Liver Transplant

 Liver

If you place your right hand over the area under the ribs on the right side of your body it will just about cover the area of your liver. The liver is the largest gland, and the largest solid organ in the body, weighing some 1.8 kg in men and 1.3 kg in women. It holds approximately 13% (about one pint or 0.57 litres) of your total blood supply at any given time and has over 500 functions.

The liver is dark reddish brown in colour and is divided into two main lobes (the larger right and the smaller left) which are further subdivided into approximately 100,000 small lobes, or lobules. About 60% of the liver is made up of liver cells called hepatocytes which absorb nutrients and detoxify and remove harmful substances from the blood. A hepatocyte has an average lifespan of 150 days. There are approximately 202,000 in every milligram of your liver tissue. The liver receives its blood supply via the hepatic artery and portal vein.

What is liver transplantation?

Liver transplantation is surgery to remove a diseased or injured liver and replace it with a healthy whole liver or a segment of a liver from another person, called a donor. A successful liver transplant is a life-saving treatment for people with liver failure, a condition in which the liver no longer works as it should.

Liver functions

Liver functions include:

    * processing digested food from the intestine

    * controlling levels of fats, amino acids and glucose in the blood

    * combating infections

    * clearing the blood of particles and infections, including bacteria

    * neutralising and destroying all drugs and toxins

    * manufacturing bile

    * storing iron, vitamins and other essential chemicals

    * breaking down food and turning it into energy

    * manufacturing, breaking down and regulating numerous hormones including sex hormones

    * making enzymes and proteins which are responsible for most chemical reactions in the body, for example those involved in blood clotting and repair of damaged tissues.

Some of the most important functions are:

Producing quick energy

One of the liver’s most important functions is to break down food and convert it into energy. Carbohydrates, such as bread and potatoes, are broken down to glucose and stored mainly in the liver and muscles as glycogen. When energy is required in an emergency the liver rapidly converts its store of glycogen back into glucose ready for use.

Your liver also helps the body to get rid of waste. Waste products which are not excreted by your kidneys are removed from the blood by the liver. Some of them pass into the duodenum and then into the bowel via the bile ducts.

People with liver damage may sometimes lose the ability to control glucose concentration in the blood and need a regular supply of sugar.

Fighting infections

Your liver plays a vital role in fighting infections, particularly infections arising in the bowel. It does this by mobilising part of your body’s defence mechanism called the macrophage system. The liver contains over half of the body’s supply of macrophages, known as Kuppfer cells, which literally destroy any bacteria that they come into contact with. If the liver is damaged in any way its ability to fight infections is impaired.

Symptoms of liver damage can be difficult to spot as they are not always obvious – they can include tiredness, nausea and itching.

Why do you need a liver transplant?

You may need a liver transplant if your liver is damaged to the point where it is unable to repair itself and is likely to fail completely. Your doctor may advise you to have a transplant when it is thought this will either dramatically improve your quality of life or that, without a transplant, you will die.

The main causes of severe liver damage that lead to people needing a transplant are:

    * cirrhosis

    * viral hepatitis

    * metabolic conditions (problems with the physical and chemical processes that take place inside your liver to keep you alive)

    * paracetamol poisoning

What are the signs and symptoms of liver failure?

By the time you discover you need a transplant your liver might begin to fail and your quality of life may be very poor. You may have experienced the following symptoms:

    * loss of appetite

    * generally feeling unwell and being tired all the time

    * feeling sick and being sick

    * very itchy skin

    * loss of weight and muscle wasting

    * enlarged and tender liver (you may feel very tender below your right ribs)

    * increased sensitivity to alcohol and drugs (medical and recreational)

    * yellowing of the skin and whites of the eyes (jaundice)

    * swelling of the lower abdomen, or tummy (ascites), or the legs (peripheral oedema)

    * fever with high temperatures and shivers, often caused by an infection

    * vomiting blood

    * dark black tarry stools (faeces) or pale stools, associated with cholestatic disease

    * periods of mental confusion.

Having a liver transplant is a major undertaking but can lead to a resolution for these symptoms and, if successful, you should have an average life expectancy.

What is the process for getting a liver transplant?

