Genetic mutations

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Peregrine
Posts: 99
Joined: Tue Mar 01, 2022 1:18 am

Re: Genetic mutations

Postby Peregrine » Fri Jun 03, 2022 4:10 am

Lo-oc wrote:... Laparoscopic liver resection set for June 6th, and radiation to start right after, so no chemo until after that's wrapped up...

Lo-oc -

Good luck on your liver resection next week! We'll be thinking about you on Monday.

I don't know much about liver resections, but I noticed that the College of American Pathologists (CAP) has a template for primary liver cancer resections (see link below). You might be able to gain some insight about the surgery by looking at the template and noticing what kinds of pathology data elements are required, and what kinds are only optional. The document states clearly that this template is not designed for reporting of metastasis resections. However, there is no template specifically designed for mets so the template below is probably the closest one that might apply.

I'm not even sure what kind of pathology report will be generated from your liver resection (if any), but if they do generate a path report it would be good if you could be sure to get a copy of it (not just an oral summary of it) and try to understand the findings. The template cited below has references to hepatic steatosis and other indicators of liver health, so you might be able to get some idea about the important things that a pathologist would be looking for and also get some idea about how fast your liver remnant can recover from the surgery, given whatever liver abnormalities you already have.

Apparently there is no template designed specifically for the reporting of genomic biomarkers found in liver resections, so I'm not sure if they will be sending any resected tumor tissue out for genomic testing. But you could always ask the surgeon if there is a way for you to get genomic testing done on the resected tumor because the test might have some useful information for future treatment planning. It might require special authorization from your insurance company, however, or the surgeon might say that the information gained from such a test might not be worth all the expense.

Also, you might be able to get some feedback from members here who have already had liver resections and who might have received path reports from their surgeries.

Primary Liver Cancer - Pathology Template
https://documents.cap.org/protocols/Liv ... _CAPCP.pdf

There is also no template defined for liver cancer biometric (genomic) markers, but there is a template for colorectal cancer genomic biomarkers. (see below). This template lists some of the main mutations found in colorectal cancer specimens, e.g., KRAS, NRAS, BRAF, PIK3CA, HER2, etc.

Colorectal Cancer - Pathology Biomarker Template
https://documents.cap.org/protocols/ColoRectal.Bmk_1.3.0.0.REL_CAPCP.pdf

Another question you might ask is whether your liver mets are considered oligometastases or not.

 "Patients with limited metastatic disease in which long-term control or even cure may be achievable are regarded as oligometastatic. The definition of oligometastatic is continually evolving, but typically refers to patients with 1-3, or 1-5 metastases".

Reference:  https://appliedradiationoncology.com/ar ... metastases


Good luck, and take care ...

Lo-oc
Posts: 21
Joined: Sat Mar 26, 2022 4:40 pm

Re: Genetic mutations

Postby Lo-oc » Fri Jun 03, 2022 10:25 am

Thank you again Peregrine for the relevant and helpful information, a reason why discovering this forum has eased my mind and shown what to expect and ask.
thank you for the well wishes for liver surgery Monday, although I had asked the oncologist I will be asking the surgeon about genetic profiling of the liver met, the oncologist said that a specimen would be saved to test, but won't automatically be done initially. Maybe the liver surgeon can submit a request for this to happen (I'm sure it's all because of the expense and what insurance will cover).
Although I have not heard the term "oligometastatic" the oncologist initially told me that the liver mets were operable and he is moving forward with a curative intent with my treatment. I will post after the resection, anything that I can share that can help someone else out is so worthwhile. I'm hoping the resection won't be too bad, suppose to be laparoscopic but will prepare for anything mentally. I have met with the radiation oncologist, have an appt for the CT simulation, and will start radiation treatments towards the end of June. Although the 3 Folflox and 1 5FU have shrunk the rectal tumor so that it can no longer be felt, that confirms what the rectal surgeon said, the tumor has shrunk and flattened out, but without the radiation there is not chance to get clearance from the AV without it - this will be my next hurdle.
As you brought up on the stage IV checklist that people might find helpful, too much information too quickly just doesn't get absorbed, at least for me, that is why my husband comes along to listen and write down what the doctors are saying. I think a checklist is a great idea for newbies though, possibly broken down into stages, but as you have all said it's important to get an overall picture/direction of how each person's cancer will be treated.
all the best.........
2/22 - Dx with stage 4 rectal cancer 4cm on/1cm from AV - age 60
T4, poorly diff., EMVI + MSS
3/22 - CT/MRI 2 liver mets 2.1 cm and 1 smaller close to hepatic vein
3/22 Infusion - plan 6 treat. Folflox 6, liver res., chemoradiation, rectal surgery 6 more cycles Folfox
5/5 - CT/MRI, lung nodules no change, liver lesions red. to 1.1 and .9cm, rectal tumor/suspicious lymph node red..

