a lot different to go to radiology versus the scenario I just gave you, or in the OR itself.
ALEXANDER A. PARIKH: Now it's a biopsy. Do you feel comfortable doing intraoperative liver biopsy? And certainly, you know, laparoscopically as most of these are often done. And then there's the risk of biopsy. Where is the location? If it was right next to a major blood vessel, or next to the major bile duct, that may be difficult. Are the patients coagulopathic?
ALEXANDER A. PARIKH: And again, this is something that's preoperatively-- a lot for patients, certainly in Eastern Carolina, are on some sort of anticoagulation, or Plavix, or something. And that's a problem. Not many people are going to be comfortable putting a needle into the liver. Are you are you comfortable taking them off of that medication?
ALEXANDER A. PARIKH: Or they have thrombocytopenia. Certain lesions, we talked about, hemangioma, you definitely don't want to biopsy that. So these are considerations. And again, I think between all the different tests and the history and imaging, less and less do we actually need a liver biopsy. In terms of the technique, by far, the most common is percutaneous.
ALEXANDER A. PARIKH: The important thing to remember here is if you can't see it on ultrasound or noncontrast CT scan, the radiologist are going to have a really hard time getting this. This is not something they give IV contrast to and then run in and do this percutaneous biopsy. That's a very difficult. And they certainly-- most places do not do it under MRI. So they've got to be able to see it on their ultrasound or noncontrast CT.
ALEXANDER A. PARIKH: Laparoscopic, again, ultrasound guided, it's certainly an option. I think in most patients, particularly if they're undergoing a lap chole, for example. And I get called in by some of the general surgeons, we'll lap chole. Take a look, and I'll ultrasound the liver and biopsy if needed. And certainly, intraoperative open. If you're doing an open operation, that's certainly much easier to palpate the liver and biopsy it.
ALEXANDER A. PARIKH: So those are kind of in your mind when you're thinking about a liver biopsy. Next slide, please. I know we're running out of time. But so, I want to quickly go through a liver ultrasound. Because there were some-- and I think that one thing I have to say is that I really didn't understand liver ultrasound until I was a fellow.
ALEXANDER A. PARIKH: I will say, if you're going to operate in a liver, you have to be fast [? with ?] liver ultrasound yourself. Especially with all these segmental resections. It's really. really important to learn how to do that. It can be open or laparoscopic. You want to mobilize the liver as much as you can. And you really want to do it before anything else. Because it may make a difference.
ALEXANDER A. PARIKH: I mean, if you're playing a liver resection, the first thing to do is ultrasound and make sure I don't see a surprise, or may change the operation I'm doing. See what I really want to do before anything else. Next slide, please. So the goals, you want to map, anatomy and vascular structures vary enough. In your mind, as I showed you these segments, first thing I do is I map out all the segments in my mind, think of 3D using the ultrasound to look.
ALEXANDER A. PARIKH: You want to identify and measure all the lesions. What segments are they? What are they near? You want them marked and ensure adequate margin. We will mark our margins with the ultrasound itself. So we know where we're resecting. And you also want to ensure adequate inflow and outflow. For example, you can use Doppler. So if I clamp something, or if I resect something, I'll again, and use Doppler to make sure there's adequate inflow and outflow of the rest of the liver.
ALEXANDER A. PARIKH: Next slide, please. So the anatomy again. Next slide, will go over that again because we have seen that slide a million times now. So when you do the probe, you want to do it-- you want to rotate. So you want to go side to side, up and down. And you don't when you want to press very hard.
ALEXANDER A. PARIKH: It's a rotation. Next slide. That's the up and down on the liver, and then again the side to side of the liver. Next slide. So this is the first position. For example, I always start at the confluence, the three hepatic veins here. Next slide, I'll share an ultrasound image of that.
ALEXANDER A. PARIKH: Again, this is the schematic. Here at the top, you're going to see the left, the right, and the middle veins. And again, in your mind, the segments. This is a pie now. So you're going to look at again, 2, 4, 8, and 7. And you see it very clearly on the ultrasound. Next slide, please. And this is it here.
ALEXANDER A. PARIKH: So example, you see this. You see segment 7 and 8 divided by the right hepatic vein. You see the middle hepatic vein joining with the left, and then to the IVC, which it usually does. And that separates 8 and 4, the right and the left liver, and then segment 2 up top. So that's the view that I always try to get first at the top of the liver. Next slide.
ALEXANDER A. PARIKH: Then you go down, typically, to the portal bifurcation on the right. Next slide. Again, this is the area you can see, on the white line, you're going down now. So now you're right in the middle. So now the portal vein is in there. And so again, you're at the border of the top and the bottom livers, the border of 6, 7, the border of 5, 8, 4a and 4b, and 2 and 3.
