Download MODULE 5 – LIVER CANCER LIVER CANCER Primary Liver

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MODULE 5 – LIVER CANCER
LIVER CANCER
Primary Liver Cancer
Secondary Liver Cancer
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MODULE 5 – LIVER CANCER
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MODULE 5 – LIVER CANCER
Despite the fact that primary liver cancer is
not quite common in the western world,
some authors suggest HCC being one of the
most common fatal tumours worldwide with
an estimated 1 million cases occurring
annually.
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MODULE 5 – LIVER CANCER
The geographical distribution of HCC varies
greatly and correlates almost 100 per cent
with the regional incidence rates of hepatitis
B and C infections. HCC affects persons of all
age groups. In Asian and African countries,
the morbidity peak is reached in adolescence
or between the ages of 20 and 40years,
corresponding to predominantly perinatal or
postnatal infections with hepatitis viruses.
The HCC gender ratio between men and
women is 2.5:1 up to 8:1 in countries with
high incidence. In a cirrhosis free liver,
however, men and women are effected by
HCC at the same rate.
The patient is suspected to be suffering from
HCC when the subjective complains continue
to deteriorate and when an increase in
complains cannot be explained by the
progression of cirrhosis. Occasionally, the
course of HCC may be acute, resembling liver
failure or liver abscess. It is widely accepted
that when HCC is discovered in a
symptomatic patient, the disease is usually
rapidly fatal.
The clinical situation deteriorates rapidly:
febrile temperatures and leucocytosis as well
as subicterus are observed; there are also
signs of encephalopathy. An arterial murmur
can often be heard on auscultation, since the
tumour is mainly supplied with blood from
the hepatic artery.
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MODULE 5 – LIVER CANCER
An AFP>20ng/mL in a group of patients with
cirrhosis has been shown to be an
independent predictor for developing HCC.
With regard to imaging techniques,
sonography is the method of choice in
monitoring the course of risk patients,
particularly in combination with AFP (alphafoetoprotein) determination. Nevertheless the
sensitivity has been reported to vary from
43% to 90%. Other imaging procedures
include angiography, magnetic resonance
imaging and scintigraphy. The FNB is
associated with the risk of tumour spreading.
The nodular surface indicating liver cirrhosis
(HCC and alcohol) can be seen. Tumour
formation can been seen in the right lobe of
liver, in parts at the margin.
Left hand picture: Large-bulbous
hepatocellular carcinoma due to alcohol
abuse and active chronic hepatitis B with
cirrhotic transformation in some places.
Right hand picture: Small to medium-coarse
nodular, alcoholic cirrhosis with
undifferentiated, multilobular hepatocellular
carcinoma and subcapsular vascularization.
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MODULE 5 – LIVER CANCER
The rule of thumb is that the bigger the
tumour and the quicker it grows the shorter
is the life expectancy. The prognosis is if
even worse if the tumour has already spread
to other organs such as the lung.
The prognosis of HCC is very bad. Almost all
patients die within the first year after
diagnosis, some of them within only two
month.
Secondary liver cancer is referred to with the
staging of the primary tumour.
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By including clinical and laboratory
parameters, K.Okuda introduced a
classification into stages in order to improve
the prognostic accuracy regarding survival
time. The survival rate in the untreated
course was calculated to be 11 month in
stage 1, 3 month in stage 2 and 1 month in
stage 3. There are a few cases of
spontaneous regression reports. However,
recurrence after regression has also been
reported.
Anorexia is a loss of appetite or lack of desire
to eat. Cachexia is often seen as loss of
weight and is a consequence of emaciation.
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MODULE 5 – LIVER CANCER
Liver metastasis may occur as solitary or
multiple nodes and many ultimately infiltrate
almost the whole liver tissue. Histology of
liver metastasis is often similar to that of a
primary liver tumour which makes the
classification almost impossible.
Carcinoid tumours: The curious name of
these tumours was coined in 1907 to
emphasize the benign course which they
follow, although a proportion are malignant
at the outset and others become so with
time.
The liver is the first destination of venous
blood drainage from multiple intra-abdominal
organs. As a result of its dual blood supply
(75% from the portal vein and 25% from the
hepatic artery) and histological filtering
structure, the liver is a common site of
metastatic deposits.
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There has been little enthusiasm for resection
and local therapy of non-portal hepatic
metastasis (breast, lung, melanoma) because
of the high probability of extra-hepatic
disease. Only colorectal, pancreaticneuroendocrine and carcinoid tumours have a
reasonable chance of having liver metastasis
only because the liver is the first ‘filter’.
Colorectal cancer metastasis to the liver is by
far the most extensively studied and its
management continues evolve.
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Large metastases in the right hepatic lobe
subsequent to breast cancer. A solitary node
is found in some 10% of patients at the time
of diagnosis. The metastasis often shows a
central depression due to tumour necrosis
caused by insufficient blood supply within the
tumour (= cancer umbilicus)
Pronounced liver invasion by metastases of
varying size and neo-vascularization
(bronchial carcinoma). Liver metastasis may
ultimately infiltrate the whole liver tissue.
This may result in extreme hepatomegaly
with a liver size of more than 5kg.
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In addition jaundice with advancing cachexia
usually develops as the tumour continues to
grow.
Symptoms like ascites, thrombosis often
show up at a very late stage when the liver
function is already weakened.
In sonography metastases from 0.5-1cm can
be detected. However, this method is not
able to differentiate between benign and
malign disease.
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Tumours arising from neuroendocrine cells of
the gastrointestinal tract and pancreas
present special challenges in diagnosis and
therapy. These tumours often cause
symptoms from excess hormone secretion
rather than from growth. Frequently slow
growing, they may nonetheless be lifethreatening because of uncontrolled release
of specific hormones or neurotransmitters.
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