The process for getting a liver transplant begins with a referral by a doctor to a transplant center. People seeking a liver transplant are carefully evaluated by a team at the transplant center to determine whether they are suitable candidates for transplantation. The evaluation includes a complete medical history, physical examination, blood and urine tests, x rays and other imaging tests, and tests to check the function of the heart, lungs, and kidneys. The transplant team usually includes liver transplant surgeons; liver specialists, called hepatologists; nurses; transplant coordinators; social workers; a psychiatrist; and other specialists. A financial counselor may help with making arrangements to pay for the transplant.

The evaluation of a transplant candidate typically includes assessment of

    * the status of the person’s liver disease

    * other diseases and conditions the person has

    * the likelihood the person will survive the transplant operation

    * the person’s ability to follow instructions and the complex medical regimen required after a transplant

    * the person’s mental and emotional health

    * the person’s support system

Status 1 Patients

Critically ill patients with acute liver failure who are likely to die within a week are categorized as status 1 patients and are given highest priority for liver transplantation.

What might prevent a person from having a liver transplant?

Each transplant center has its own guidelines regarding eligibility for liver transplantation. A center might determine that a person with acute or chronic liver failure is not a candidate for a liver transplant if the person has

    * cancer outside the liver

    * infection throughout the body

    * advanced heart or lung disease

    * an alcohol or drug abuse problem

    * AIDS

    * the inability to follow a treatment regimen

    * a lack of psychosocial support

In addition, the transplant candidate may decide not to go forward with a transplant.

Where do donated livers come from?

Most donated livers come from deceased donors—donors who have recently died. Adults usually receive the entire liver from a deceased donor, although a segment of the liver can be transplanted when the donor liver is too large. Because few donor livers come from children, pediatric recipients more often receive a portion of a liver from an adult donor. Occasionally, an adult liver is split into two portions and given to two different recipients. For example, the smaller left lobe may be given to a child and the larger right lobe given to an adult.

A small number of liver transplants are performed using living donors. Most living donors are relatives of the recipient. In living donor transplantation, a segment of the donor’s healthy liver is surgically removed and transplanted into the recipient. Because a healthy liver can regenerate, the donor’s liver soon grows back to normal size after the surgery, while the segment of the liver that was transplanted into the recipient also grows to normal size.

The entire left lobe or a portion of the left lobe of the liver from a living adult donor is usually sufficient for transplantation in a child. For adult recipients, the larger right lobe of the liver may be needed. However, the removal of the right lobe of the liver from a living donor is a challenging and complex surgery with significant risks to the donor, including death.

What happens during liver transplant surgery?

When a suitable liver from a deceased donor is matched to a person who is ready to receive it, the surgery is scheduled as quickly as possible. The recipient completes presurgical testing and is prepared for surgery while the donor liver is obtained, transported to the hospital, and carefully checked to ensure it is suitable for transplantation.

Liver transplant surgery is complex and can take up to 12 hours. The patient receiving the liver requires general anesthesia given through a breathing tube inserted into the windpipe, intravenous lines to provide medicine and fluids, and a catheter to drain urine.

An incision is made in the upper abdomen, and the surgical team detaches the diseased or injured liver from blood vessels and the common bile duct, clamps the vessels and duct, and removes the liver. The team then attaches the recipient’s blood vessels and common bile duct to those in the donor liver. The donor liver is typically placed in the same location where the diseased or injured liver was. Tubes are sometimes placed around the transplanted liver to allow blood and fluids to drain out of the abdomen. A tube may be used to temporarily drain bile from the new liver into an external pouch so the bile can be measured to determine whether the liver is producing bile as it should. In cases where the recipient’s common bile duct cannot be connected to the donor’s bile duct, the donor bile duct is drained into a loop of small intestine.

After surgery, the patient goes to an anesthesia recovery area and then to an intensive care unit. After the patient is stabilized, the breathing tube used for anesthesia is removed and the patient moves out of intensive care and into a regular hospital room. Patients usually stay in the hospital from 1 to 2 weeks after a liver transplant.

Living donor transplants involve two surgeries performed in the same hospital. In one operating room, a surgical team removes the transplant recipient’s diseased or injured liver. In another operating room, another surgical team removes a segment of the donor’s healthy liver. Then the segment of donor liver is transplanted into the recipient. Otherwise, the surgery and recovery for the recipient is similar to that for a recipient of a liver from a deceased donor. The living donor typically remains hospitalized for about 1 week after surgery.

What are the complications of liver transplantation?

