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Diagnosing Liver Cancer
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.
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.
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.
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. New technique which stimulates
regeneration before surgery are under evaluation. 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.
Some 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 anaesthesia have also led to less blood loss
during surgery. This results in a quicker and less complicated recovery.
Some 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 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.
Rehabilitation Therapy
Rehabilitation therapy plays a role in improving the function and quality of
life of patients with liver cancer. Patients are often given 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 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..
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