ALEXANDER A. PARIKH: If you go lower down, you're in the lower parts. Again, 3, 4b, 5, and 6. Again, depending on the ultrasound, you can see these hepatic veins much more in the periphery now as you get down on the liver. Next slide. So shown here, the right portal vein. You can see Doppler flow, as I said. This is the right anterior and posterior bifurcation, you can see the red that's going up.
ALEXANDER A. PARIKH: That's the right anterior. The blue, because there's flow, that's opposite, it's going posterior, but that is the right portal vein. So you'll see that, again, by Doppler, identify that. Next slide. The other thing we do, the main portal vein here, the bifurcation here. Next slide. And then here, it will come here as I labeled it.
ALEXANDER A. PARIKH: The right portal vein is there. The left is there. That's the actual bifurcation. You can actually see the branches on the left. There's the IVC. There's the caudate lobe. And there's the ligamentum venosum, which is underneath that left lateral sector or ligamentum Arantius.
ALEXANDER A. PARIKH: Again, these are the different images that you can see on the ultrasound. And you can do this laparoscopically, or open. These all happen to be open image. You do laparoscopically as well. Next slide. And then finally, position 4, right on the falciform ligament. Next slide.
ALEXANDER A. PARIKH: Concentrating on the left, and here you can see the different segments. Segment 1, the caudate. So that's the left portal being shown there right in the middle. You can see the branches going off to 3, down to 2, and then there's segment 4. And then that's right in the falciform. You basically can see the entire left liver, that one in the arrow where there's actually a cyst in segment 2 of the liver with a thicker arrow width.
ALEXANDER A. PARIKH: Next slide. And then the other thing I would like to ask for is how do you tell the hepatic vein versus the portal vein. Well, again, the portal vein has that sheath around it. So you can see that bright acrogenecity around the portal vein versus hepatic vein, which is just pure black, much thinner.
ALEXANDER A. PARIKH: It's also much more compressible. If you compress that liver with that ultrasound, those hepatic veins, presuming you have a low CVP, will actually collapse. The portal vein will not. So that's how you can tell the difference between hepatic vein and the actual portal vein. Next slide, please. For those questions here, the laparoscopic ultrasound.
ALEXANDER A. PARIKH: So here we typically will put in, it's a 10, 12, port. So the 10, most of the ultrasounds, they reticulate, which is good. But it is a larger port. I'll oftentimes go ahead and either put the port umbilical, or in the left side, we can go through here and articulate. And oftentimes, we'll just go through the falciform one underneath it. And you can actually ultrasound in robotically as well for those.
ALEXANDER A. PARIKH: I don't do robotic liver in the laparoscopic. But for those do a robotic liver, there's also robotic probes that you can also use for the liver. Again, different positions. Next slide. Terms of detection. Cyst versus solid, ultrasound is great on that. Cysts are typically black with a comet tail.
ALEXANDER A. PARIKH: Solids are bright here in the [? hemangiomas. ?] adenomas, you can actually tell that. Next slide. I'll give you some examples of that. I know we're running out of time. Cyst, again, very dark here, fluid-filled. You can see that little, where the [INAUDIBLE] is, that comet behind is actually brighter because the sound waves travel faster through that liquid.
ALEXANDER A. PARIKH: Next slide. Hemangioma. That bright, that's actually very compressible, is very indicative. So if you see a lesion like this in the ultrasound, that's hemangioma. You're just going to leave it alone. Next slide. Tumor, again, shown here is an MRI and CT.
ALEXANDER A. PARIKH: What it looks like in the left lower quadrant there, a solid lesion Next is some blood vessels, hyperechoic, I'm sorry, hypoechoic solid lesion, or certainly, a tumor. Next slide. And the other thing we like to do is margins check. For example, here in the pink outline is the actual tumor. The reason that you see that white is actually we [INAUDIBLE]. So for example there's markings on the ultrasound.
ALEXANDER A. PARIKH: So if I'm going to do my parenchymal margin in my resectional, and I will mark it on the surface of the liver, put an ultrasound, you'll see shadowing all the way down. And you can measure your distances. So yes, we would have that margin prior to any liver resection. You can do this over and over again as a resected liver. Next slide, please.
ALEXANDER A. PARIKH: And that should be it. So I want to thank you I'm sorry I ran a few minutes over. But I appreciate it. Any other questions, please go ahead and put on the chat board. All right. All right.
A. ALFRED CHAHINE: Thank you so much, Dr. Parikh. This was wonderful. We appreciate your insights. And take care, everyone. And don't forget, you can view this. Tell your friends to view them asynchronously on the site. Good night.
ALEXANDER A. PARIKH: Absolutely. And good night. If you need to look me up, any questions, please let me know. Thank you.
A. ALFRED CHAHINE: Thank you. We're going to stop the recording. And have a good night.

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Segments