Possible complications of liver transplant surgery include

    * bleeding

    * damage to the bile ducts

    * blood clots in the liver’s blood vessels

    * infection

    * rejection of the new liver by the body’s immune system

    * side effects from the immunosuppressive medications liver transplant recipients must take to prevent rejection

In addition, liver diseases can recur in transplanted livers. The transplanted liver can be damaged if, for example, a person who had cirrhosis caused by long-term alcohol abuse resumes drinking after the transplant. Recurrence of certain liver diseases such as hepatitis C can also damage the transplanted liver. Recurrence of hepatitis B in the transplanted liver can now be prevented. Finally, autoimmune diseases, such as autoimmune hepatitis, primary biliary cirrhosis, and primary sclerosing cholangitis, may also recur.

If a person’s transplanted liver fails as a result of rejection or recurrent disease, the doctors on the transplant team must decide whether another transplant is possible.

Conclusions

A liver transplant is a surgical procedure by which a surgeon replaces a dysfunctional or damaged liver with a healthy one. Either a part of liver or whole liver is transplanted, according to the indication of the transplant.

In most cases, liver is taken from a deceased donor. It is also possible to take a part of liver from living donor. Since liver is the only organ in the body which can regenerate to increase its size, a part of liver when transplanted in the body rebuilds to the normal size liver within few weeks.

India is a home for one of the best surgeons and hospitals for Liver Transplant at much affordable cost. This makes India at the top destination option for the Liver Transplant.

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Understanding Cancer

What is Cancer

In the most basic terms, cancer refers to cells that grow out-of-control and invade other tissues. Cells become cancerous due to the accumulation of defects, or mutations, in their DNA. Certain inherited genetic defects (for example, BRCA1 and BRCA2 mutations) and infections can increase the risk of cancer. Environmental factors (for example, air pollution) and poor lifestyle choices -- such as smoking and heavy alcohol use -- can also damage DNA and lead to cancer.

Most of the time, cells are able to detect and repair DNA damage. If a cell is severely damaged and cannot repair itself it undergoes so-called programmed cell death or apoptosis. Cancer occurs when damaged cells grow, divide, and spread abnormally instead of self-destructing as they should.

 

Metastasis

 

Metastasis is the process whereby cancer cells break free from a tumor and travel to and invade other tissues in the body. Cancer cells metastasize to other sites via the lymphatic system and the bloodstream. Cancer cells from the original -- or primary -- tumor can travel to other sites such as the lungs, bones, liver, brain, and other areas. These metastatic tumors are "secondary cancers" because they arise from the primary tumor.

Metastatic cancer retains the name of the primary cancer. For example, bladder cancer that metastasizes to the liver is not liver cancer. It is called metastatic bladder cancer. Metastasis is significant because it helps determine the staging and treatment of cancer. Some types of metastatic cancer are curable, but many are not.

Cancer Tumors

Tumors: Benign vs. Malignant

A tumor is an abnormal mass of cells. Tumors can either be benign (non-cancerous) or malignant (cancerous). Benign tumors grow locally and do not spread. Malignant tumors have the ability to spread and invade other tissues. This process, which is a key feature of cancer, is known as metastasis.

 

 

 

 

 

Cancer Causes

Certain genes control the life cycle – the growth, function, division, and death -- of a cell. When these genes are damaged, the balance between normal cell growth and death is lost. Cancer occurs due to DNA damage and out-of-control cell growth. The following is a partial list of factors known to damage DNA and increase the risk of cancer:

    * Genetic mutations (for example, BRCA1  and BRCA2)

    * Environmental exposure to UV radiation, air pollution

    * Bacterial (H. pylori) and viral infections (Epstein-Barr, HPV, hepatitis B and C)

    * Lifestyle choices (poor diet, inactivity, obesity, heavy alcohol use, smoking cigarettes and tobacco use, exposure to chemicals and toxins)

    * Treatment with chemotherapy, radiation, or immunosuppressive drugs

Cancer Symptoms & Signs

There are more than 100 different types of cancer. Every cancer and every individual is unique. The symptoms and signs of cancer depend on the size and location of the cancer as well as the presence or absence of metastasis. Symptoms and signs such as fever, pain, fatigue, skin changes (redness, sores that won't heal, jaundice, darkening), and unintended weight loss or weight gain are not unique to cancer, but they often occur with cancer. More potential cancer signs and symptoms include the presence of a lump, difficulty swallowing, changes or difficulties with bowel or bladder function, persistent cough, hoarseness, and unexplained bleeding or discharge.