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Peregrine
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Joined: Tue Mar 01, 2022 1:18 am

Re: Genetic mutations

Postby Peregrine » Thu Jun 16, 2022 9:46 am

Lo-oc wrote:... I will post after the resection, anything that I can share that can help someone else out is so worthwhile. I'm hoping the resection won't be too bad, suppose to be laparoscopic but will prepare for anything mentally...

Hi Lo-oc,

I see that you have logged in here three or four times since your surgery, but you haven't posted anything so far. I hope everything is OK.

Are you still in the hospital, or are you now back at home?

Take care ...

Lo-oc
Posts: 21
Joined: Sat Mar 26, 2022 4:40 pm

Re: Genetic mutations

Postby Lo-oc » Thu Jun 16, 2022 12:50 pm

Hi Peregrine,
Thanks for thinking of me. Liver resection done, just home recovering day 10 post op. My only glitch was about 12 hours of Afib the day after the surgery, and some neck pain from laparoscopic gas. Will meet with cardiologist, they think it was caused by the surgery, who knows?
Liver surgeon said there were no surprises, wedge resection on the larger met (about 1 cm), the smaller one he had a hard time locating, treated with ablation. I did ask about the heat sink effect, as it was close to a major vein, he assured me it was far enough from the vein and used microwave? ablation. There was about 5 percent liver steatosis (fatty liver), not sure if that was from chemo or just my 61 year old liver. The tumor removed was the same as rectal tumor from pathology, indicated 70 % necrosis, I can't tell if that is good or bad? waiting on genome testing on it. He did a wedge resection and removed about 10 percent of my liver.

I'm not sure why I am feeling so defeated after this surgery, it went well and I have no business feeling that way, but maybe it's just the anticipation that I will probably be back doing another resection. Im' not sure where people get the inner strength to keep soldiering on, I am in awe of the mental fortitude some have.
Had my ct simulation for the start of chemoradiation next week for the rectal tumor - it sounds tough, any advice?
positive thoughts to you all.........
2/22 - Dx with stage 4 rectal cancer 4cm on/1cm from AV - age 60
T4, poorly diff., EMVI + MSS
3/22 - CT/MRI 2 liver mets 2.1 cm and 1 smaller close to hepatic vein
3/22 Infusion - plan 6 treat. Folflox 6, liver res., chemoradiation, rectal surgery 6 more cycles Folfox
5/5 - CT/MRI, lung nodules no change, liver lesions red. to 1.1 and .9cm, rectal tumor/suspicious lymph node red..

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Peregrine
Posts: 99
Joined: Tue Mar 01, 2022 1:18 am

Re: Genetic mutations

Postby Peregrine » Thu Jun 16, 2022 2:30 pm

Lo-oc wrote:...Had my ct simulation for the start of chemoradiation next week for the rectal tumor - it sounds tough, any advice?...

Hi Lo-oc,

I don't have any personal experience with neoadjuvant chemoradiation, but there are plenty of members here who have had such experience. Here are some of their comments on radiation proctitis and other topics.

MadMed
Posts: 146
Joined: Sun May 02, 2021 5:52 pm
Location: Massachusetts

Re: Genetic mutations

Postby MadMed » Thu Jun 16, 2022 3:20 pm

I can share my experience, it was November 2021. The process is as follows:
Chemo Pills every week-day (Mon-Fri) depending on your weight, could be a bunch of pills. The pills are capecitabine (Xeloda) available in 500mg and 300mg. I was on 3200mg a day, so mix and match.
My oncologist wanted me to be on the chemo pump due to some stomach issues in previous treatment. Capecitabine can cause digestive issues:https://www.webmd.com/drugs/2/drug-7777/capecitabine-oral/details#:~:text=Nausea%2C%20vomiting%2C%20loss%20of%20appetite,or%20relieve%20nausea%20and%20vomiting.
I managed to get the pills and tolerate them. 5 days a week of chemo pump was not something I wanted to do. The pills will turn in 5FU in your liver and be equivalent to the 5FU pump we get for regular chemo. Its purpose is to amplify the effect of the Radiation.

