Liver Cancer Ppt

8/13/2019 Liver Cancer Ppt

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The liver is the largest solid organ of the body.It is located on the right side of the abdomen.The liver is triangular in shape and is divided into aright and left lobe, the right lobe being the larger ofthe two.It provides several important functions to the bodyincluding:Filtering the blood to remove and process toxins.Synthesizing and excreting bile, which is important inprocessing fat from our diet.Helping regulate blood sugar (glucose) levels.Producing factors that play an important role in bloodclotting.


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Prognosis is poor, with overall 5-year survivalof 5%.

If untreated , death occurs in 6-8 weeks


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Most common presentingsymptom is right upper quadrantabdominal pain, usually dull oraching and may radiate to theright shoulder.Right upper quadrant mass,abdominal distention, fever,malaise, weight loss, andanorexia become evident.Jaundice is present in fewpatients at diagnosis in primaryliver cancer. Incholangiocarcinoma, thepresenting symptom is usuallyobstructive jaundice.If there is portal vein obstruction,ascites and esophageal varicesoccour.


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Serum, bilirubin, alkaline phosphatase, and serumtransaminases are all increased.Alpha-fetoprotein: Principal tumor marker forhepatocellular carcinoma elevated in 70% to 95% ofpatients with the disease.Ultrasonography, computed tomography (CT), andmagnetic resonance imaging (MRI) are used to detectcancer and assess if the tumor can be surgicallyremoved.Arteriography helps determine resectability of livertumor.Percutaneous needle biopsy or biopsy throughultrasonography may be done.Laparoscopy with liver biopsy may be performed.


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1. Choice of treatment depends onWhether tumor is primary or secondary

Type and extent of tumorConcomitant diseasesLiver functionsPatient status


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2.Pretreatment therapy

Anemia, clotting deficits, and fluid andelectrolyte abnormalities should be correctedVitamin A, C, D, and B complex can reduceeffect of jaundicePruritus can be relieved with good hygieneand by avoiding products that dry skin and by

using oil-based lotions, antihistamines;cholestyramineNutritional improvement is critical


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Cancer that starts in the liver.There are two main types:Hepatocellular carcinoma (HCC) starts in the

main cell of the liver (hepatocytes).Cholangiocarcinoma starts in the bile duct.Hepatocellular carcinoma (HCC) is by far themost common type of primary liver cancer.Primary liver tumors usually are associated withchronic liver disease, hepatitis B and Cinfections, and cirrhosis.Angiosarcoma is a rare liver cancer starting inthe blood vessels.


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Liver cancer is much common particularly insub-Saharan Africa and Southeast Asia.Liver cancer is the fifth most common cancer.

Metastases are often from:Lung

KidneyBreastIntestinal tract


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Infection with Hepatitis BLiver scarring (cirrhosis) due to Hepatitis B orC, inflammation or genetic disorders such ashaemochromatosis or alpha 1-antitrypsindeficiencyAlcohol drinking over a long period of time

DiabetesSmokingHigh-fat dietBeing overweight or obese


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Cancer that starts in other part of the body but has spread(metastasized) to the liver.Most common types to spread to the liver start I thedigestive sytem:BowelPancreasEsophagusStomachOthers that also commonly spread to the liver:BreastOvaryKidneyLungSecondary cancer is sometimes found at he same time thatthe primary cancer is diagnosed.


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The early manifestations of malignancy of the liverinclude:PainContinuous dull ache in the right upper quadrant,epigastrium, or backWeight lossLoss of strengthAnorexiaAnemia

The liver may be enlarged and irregular on palpation.Jaundice is present (only if the larger bile ducts areoccluded by the pressure of malignant nodules obstructthe portal veins of if tumor tissue is seeded in theperitoneal cavity.)


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Metastases from other primary sites arefound in the liver in about half of all advanced

cancer cases (Bacon & Di Bisceglie, 2000).By way of portal systems or lymphaticchannels, or by direct extension from anabdominal tumor, malignant tumors are likelyto reach the liver eventually.The liver apparently is an ideal place for thesemalignant cells to thrive.


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The liver cancer diagnosis is based on:Clinical signs and symptomsHistory

Physical examinationResults of laboratoryX-ray studiesIncreased serum levels of bilirubin, alkalinephosphatase, AST, GGT, and lacticdehydrogenase may occur.Leukocytosis (increased white blood cells).Erythrocytosis (increased red blood cells).


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Hypercalcemia, hypoglycemia, andhypocholesterolemia may also be seen onlaboratory assessment.

