Treatment of primary and secondary liver malignancy

The management of hepatic malignancy is one of the most controversial areas in medicine. It is a continuously evolving field which requires a multimodal approach and the inclusion of a medical oncologist, a hepatobiliary surgeon, a radiotherapist, an interventional radiologist and in some cases a transplant surgeon. In addition, the recent development of novel approaches such as neoadjuvant tumour therapy, cryosurgery, thermal ablative techniques as well as biological and immunological manipulation of malignant cells has added to the complexity of this field. Today, the availability of such innovative modalities, in the absence of an extrahepatic localisation of disease, allows the potential to cure many large primary and secondary hepatic tumours. However, the appropriate use of these various treatment modalities should be limited to centers with experience in treating patients with advanced disease where innovative study protocols are available. Experience of the surgeon with difficult hepatectomies is of paramount importance. Currently, mortality following major hepatectomies in non-cirrhotic patients is below 5% in centers of reference. For example, in the series from Duke University Medical Center there were no fatalities in more than 150 liver resections in patients with benign diseases and a 2% mortality in more than 300 patients with malignant diseases. Mortality, however, reached 5% in cirrhotic patients undergoing a resection involving more than 2 segments. This review will attempt to focus on an overview of the diagnosis and treatment of a selection of more common hepatic malignancies.