Radiation itself is every week-day, you show up, badge in, lay on a table, lower your pants and in less than 10 minutes you are done and can go home. It's super quick and painless. There's a big arm that rotates around your hips and gives you high dose X-Rays.
Image

Before you get radiation, you do what's called a simulation. They do a quick CT and put markers on your body, mine were tiny tattoos (little dots on my hips). Some are offered markers that you should not wash, tattoos are better. This marking helps position you on the table using lasers, they really need to target the tumor, so they want to be as precise as possible.

The effects of radiation didn't show up for me until the 4th week. I was scheduled to get 28 treatments. The first three weeks were so uneventful that I told the doctor that it was not working. The chemo pills had little effect on me, some diarrhea and some mild nausea that I headed off with the meds i had from the actual chemo. Urinating was interesting, because of inflamation and swelling, i had to go on FLOMAX. Full bladder and nowhere to go was weird. Thankfully, that was managed.

At 4 weeks, i started to darken seriously around my groin and thighs, then I started having a bit of pain when having a bowel movement. The pain kept getting worse and worse. It didn't get better until 3 weeks after i finished. It is basically getting a really bad sunburn in your butt!

You should be meeting with the Radiation Dr once a week, every week. Ask for help and tell them what's going on with you.

What can you do to help:
Ask and apply novocain locally
Get the lotion they recommend or give you
Hydrate plenty, drink a lot and make sure you are hydrated
Use a sitz bath, i tried it once but i found that using the shower head worked better for me.
Apply cream after treatment, you are going to get a sunburn down there.

Now, my tumor was very low, 1.5 cm from the anal verge, so that means my sphincter was burning like you can't believe. Others that have a higher tumor, further in have less pain and manage better.

This is what I can think of right now, check also NHMike's reports on his radiation, he gives a ton of information and walks you through every treatment. Ask any questions you may have.
52M DX: RC lower rectum, guessing now 2cm from AV 4/27/2021
T3N0M0 adenocarcinoma with signet ring cell features
Tumor size 30mm
Tumor grade: G3
Baseline CEA 1.0
MSI status: MSS pMMR
Started Folfox 5/12/2021
Switched to FOLFIRINOX from session 2. 8 rounds total.
CT+MRI tumor contained shrunk 80%, no spread to other organs.
CRT started xeloda + 28 days Radiation 9/27-11/04
NED as of 4/06 CT/MRI/sigmoidoscopy
On W&W 04/06/2022

Lo-oc
Posts: 21
Joined: Sat Mar 26, 2022 4:40 pm

Re: Genetic mutations

Postby Lo-oc » Thu Jun 16, 2022 4:31 pm

thank you MadMed for sharing your experiences, it's really helpful. My situation is very similar to yours, low rectal tumor 1 to 2 cm from anal verge, so I'm guessing I can expect some significant pain - did you take anything for pain, or use the Novocain and lotion they recommend?
I was curious about the amount of Xeloda (which turns into 5FU) - is it roughly the same amount of chemo that is given during the infusion? or is it a lessor amount that over 5 and 1/2 weeks amounts to about what is given during an infusion of 5FU - do they monitor your bloods just as they would with 5FU infusion?
I'm going to expect the worse and hope for the best - appreciate your input.
thanks Peregrine for the links to read about others who have undergone the chemoradiation prior to surgery, always appreciate your help.
2/22 - Dx with stage 4 rectal cancer 4cm on/1cm from AV - age 60
T4, poorly diff., EMVI + MSS
3/22 - CT/MRI 2 liver mets 2.1 cm and 1 smaller close to hepatic vein
3/22 Infusion - plan 6 treat. Folflox 6, liver res., chemoradiation, rectal surgery 6 more cycles Folfox
5/5 - CT/MRI, lung nodules no change, liver lesions red. to 1.1 and .9cm, rectal tumor/suspicious lymph node red..

MadMed
Posts: 146
Joined: Sun May 02, 2021 5:52 pm
Location: Massachusetts

Re: Genetic mutations

Postby MadMed » Thu Jun 16, 2022 5:21 pm

So in terms of the pain, good news is that it's not constant pain, only when I went #2. Bad news is that it was like crapping blades and got worse until a couple of weeks after radiation.
I did take the novocain after to calm things down and was for the most part ok during the day and night. Sitting might be uncomfortable, use a soft pillow or a donut.

