About the
Liver
The liver is the largest organ inside the body. It lies just
beneath the right lung and diaphragm under the right ribs.
It is an important organ performing several functions:
a) processing and storing nutrients absorbed by the
intestine. Some nutrients must be chemically changed
to a form that can be used by the body.
b) it is also used to secrete bile into the intestine -
which in turns helps absorb nutrients and fats.
c) it is the source of clotting factors that is used to
protect the body from bleeding too much (as in the case of
injury)
d) and it is important for ridding the body of toxic wastes.
Liver Cancer
When other cancers are present in the body (such as breast,
colon, etc), some tumor cells sometimes "break off" and
travel through the body. The migration of these cells
often find themselves producing cancer in the liver.
This migration of cancerous cells is referred to as
Metastasis.
There are two categories of cancers that can develop -
Benign and malignant. In general Benign Tumors
(referred to as Hemangioma) are not dangerous and often do
not cause symptoms. However, sometimes they can be the
source of bleeding, or abdominal pain and may also present a
risk of rupturing. In cases where there are symptoms,
a physician may often elect to have surgery to remove it.
Another form of "tumor-like" growth is called Focal Nodular
Hyperplasia or FNH. This benign grow is difficult to
distinguish from actual tumors and are often removed
surgically.
Malignant tumor cells are abnormal and grow uncontrollably
without order. Unlike Benign tumors, malignant tumors
require a more aggressive treatment approach. The most
common form of malignant liver cancer in adults accounting
for approximately 75% is Hepatocellular carcinoma or HCC and
is also referred to as hepatoma.
Diagnosis
Diagnosis of primary liver cancer is generally made using
blood tests, diagnostic imaging, surgical biopsy or
laparoscopy, or in combination. The alpha-fetoprotein blood
test and ultrasound imaging of the liver are also used to
screen high-risk populations (including those with hepatitis
B and hepatitis C infections) for the disease. Since the
risk of liver cancer is relatively low for healthy
individuals, these tests are not used to screen the general
population.
The alpha-fetoprotein (AFP) blood test measures the level in
the blood of a certain protein produced by the liver.
Elevated levels of AFP can be an indication of
hepatocellular carcinoma, the most common type of primary
liver cancer. If liver cancer is suspected, other blood
tests are done to measure liver function. These tests can
help doctors determine the condition of the liver. Since
successful treatment for liver cancer involves removing a
substantial part of the normal liver tissue in addition to
the cancer, other treatments might be used in people with
blood tests that indicate a high degree of liver disease.
Our team of radiologists specialize in hepatobiliary
imaging. Diagnosing hepatocellular cancer can be difficult
since this part of the body is complex and includes several
organs and major blood vessels.
As non-invasive diagnostic imaging techniques have become
more sophisticated, they can be used to gather important
information about a newly diagnosed tumor -- including its
exact size and density. These techniques can also be used to
gauge how well a tumor will respond to treatment.
In some cases, diagnosis is performed invasively, by
removing a small amount of tissue for a biopsy, or by
laparoscopy (insertion of a small tube with an attached
camera into the abdomen to survey the cancer site).
Laparoscopy can also be used to remove a sample of tissue
for biopsy.
Non-invasive Diagnostic Imaging Techniques
CT (computed tomography) scanning
Useful for determining the extent of tumor growth within the
gallbladder or bile duct. It can also be used to tell
whether tumor cells have spread into the lymph nodes or
other nearby parts of the body.
MRI (magnetic resonance imaging)
Can be used to determine if a tumor can be surgically
removed. It shows the extent of tumor growth within the
gallbladder or bile duct, and reveals whether the tumor has
invaded any blood vessels.
Magnetic resonance cholangiopancreotography (MRCP)
Gives a detailed examination of the bile ducts. It is useful
for determining the stage of a tumor in the bile duct.
Ultrasound
Useful for detecting the location and number of tumors as
well as tumor involvement with blood vessels (tumors
situated close to blood vessels may be more difficult to
remove). It can also be used to distinguish a cancerous mass
from a benign tumor.
Invasive Diagnostic Techniques
Biopsy
A small amount of tissue is removed from a specific area of
the body so it can be examined more closely.
Endoscopy
The interior lining of a body cavity, such as the esophagus,
stomach, bile duct, or colon, is examined using a device
called an endoscope.
Laparoscopy
Allows for the examination of the abdominal cavity and its
contents. A tube with an attached camera (called a
laparoscope) is passed through an incision made in the
abdominal wall.
Cholangiography
A needle is inserted into the bile ducts within the liver.
The ducts are injected with dye so they can be seen more
clearly.
Treatment
Surgery
Most primary liver cancers are best treated by surgery to
remove the diseased portion of the liver. Until the early
1980s, surgery to remove primary liver tumors was rarely
done. But now, highly complex liver operations are performed
at Memorial Sloan-Kettering with great frequency, success,
and safety. Our researchers have recently shown that
hepatobiliary surgery can also be successfully performed in
elderly patients. These patients can have outcomes
comparable to those of younger patients, so age alone should
not be the determining factor when deciding upon surgery in
patients over the age of 70.
Operating on the liver can be difficult for several reasons.