There are two markers that are useful todistinguish between metastatic liver diseaseand primary liver cancer:The serum level of alpha fetoprotein (AFP),

which serves as a tumor marker.Levels of carciembryonic antigen (CEA), amarker of advanced cancer of the digestivetract, maybe elevated.


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X-raysLiver scansCT scansUltrasound studiesMRIArteriographyLaparoscopy


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Confirmation of a tumors histology can bemade by biopsy under imaging guidance (CTscan or ultrasound) or laparoscopically.Local or systemic dissemination of the tumorby needle biopsy or refine-needle biopsy canoccur but is rare.

Primary HCC diagnosis should be confirmedby frozen section at the time of laparotomy.


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Radiation therapy and chemotherapy havebeen used in treating cancer of the liver with

varying degrees of success.


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The use of external beam radiation for thetreatment of liver tumors has been limited bythe radiosensitivity of normal hepatocytes.More effective ways of delivering radiations totumors of the liver include:Intravenous or intraarterial injections ofantibodies tagged with radioactive isotopes thatspecifically attack tumor-associated antigens.Percutaneous placement of a high-intensitysource for interstitial radiation therapy.


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Chemotherapy has been used to improvequality of life and pro-long survival.May also be used as a therapy after surgicalresection of hepatic tumors.Systemic chemotherapy and regionalinfusion are used to administer antineoplastic

agents.An implantable pump is used to deliver high-concentration chemotherapy to the liverthrough the hepatic artery.


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Percutaneous biliary drainage is used to bypassbiliary ducts obstructed by the liver, pancreatic,or bile ducts in patients with inoperable tumorsor those who are poor surgical risks.

Complications include sepsis, leakage of bile,hemorrhage, and reobstruction of the biliarysystem.Observe patient for fever and chills, biledrainage around the catheter, changes in vitalsigns, and evidence of biliary obstruction,including increased pain or pressure, pruritus,and recurrence of jaundice.


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Hyperthermia: heat by laser or radiofrequencyenergy is directed to tumors to cause necrosis of

the tumors while sparing normal tissue.Cryosurgery is a newer treatment modality.Embolization of arterial blood flow to the tumor;effective in small tumors; injection of smallparticulate embolic or chemotherapeutic agentsmay be used to cause tumor necrosis.Immunotherapy: lymphocytes with antitumorreactivity are administered.


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Surgical resection is a treatment of choice when HCC isconfined to one lobe of the liverWhen the primary site can be completely excised &metastasis is limited, hepatic resection can be performedMetastases to the liver are rarely limited or solitarySurgeons have capitalized on the regenerative capacity ofthe liver cells removing 90% of itThe presence of cirrhosis limits the ability of the liver toregenerateStaging of liver tumors aid in predicting the chances ofsurgical cureNutritional, fluid and general physical status is assessed inpreparation for a surgeryPatients aided psychologically in preparing for the surgery


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Extensive diagnostic studies may be performedas well as Specific studies that may include:

Liver scansLiver biopsyCholangiographySelective Hepatic angiography

Percutaneous needle biopsyPeritoneoscopyLaparoscopyUltrasoundCT scansMRIBlood tests, Particularly determinations ofserum alkaline phosphate, AST, and GGT


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Primary tumor (T)TX- Primary tumorTo- No evidence of primary tumorT1-Solitary tumor without vascular invasion

T2-Solitary tumor without vascular invasion ormultiple tumors-none more than 5 cm T3-Multiple tumors more than 5 cm or tumorinvolving a major branch of the portal or hepaticvein(s) T4-Tumor(s) with direct invasion of adjacent organsother than the gallbladder or with perforation ofvisceral peritoneum


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NX -Regional lymph nodes cannot be

assessedN0 -No regional lymph node metastasisN1 -Regional lymph node metastasis


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Mx -Distant metastasis cannot be assessed

Mo -No distant metastasisM1 -Distant Metastasis


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Stage I T1 No Mo

Stage II T2 No Mo

Stage IIIA T3 No Mo

Stage IIIB T4 No Mo

Stage IIIC Any T N1 Mo

Stage IV Any T Any N M1


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Removal of a lobe ofthe liver is the mostcommon surgicalprocedure.For right liverlobectomy or anextended rightlobectomy athoracoabdominalincision wll be used.An extensiveabdominal incision ismade for a left

lobectomy.