The Xeloda is much less than regular 5FU chemo and more manageable. Honestly, the chemo part was no big deal. I had maybe nausea one time and felt chemo brain one day at the beginning.

The other piece of good news is that you might get the cancer completely wiped out by chemoradiation. I am yet to have LAR since last scan was clear. I am obviously waiting and expecting a recurrence, but a number of people get away with no surgery!
52M DX: RC lower rectum, guessing now 2cm from AV 4/27/2021
T3N0M0 adenocarcinoma with signet ring cell features
Tumor size 30mm
Tumor grade: G3
Baseline CEA 1.0
MSI status: MSS pMMR
Started Folfox 5/12/2021
Switched to FOLFIRINOX from session 2. 8 rounds total.
CT+MRI tumor contained shrunk 80%, no spread to other organs.
CRT started xeloda + 28 days Radiation 9/27-11/04
NED as of 4/06 CT/MRI/sigmoidoscopy
On W&W 04/06/2022

MadMed
Posts: 146
Joined: Sun May 02, 2021 5:52 pm
Location: Massachusetts

Re: Genetic mutations

Postby MadMed » Thu Jun 16, 2022 5:34 pm

btw, this may be interesting. I was fascinated with the technology behind the radiation. It is spectacular. The process I had is called VMAT-IMRT. It basically means the Dr made a 3D model of the tumor and precisely burnt slices of the tumor with the beam. They even hit the lymph nodes nearby:
https://www.youtube.com/watch?v=QcdrIZVos50

One more thing, the treatment is 25+3. 25 regular treatments and then 3 boosted, meaning more focused beam.
52M DX: RC lower rectum, guessing now 2cm from AV 4/27/2021
T3N0M0 adenocarcinoma with signet ring cell features
Tumor size 30mm
Tumor grade: G3
Baseline CEA 1.0
MSI status: MSS pMMR
Started Folfox 5/12/2021
Switched to FOLFIRINOX from session 2. 8 rounds total.
CT+MRI tumor contained shrunk 80%, no spread to other organs.
CRT started xeloda + 28 days Radiation 9/27-11/04
NED as of 4/06 CT/MRI/sigmoidoscopy
On W&W 04/06/2022

Claudine
Posts: 694
Joined: Tue Mar 12, 2019 2:41 pm
Location: Montana

Re: Genetic mutations

Postby Claudine » Thu Jun 16, 2022 5:39 pm

Hi Lo-oc,
My husband is smack in the middle of this (finishing week 3 out of 5). He gets IMRT radiation every morning 5 days/week and takes 3 capecitabine pills twice a day (once morning once evening). So far it hasn't been too bad, he had Xeloda before which caused hand-and-foot syndrome but that hasn't happened yet. Now his situation is a bit different in that this is adjuvant treatment - he had LAR in April, with a fairly low tumor (4cm from AV); the reason he didn't get the treatment prior to surgery was that his MRI indicated a T1/2 tumor... But it turns out it was T3 (barely, but still), so even though he's got a low chance of recurrence, he decided to get pelvic chemoradiation anyway. So he has an ileostomy, which means no #2 - no pain with BMs; but he has to be very careful with hydration. Main thing has been fatigue, and not feeling great towards the end of the week, but weekend breaks from treatment have been helpful. He still works full time. He's scheduled for a blood test tomorrow; if toxicity from Xeloda is too high, his onc will cut the dose a bit.
Good luck! I hope you get complete response and can avoid/postpone LAR, as it comes with its own suite of issues.
Wife of Dx 04/18 (51 yo). MSS, KRAS G12A, no primary
Lytic met L4 vertebrae, EBRT 04/18, SBRT 02/19
Resect small intestine 05/18 (no cancer - Crohn's)
Failed adjuvant Xelox ; Folfiri + Avastin 03/19 to 01/20
6.7 cm left adrenal mass 03/19, successful resection 02/20
Multiple small lung nodules (03/19) now gone/calcified
L3-L4-L5 fusion surgery and partial corpectomy 05/20
CEA since 03/19: high 81.1, low 3.2, now 66
MRI 2/11/22: rectal adenocarcinoma pT3 pN0 stage 2A
LAR surgery April 11

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Peregrine
Posts: 99
Joined: Tue Mar 01, 2022 1:18 am

Re: Genetic mutations

Postby Peregrine » Thu Jun 16, 2022 10:18 pm

Lo-oc wrote:... I was curious about the amount of Xeloda (which turns into 5FU) - is it roughly the same amount of chemo that is given during the infusion? or is it a lessor amount that over 5 and 1/2 weeks amounts to about what is given during an infusion of 5FU

- do they monitor your bloods just as they would with 5FU infusion?
...