Many of the major blood vessels leading to and from the
heart pass behind or through the liver, so in essence, the
liver is "attached" to the heart. Also, the anatomy of the
liver is not always obvious from the surface. The organ is
large, dense, and delicate, and covered in part by the rib
cage. It bleeds profusely when injured, and it tears easily.
Since hepatocellular cancer is relatively rare in the United
States, many surgeons may not be experienced in performing
liver resections. Our surgeons perform the highest number of
liver resections of any cancer center in the country --
between 200 to 300 per year.
One unusual fact about the liver is that it has the capacity
to regenerate, or grow anew. For example, up to 80 percent
of the organ can be surgically removed and within several
weeks, the liver will have entirely regenerated itself. If
one lobe -- along with its associated blood vessels -- is
surgically removed, the remaining lobe will compensate for
the loss. A new technique which stimulates regeneration
before surgery is also being evaluated here. The technique
is called pre-operative portal vein embolization. If doctors
feel the portion of the liver remaining after resection
would be too small to allow for a good outcome, they can
shift the blood supply to the normal portion of the liver
before the resection is done. That normal area grows larger,
and when it reaches sufficient size, the resection can be
performed.
Our doctors are also developing new liver sparing surgical
techniques that leave more of the normal liver intact, aid
regeneration, and result in less blood loss. Recent
improvements in anesthesia have also led to less blood loss
during surgery. This results in a quicker and less
complicated recovery.
Our surgeons are also pioneering laparoscopic surgical
methods. In this type of surgery, a small incision is made
and a tube with a small camera on its end is passed through
the abdominal wall. This technique is sometimes used to
stage or determine the extent of a cancer, which eliminates
the need for exploratory surgery in some patients. It has
also been used to biopsy cancers (by removing a small piece
of the cancer to examine further) or, in selected cases, to
remove part of the liver (partial hepatectomy). Since the
procedure is less invasive than traditional surgery,
recovery is quicker.
When the liver is burdened with another disease aside from
the cancer, surgery is complicated and sometimes impossible.
A disease such as cirrhosis dramatically weakens the liver
and often leaves it permanently damaged, with limited
regenerative capacity. A patient with a liver hampered by
both cirrhosis and a tumor is more likely to be treated with
a method other than surgery. Some of these treatments are
listed below.
Ablative Therapies
Ablation uses a chemical agent or electrical current to
destroy a tumor. Ablative procedures can be performed both
percutaneously (through the skin without an incision) or
during surgery. Procedures which can be performed
percutaneously include cryosurgery (freezing and killing the
tumor cells), radiofrequency (RF) ablation, alcohol
ablation, and embolization (blocking the blood supply to a
tumor). These therapies can be very effective, but they are
usually intended to control cancer rather than cure it.
Ablative therapies can be used alone or in combination with
surgical removal of a tumor. For example, a patient with
hepatocellular cancer who is not a candidate for surgery may
first be treated with embolization to shrink the tumor so
that it is small enough to make another form of ablative
therapy or surgery possible.
In cryosurgery, a needle is introduced into the middle of a
tumor to freeze it. Residual, or remaining, tumor cells can
be left behind, making this method less effective than
surgery. It can also be difficult to keep the tumor at
temperatures low enough to completely freeze it, since
tumors are often near large blood vessels. Nevertheless,
cryosurgery can be a very effective way to control liver
tumors.
Radiofrequency ablation is the opposite of cryosurgery.
Rather than freezing the tumor, physicians use radio waves
to heat it up to such a high temperature that the tumor is
destroyed. Radiofrequency ablation is effective, but can
only be used for smaller tumors. This therapy is not
curative; it is intended to control tumor growth.
Alcohol ablation, or PEIT (percutaneous ethanol injection
treatment), is a way to administer toxins directly to a
tumor. It is quite effective for small tumors of less than
five centimeters. This treatment is usually selected for
patients who are not candidates for surgery.
Radiation Therapy
Radiation therapy is used in selected cases to help control
tumors. Radiation oncologists here use new techniques to
focus the radiation beam on the tumor and spare the normal
liver from injury.
Embolization
Embolization is a procedure that cuts off the blood supply
to the tumor. Physicians pack a branch of the hepatic artery
-- the main artery that carries blood to the liver -- with
tiny plastic particles, cutting off most of the blood flow
and depriving the tumor of life-giving oxygen. Our
hepatobiliary team performs approximately 200 embolizations
a year. In conjunction with the Integrative Medicine
Service, our physicians will soon begin testing a
combination of seven herbal medications on some patients who
have undergone hepatic artery embolization. The drug, called
Sho-saiko-to, has been used extensively in some parts of
Asia to prevent patients with hepatitis from developing
cirrhosis.
Rehabilitation Therapy
Rehabilitation therapy plays a role in improving the
function and quality of life of patients with liver cancer.
At Memorial Sloan-Kettering, physical therapists work
closely with the medical team to improve patient's mobility,
strength, and endurance after surgery or medical treatments.
They offer patients valuable techniques to increase mobility
without increasing pain and discomfort and teach
energy-conserving techniques to help patients decrease the
fatigue they may experience during hospitalization and
medical treatments. Occupational therapists here educate
patients about the changes they may experience during and
after treatment and about adaptive equipment and
compensatory techniques that can increase their independence
during their daily routines. They also evaluate and treat
patients' ability to perform basic daily activities such as
bathing, dressing, and moving around their environment.