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Cyrosurgery(cyroablation), tumorsare destroyed by liquid

itrogen at - 196C. This technique ha beenused alone.Its efficacy is still beingevaluated


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Procedure involves total removal of thediseased liver and its replacement witha healthy liver in the same anatomiclocation (orthotopic livertransplantation [OLT]).It is not a routine procedure and it maybe accompanied by complications.

Recurrence of primary liver malignancyhas been reported.The patient with small tumors mayhave a good prognosis aftertransplantation.Established therapeutic modality ratherthan experimental procedure to treatthese disorders.To prepare the patient and family forliver transplantation, nurses in allsettings must understand the processand procedure of liver transplantation.


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The postoperative complication rate is highbecause of technical complications or

infections.Immediate postoperative complications mayinclude:Bleeding common in postoperative periodInfection leading cause f death in livertransplantation.Rejection a key concern.


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Assess for problems related tocardiopulmonary involvement, vascular

complications, and respiratory and liverdysfunction.Give careful attention to metabolicabnormalities (glucose, protein, and lipids).


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Provide close monitoring and care for the first 2or 3 days.Encourage early ambulation, and initiate otherpostoperative care measures.Closely monitor the patient undergoingcryosurgery for hypothermia, hemorrhage, bileleak, and myoglobinuria.Instruct patient about the importance of follow-up visits.Encourage patient to resume activities as soonas possible, but caution patient to avoidactivities that may damage the pump.


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Teach patient about signs of complications,and encourage patient to notify nurse orphysician if problems or questions occur.Provide reassurance and instructions topatient and family to reduce fear.Refer patient for home care.

Assist patient and family in making decisionsabout hospice care, and initiate referrals.Encourage patient to discuss end-of-life care.


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Therapeutic Interventions Radiation therapy can help reduce pain anddiscomfort.

Liver cancer is radiosensitive, but treatmentis restricted by the limited radiation toleranceof normal liver.Hyperthermia has been used to treat hepatic

metastases.Management of ascites and edema throughfluid restriction, albumin, and diuretics.


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Chemotherapy is used as an adjuvant therapyafter surgical resection of liver cancer.Systemic chemotherapy is the only treatmentapplicable once the cancer has spread outside theliver.Regional infusion chemotherapy by implantablepump has been used to deliver a high concentration ofchemotherapy directly to the liver through thehepatic artery.

Hepatic artery occlusion and embolization withchemotherapeutic agents is another possiblemethod.Immunotherapy is currently under investigation.


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Surgery is the best treatment but is only feasible in25% of cases, after extent of tumor and hepaticreserve have been considered.Surgical resection may be along anatomic divisions ofthe liver or nonanatomic resections.Freezing hepatic tumors by cryosurgery is a newmodalilty that preserves normal liver.Liver transplantation has been performed to treatliver tumors, but results have been poor because ofthe high rate of recurrent primary liver malignancy. Itis now recommended that the patient be treatedbefore and after transplantation with chemotherapyand radiation therapy.


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Percutaneous transhepatic biliary drainage(PTBD) is used to drain obstructed biliary ductsin patients with inoperable tumors or in patientsconsidered poor surgical risks. A percutaneouscatheter drains the biliary tree to relieve jaundice, decrease pruritus, and decreaseanorexia.Percutaneous or endoscopic placement of

internal stents may also be used as palliativetreatment for a patient with obstructed bileducts with a terminal diagnosis.


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Administer pain control agents as ordered, keeping inmind decreased liver metabolism. Monitor signs of drugtoxicity.Provide nonpharmacologic methods of pain relief, such as

massage and guided imagery.Position the patient for comfort usually in semi Fowlers position. Encourage the patient to eat small meals andsupplementary liquid feedings.

Asses and report factors that may increase nutritionalneeds: Increased body temperature, pain, signs ofinfection, stress level. Encourage additional calories astolerated.Restrict sodium and fluid intake as prescribed.


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If the patient has PTBD, monitor catheter exit site forbleeding or bile drainage, and asses drainage in bagfor color, amount, consistency. The drainage initiallymay have some blood mixed with bile but should clearwithin a few hours.

Flush catheter if orderedCheck for and report signs of peritonitis from bile leakinginto abdomen: Fever, chills, abdominal pain andtenderness, distention.

Provide psychological support to patient and family tohelp them cope with uncertain prognosis.


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Instruct the patient and family on preparationfor surgery, reinforcement and clarify proposedsurgical procedure, and review postoperativeinstructions.Instruct the patient to recognize and report signsand symptoms of complication.Instruct the patient in continued surveillance forrecurrence.Instruct the patient and family in care of anytubes or drains.

Liver Cancer Ppt

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