 

Types Of Cancer

Cancer can occur anywhere in the body. Broadly, cancers are classified as either solid (for example, breast, lung, or prostate cancers) or liquid (blood cancers). Cancer is further classified according to the tissue in which it arises.

Carcinomas are cancers that occur in epithelial (lining) tissues in the body. They comprise 80% to 90% of all cancers. Most breast, lung, colon, skin, and prostate cancers are carcinomas. Sarcomas occur in connective tissue like the bones, cartilage, fat, blood vessels, and muscles. Myelomas are cancers that occur in plasma cells in the bone marrow. Leukemias are blood cancers of the bone marrow. Lymphomas are cancers of the immune system cells. Mixed cancers arise from more than one type of tissue.

Common Causes Of Cancer

Common Cancers

Cancer is the second leading cause of death in the United States. The most common cancers diagnosed in the world are those of the breast, prostate, lung, colon and rectum, and bladder. Cancers of the lung, colon and rectum, breast, and pancreas are responsible for the most deaths. The prognosis of different cancers is highly variable. Many cancers are curable with early detection and treatment. Cancers that are aggressive or diagnosed at a later stage may be more difficult to treat, and can even be life threatening.

 

 

Cancer Staging

Cancer StagingCancer staging is the process doctors use to classify cancer according to its size, location, and extent of spread. Staging helps doctors determine the prognosis and treatment for cancer. The TNM staging system classifies cancers according to:

    * Tumor (T): Primary tumor size and/or extent

    * Nodes (N): Spread of cancer to lymph nodes in the regional area of the primary tumor

    * Metastasis (M): Spread of cancer to distant sites away from the primary tumor

Some cancers, including those of the brain, spinal cord, bone marrow (lymphoma), blood (leukemia), and female reproductive system, do not receive a TNM classification. Instead, these cancers are classified according to different staging systems.

Cancer Stages

Cancer StagesThe TNM classification of a cancer usually correlates to one of the following five stages.

    * Stage 0: This refers to cancer that is "in situ," meaning that cancerous cells are confined to their site of origin. This type of cancer has not spread and is not invading other tissues.

    * Stage I – Stage III: These higher stages of cancer correspond to larger tumors and/or greater extent of disease. Cancers in these stages may have spread beyond the site of origin to invade regional lymph nodes, tissues, or organs.

    * Stage IV: This type of cancer has spread to distant lymph nodes, tissues, or organs in the body far away from the site of origin.

Cancer Lymph Nodes

Lymph NodesLymph nodes are small structures that filter lymph -- the clear, watery fluid that contains infection-fighting blood cells -- throughout the body. Lymph nodes are an important part of the immune system. They remove viruses, bacteria, and other waste materials from the lymph. Lymph nodes become inflamed and enlarged when they are fighting an infection or disease process in the body. Groups of lymph nodes are found in the chest, groin, abdomen, neck, and under the arms.

Cancer that originates in the lymph nodes or other area of the lymphatic system is called lymphoma. Cancer that originates elsewhere in the body can spread to lymph nodes. The presence of cancer that has spread to the lymph nodes is significant because it may mean that the cancer is growing quickly and/or is more likely to spread to other sites. The presence of cancer in lymph nodes may affect prognosis and treatment decisions.

Doctors often remove lymph nodes during surgery to remove cancer to determine the extent of spread of the cancer. Removal of lymph nodes can affect the flow of lymph in the body. The removal of many lymph nodes can result in the build-up of lymph fluid, a condition known as lymphedema.

Cancer Treatment

Cancer treatment is highly variable depending on the type and stage of a cancer as well as the overall health of the patient. The most common treatments for cancer are surgery, radiation, and chemotherapy. Other treatments include targeted/biological therapies, hematopoietic stem cell transplants, angiogenesis inhibitors, cryosurgery, and photodynamic therapy.

Every cancer treatment has potential risks, benefits, and side effects. The patient and his or her care team, which may include an internist or other specialist, surgeon, oncologist, radiation oncologist, and others, will help determine the best and most appropriate course of treatment.

 

 

Cancer Surgery

Surgery is often performed to remove cancerous tumors. Surgery allows for the determination of the exact size of the tumor as well as the extent of spread and invasion into other nearby structures or lymph nodes – all-important factors in prognosis and treatment. Surgery is often combined with other cancer treatments, such as chemotherapy and/or radiation.