Lo-oc,


In all of the above the general message is: "An ounce of prevention is worth a pound of cure" or "A stitch in time saves nine". It's much better to prepare in advance to prevent these problems rather than waiting passively until the problems erupt in full force and require treatment.

This means that now is the time to think about getting a prescription for Novacain or Lydocaine, or for special antibiotic creams, or for getting a bidet attachment for the toilet, or for getting some oral rehydration salts, or a supply of Gatorade, etc.

Rock_Robster
Posts: 690
Joined: Thu Oct 25, 2018 5:27 am
Location: Brisbane, Australia

Re: Genetic mutations

Postby Rock_Robster » Fri Jun 17, 2022 4:21 am

Great advice from Peregrine. Particularly around prevention.

My guidelines for radiation…

1. No dry toilet paper shall touch your rear end from day 1 of radiation until it’s over. Even if it feels ok, one day it won’t and you’ll wish you had delayed that moment. A bidet attachment for the toilet is ideal, but a spray bottle is good too. Wet wipes are handy in a pinch, but you’ll go through a lot of them.

2. Start preparing your rear end with a gentle moisturiser containing Aloe Vera (make sure the radiotherapy nurses approve any products you use). After treatment, I found Calmoseptine to be an amazing barrier cream you put on *before* going to the toilet - but it contains zinc oxide so again make sure the nurses are ok with it. The point of a barrier cream is to protect your rear end from acidic diarrhea while it’s sensitive.

3. Hydrate hydrate hydrate. Buy some pedalyte/hydralyte or make some St Mark’s Solution (I can post a recipe). Don’t use Gatorade etc. as the sugar content may just make things worse.

4. Have Imodium handy and take as needed. Try to prevent rather than treat diarrhea.

5. Have a urinary alkalizer (like Ural) handy so you can quickly respond to any bladder/urinary pain.

6. Make sure you take the Xeloda with or immediately after a proper meal (eg at least 300-500 calories) - not just a snack or a drink - to avoid nausea.

7. Rest if you get tired. You will probably get tired.

8. As always make sure you report all side effects to the nurses - they have treatments for almost everything that can be very effective. Given it’s a short period they’re usually happy to give you stronger drugs if you need it too.

In my case I felt nothing for about 2-3 weeks except some fatigue, then the diarrhea and rear end pain started on week 3. It continued for about 2 weeks after finishing treatment, but started improving rapidly after the last dose. My tumour was high up and I (unusually) did the treatment lying on my back, so I had a bit more nausea than most (still not very bad though by any means).

I’ll be blunt here too - from what I’ve seen this treatment is harder for women than men. Women have a lot more complicated delicate stuff in the area to be affected, so if this applies to you then again make sure you’re staying on top of side effects and being open with your doctor as necessary.

The other good news is this stuff works - lots of people have complete clinical responses; I had a complete metabolic response (ie no active tumour left on PET, but still viable cells in surgical pathology).

Good luck!
Rob
Last edited by Rock_Robster on Fri Jun 17, 2022 8:51 am, edited 1 time in total.
40M Australia
2018 Dx RC, 12cm high
G2, EMVI, LVI. 4 liver mets
pT3N1aM1a Stage IVa. MSS NRAS G13R
CEA: Nov-18= 14; then <2. Jun-22: 5
11/18 FOLFOX x6
3/19 Liver resection
5/19 25x pelvic IMRT radiation
7/19 ULAR & ileo (reversed)
8/19 Liver lesion
8/19 FOLFOX, FOLFOXIRI, FOLFIRI x7
12/19 Liver resection
NED
11/21 Liver met & celiac node; 2-3 tiny lung things
12/21 PVE
3/22 Nodal spread & 3 liver mets. Lymphadenectomy
4/22 Liver SBRT
6/22 Liver looks good. Still some small lung things

