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Liver cancer

A rare form of cancer, liver cancer (primary and metastatic hepatic

carcinoma) has a high mortality. It’s responsible for roughly 2% of all
cancers in the United States and for 10% to 50% in Africa and parts of
Asia. Liver cancer is most prevalent in men (particularly in those older than
age 60); incidence increases with age. It’s rapidly fatal, usually within 6
months, from GI hemorrhage, progressive cachexia, hepatic failure, or

Most primary liver tumors (90%) originate in the parenchymatous cells and
are hepatomas (hepatocellular carcinoma, primary lower-cell carcinoma).
Some primary tumors originate in the intrahepatic bile ducts and are
known as cholangiomas (cholangiocarcinoma, cholangiocellular
carcinoma). Rarer tumors include a mixed-cell type, Kupffer cell sarcoma,
and hepatoblastomas (which occur almost exclusively in children and are
usually resectable and curable).

The liver is one of the most common sites of metastasis from other
primary cancers — particularly those of the colon, rectum, stomach,
pancreas, esophagus, lung, or breast — or melanoma. In the United
States, metastatic liver carcinoma is more than 20 times more common
than primary carcinoma and, after cirrhosis, is the leading cause of liver-
related death. At times, liver metastasis may appear as a solitary lesion,
the first sign of recurrence after a remission.

Top Causes
The immediate cause of liver cancer is unknown, but it may be a
congenital disease in children. Adult liver cancer may result from
environmental exposure to carcinogens, such as the chemical compound
aflatoxin (a mold that grows on rice and peanuts), thorium dioxide (a
contrast medium formerly used in liver radiography), Senecio alkaloids,
androgens, or oral estrogens.

Top Risk factors

Roughly 30% to 70% of patients with hepatomas also have cirrhosis.
(Hepatomas are 40 times more likely to develop in a cirrhotic liver than in
a normal one.) Whether cirrhosis is a premalignant state or alcohol and
malnutrition predispose the liver to develop hepatomas is still unclear.
Another risk factor is exposure to the hepatitis B virus, although this risk
will probably decrease with the availability of the hepatitis B vaccine.

Top Signs and symptoms

Signs and symptoms of liver cancer include:

❑ a mass in the right upper quadrant

❑ a tender, nodular liver on palpation

❑ severe pain in the epigastrium or the right upper quadrant

❑ a bruit, hum, or rubbing sound if the tumor involves a large part of the

❑ weight loss, weakness, anorexia, fever

❑ occasional jaundice or ascites

❑ occasional evidence of metastasis through the venous system to the

lungs, from lymphatics to the regional lymph nodes, or by direct invasion
of the portal veins
❑ dependent edema.

Top Diagnosis
The confirming test for liver cancer is a needle or open biopsy of the liver.
Liver cancer is difficult to diagnose in the presence of cirrhosis, but several
tests can help identify it:

❑ Liver function studies (aspartate aminotransferase, alanine

aminotransferase, alkaline phosphatase, lactate dehydrogenase, and
bilirubin) show abnormal liver function.

❑ Alpha-fetoprotein level increases above 500 µg/ml.

❑ Chest X-ray may rule out metastasis.

❑ Liver scan may show filling defects.

❑ Arteriography may define large tumors.

❑ Electrolyte studies may indicate increased sodium retention (resulting in

functional renal failure) and hypoglycemia, leukocytosis, hypercalcemia, or

Top Treatment
Because liver cancer is usually in an advanced stage at diagnosis, few
hepatic tumors are resectable. A resectable tumor must be a single tumor
in one lobe, without cirrhosis, jaundice, or ascites. Resection is done by
lobectomy or partial hepatectomy.

Radiation therapy for unresectable tumors is usually palliative. However,

because of the liver’s low tolerance for radiation, this therapy hasn’t
increased survival.

Another treatment method is chemotherapy either I.V. or with regional

infusion of a chemotherapeutic drug. (A catheter is placed directly into the
hepatic artery or left brachial artery for continuous infusion for 7 to 21
days, or permanent implantable pumps are used on an outpatient basis for
long-term infusion.)

Appropriate treatment for liver metastasis may include resection by

lobectomy or chemotherapy. (The results are similar to those in
hepatoma.) Liver transplantation is an alternative for some patients.

Top Special considerations

❑ Patient care should emphasize comprehensive supportive measures
and emotional support.

❑ Control edema and ascites. Monitor the patient’s diet throughout

because he may need a special diet that restricts sodium, fluids (no
alcohol allowed), and protein.

❑ Weigh the patient daily, and note intake and output accurately. Monitor
him for signs and symptoms of ascites — peripheral edema, orthopnea, or
exertional dyspnea. If ascites are present, measure and record abdominal
girth daily.

❑ To increase venous return and prevent edema, elevate the patient’s

legs whenever possible.

❑ Monitor the patient’s respiratory function. Note any increase in

respiratory rate or shortness of breath. Bilateral pleural effusion (noted on
chest X-ray) is common, as is metastasis to the lungs. Watch carefully for
signs of hypoxemia from intrapulmonary arteriovenous shunting.

❑ Relieve fever. High fever indicates infection and requires an antibiotic.

Institute cooling measures, as tolerated, and administer aspirin
suppositories if no signs of GI bleeding are apparent. Avoid
acetaminophen because the diseased liver can’t metabolize it.
❑ Provide meticulous skin care. Turn the patient frequently and keep his
skin clean to prevent pressure ulcers. Apply lotion to prevent chafing, and
administer an antipruritic, such as diphenhydramine, for severe itching.

❑ Monitor the patient for encephalopathy. Many patients develop end-

stage signs and symptoms of ammonia intoxication, including confusion,
restlessness, irritability, agitation, delirium, asterixis, lethargy and, finally,

CLINICAL TIP: If signs of encephalopathy develop, lactulose therapy may

provide palliative treatment.

❑ Monitor the patient’s serum ammonia level and neurologic status.

CLINICAL TIP: Be prepared to control ammonia accumulation with

sorbitol (to induce osmotic diarrhea), neomycin (to reduce bacterial flora in
the GI tract), lactulose (to control bacterial elaboration of ammonia), and
sodium polystyrene sulfonate (to lower the potassium level).

❑ If a transhepatic catheter is used to relieve obstructive jaundice, irrigate

it frequently with the prescribed solution (normal saline or, sometimes,
5,000 units of heparin in 500 ml of dextrose 5% in water).

❑ Monitor the patient’s vital signs frequently for any indication of bleeding
or infection.

❑ After surgery, give standard postoperative care. Watch for

intraperitoneal bleeding and sepsis, which may precipitate a coma.
Monitor the patient for renal failure by checking urine output, blood urea
nitrogen, and creatinine levels hourly.

Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott

Williams & Wilkins.