Sometimes, cancer cannot be entirely surgically removed because doing so would damage critical organs or tissues. In this case, "debulking" surgery is performed to remove as much of the tumor as is safely possible. Similarly, "palliative" surgery is performed in the cases of advanced cancer to reduce the effects (for example, pain or discomfort) of a cancerous tumor. Debulking and palliative surgeries are not curative, but they seek to minimize the effects of the cancer.

In other cases, surgery is preventive or prophylactic. A woman who has BRCA1 or BRCA2 gene mutations may elect to have a mastectomy to reduce the risk of developing breast cancer in the future. Reconstructive surgery can be performed to restore the look or function of part of the body after prior cancer surgery. Breast reconstruction after a mastectomy is an example of this kind of surgery.

Radiation Treatment

Radiation is a very common cancer treatment. About 50% of all cancer patients will receive radiation treatment, which may be delivered before, during, or after surgery and/or chemotherapy. Radiation kills cancer cells by damaging their DNA. Unfortunately, radiation also damages the DNA of healthy cells. Radiation can be delivered externally -- where X-rays, gamma rays, or other high-energy particles are delivered to the affected area from outside the body -- or it can be delivered internally. Internal radiation therapy involves the placement of radioactive material inside the body near cancer cells. This is called brachytherapy.

Systemic radiation involves the administration of radioactive medication by mouth or intravenously. The radioactive material travels directly to the cancerous tissue. Radioactive iodine (I-131 for thyroid cancer) and strontium-89 (for bone cancer) are two examples of systemic radiation treatments.

Typically, external radiation is delivered 5 days a week over the course of 5 to 8 weeks. Other treatment regimens are sometimes used.

Chemotherapy

Chemotherapy, or "chemo," refers to more than 100 different medications used to treat cancer and other conditions. Ideally, chemotherapy cures cancer. If a cure is not possible, the goals of treatment may be to slow the growth of cancer, keep the cancer from spreading, and/or relieve cancer-associated symptoms (such as pain).

Depending on the type of chemotherapy prescribed, the medications may be given by mouth, injection, intravenously (IV), or topically. IV chemo may be delivered via a catheter or port, which is usually implanted in a blood vessel of the chest for the duration of the therapy. Sometimes chemo is delivered regionally, directly to the area that needs treatment. For example, intravesical therapy is used to infuse chemotherapy directly into the bladder for the treatment of bladder cancer.

The chemo regimen a patient receives depends upon the type and stage of the cancer, any prior cancer treatment, and the overall health of the patient. Chemo is usually administered in cycles over the course of days, weeks, or months, with rest periods in between.

Other Cancer Treatments

In addition to surgery, radiation, and chemotherapy, other therapies are used to treat cancer. These include:

    * Targeted or biological therapies seek to treat cancer and boost the body's immune system while minimizing damage to normal, healthy cells. Monoclonal antibodies, immunomodulating drugs, vaccines, and cytokines are examples of targeted or biological therapies.

 

    * Hematopoietic stem cell transplants involve the infusion of stem cells into a cancer patient after the bone marrow has been destroyed by high-dose chemo and/or radiation.

 

    * Angiogenesis inhibitors are medications that inhibit the growth of new blood vessels that cancerous tumors need in order to grow.

 

    * Cryosurgery involves the application of extreme cold to kill precancerous and cancerous cells.

 

    * Photodynamic therapy (PDT) involves the application of laser energy of a specific wavelength to tissue that has been treated with a photosensitizing agent, a medication that makes cancerous tissue susceptible to destruction with laser treatment. Photodynamic therapy selectively destroys cancer cells while minimizing the damage to normal, healthy tissues nearby.

 

    * Ongoing cancer research continues to identify newer, less toxic, and more effective cancer treatments. Visit the National Cancer Institute (NCI) to see a list of ongoing clinical trails.

 

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Liver cancer and Liver Transplant in India

What is liver cancer?

Cancer starts when cells in the body begin to grow out of control. Cells in nearly any part of the body can become cancer, and can spread to other areas of the body.

Only cancers that start in the liver are called liver cancer. To understand liver cancer, it helps to know about the normal structure and function of the liver.

 
About the liver  
The liver is the largest internal organ. It lies under your right ribs just beneath your right lung. It is shaped like a pyramid and divided into right and left lobes. The lobes are further divided into segments.   