Lo-oc
Posts: 21
Joined: Sat Mar 26, 2022 4:40 pm

Re: Genetic mutations

Postby Lo-oc » Fri Jun 17, 2022 7:50 am

Thank you all for the advice and tips. I have a list now of things to go through with the radiation oncologist and nurses before treatment begins. It’s always good to be prepared and you all have been through this, being proactive seems like it will save me some misery
Other than that it looks like I’m just going to have to “grin and “bare” it”
For those who have a complete response, I am under the impression it’s only the stage 1 and 2 that can take a wait and watch? Regardless of my response to radiation I’m thinking there will always be a resection, and either a reversal or not, and if reversal all the problems that go along with that. I did not think they would do a wait and watch for stage 4, no matter my response to radiation
2/22 - Dx with stage 4 rectal cancer 4cm on/1cm from AV - age 60
T4, poorly diff., EMVI + MSS
3/22 - CT/MRI 2 liver mets 2.1 cm and 1 smaller close to hepatic vein
3/22 Infusion - plan 6 treat. Folflox 6, liver res., chemoradiation, rectal surgery 6 more cycles Folfox
5/5 - CT/MRI, lung nodules no change, liver lesions red. to 1.1 and .9cm, rectal tumor/suspicious lymph node red..

Rock_Robster
Posts: 690
Joined: Thu Oct 25, 2018 5:27 am
Location: Brisbane, Australia

Re: Genetic mutations

Postby Rock_Robster » Fri Jun 17, 2022 8:47 am

Lo-oc wrote:For those who have a complete response, I am under the impression it’s only the stage 1 and 2 that can take a wait and watch? Regardless of my response to radiation I’m thinking there will always be a resection, and either a reversal or not, and if reversal all the problems that go along with that. I did not think they would do a wait and watch for stage 4, no matter my response to radiation

After my response my colorectal surgeon told me I technically had a choice now whether or not I wanted to proceed with resection, but in his view in the stage IV setting it really isn’t optional (particularly if working with curative intent). So that was quite a short conversation.

Perhaps if there were unresectable metastases one could debate the QoL impacts of a ULAR against the potential OS benefits; although presumably that assessment would have already been made prior to commencing radiation given a CCR is far from guaranteed.
40M Australia
2018 Dx RC, 12cm high
G2, EMVI, LVI. 4 liver mets
pT3N1aM1a Stage IVa. MSS NRAS G13R
CEA: Nov-18= 14; then <2. Jun-22: 5
11/18 FOLFOX x6
3/19 Liver resection
5/19 25x pelvic IMRT radiation
7/19 ULAR & ileo (reversed)
8/19 Liver lesion
8/19 FOLFOX, FOLFOXIRI, FOLFIRI x7
12/19 Liver resection
NED
11/21 Liver met & celiac node; 2-3 tiny lung things
12/21 PVE
3/22 Nodal spread & 3 liver mets. Lymphadenectomy
4/22 Liver SBRT
6/22 Liver looks good. Still some small lung things

User avatar
Peregrine
Posts: 99
Joined: Tue Mar 01, 2022 1:18 am

Minimally Invasive Liver Surgery

Postby Peregrine » Sat Jun 25, 2022 1:58 am

Lo-oc wrote:... Liver resection done, just home recovering day 10 post op. My only glitch was about 12 hours of Afib the day after the surgery, and some neck pain from laparoscopic gas....

Minimally Invasive Liver Surgery
Ioannis Konstantinidis & Laleh Melstrom
(08 February 2019)
Abstract
Minimally invasive surgery is associated with improved postoperative outcomes compared to open surgery for a variety of operations, which has led to its expansion to the field of liver surgery. Laparoscopic liver surgery has been increasingly used over the last two decades, and its safety and benefits in appropriately selected patients are being recognized. Robotic-assisted liver surgery maintains the benefits of faster recovery associated with minimally invasive surgery and provides superior visualization and ergonomics, however, at higher cost. At the same time, minimally invasive liver surgery poses unique challenges and entails a steep learning curve. The application of new technologies provides further capabilities in an exciting changing landscape. This chapter provides an overview of the evolution of minimally invasive liver surgery over the last two decades, its benefits over open liver surgery, the challenges encountered, and its future directions.

References: Click on the link below to see a list of references for this topic:
https://link.springer.com/chapter/10.10 ... 1_7#citeas


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