 

Unlike most other organs, the liver gets blood from 2 sources: the hepatic artery supplies the liver with blood rich in oxygen from the heart, and the portal vein brings nutrient-rich blood from the intestines.
You cannot live without your liver. It has several important functions:

• It breaks down and stores many of the nutrients absorbed from the intestine that your body needs to function. Some nutrients must be changed (metabolized) in the liver before they can be used by the rest of the body for energy or to build and repair body tissues.
• It makes most of the clotting factors that keep you from bleeding too much when you are cut or injured.
• It secretes bile into the intestines to help absorb nutrients (especially fats).
• It filters out and breaks down toxic wastes in the blood, which are then removed from the body.

The liver is made up mainly of cells called hepatocytes. It also is made up of other types of cells, including cells that line its blood vessels and cells that line small tubes in the liver called bile ducts. The bile ducts extend out of the liver and carry bile from the liver to the gallbladder or directly to the intestines.

These different types of cells in the liver can form several types of malignant (cancerous) and benign (non-cancerous) tumors. These tumors have different causes, are treated differently, and have a different prognosis (outlook).

What are the risk factors for liver cancer?

A risk factor is anything that affects your chance of getting a disease, such as cancer. Different cancers have different risk factors. Some risk factors, like smoking, can be changed. Others, like a person's age or family history, can't be changed.
But risk factors don't tell us everything. Having a risk factor, or even several risk factors, does not mean that you will get the disease. And some people who get the disease may have few or no known risk factors.
Scientists have found several risk factors that make a person more likely to develop hepatocellular carcinoma (HCC).

Gender

Hepatocellular carcinoma is much more common in males than in females. Much of this is probably because of behaviors affecting some of the risk factors described below. The fibrolamellar subtype of HCC is more common in women.

 

Chronic viral hepatitis

Worldwide, the most common risk factor for liver cancer is chronic (long-term) infection with hepatitis B virus (HBV) or hepatitis C virus (HCV). These infections lead to cirrhosis of the liver (see above) and are responsible for making liver cancer the most common cancer in many parts of the world.
In the United States, infection with hepatitis C is the more common cause of HCC, while in Asia and developing countries, hepatitis B is more common. People infected with both viruses have a high risk of developing chronic hepatitis, cirrhosis, and liver cancer. The risk is even higher if they are heavy drinkers (at least 6 standard drinks a day).
HBV and HCV can spread from person to person through sharing contaminated needles (such as in drug use), unprotected sex, or childbirth. They can also be passed on through blood transfusions, although this is very rare in the United States since the start of blood product testing for these viruses. In developing countries, children sometimes contract hepatitis B infection from prolonged contact with family members who are infected.
HBV is more likely to cause symptoms, such as a flu-like illness and a yellowing of the eyes and skin (jaundice). But most people recover completely from HBV infection within a few months. Only a very small percentage of adults become chronic carriers (and have a higher risk for liver cancer). Infants and small children who become infected have a higher risk of becoming chronic carriers.
HCV, on the other hand, is less likely to cause symptoms. But most people with HCV develop chronic infections, which are more likely to lead to liver damage or even cancer.
Other viruses, such as the hepatitis A virus and hepatitis E virus, can also cause hepatitis. But people infected with these viruses do not develop chronic hepatitis or cirrhosis, and do not have an increased risk of liver cancer.

Cirrhosis

Cirrhosis is a disease in which liver cells become damaged and are replaced by scar tissue. People with cirrhosis have an increased risk of liver cancer. Most (but not all) people who develop liver cancer already have some evidence of cirrhosis.
There are several possible causes of cirrhosis. Most cases in the United States occur in people who abuse alcohol or have chronic HBV or HCV infections.
Non-alcoholic fatty liver disease, a condition in which people who consume little or no alcohol develop a fatty liver, is common in obese people. People with a type of this disease known as non-alcoholic steatohepatitis (NASH) might go on to develop cirrhosis.
Some types of autoimmune diseases that affect the liver can also cause cirrhosis. For example, there is also a disease called primary biliary cirrhosis (PBC). PBC seems to be an autoimmune condition, in which the immune system attacks the bile ducts in the liver. This causes the bile ducts to become damaged and even destroyed and can lead to cirrhosis. People with advanced PBC have a high risk of liver cancer.

Heavy alcohol use

Alcohol abuse is a leading cause of cirrhosis, which in turn is linked with an increased risk of liver cancer.

Obesity 

Being obese (very overweight) increases the risk of developing liver cancer. This is probably because it can result in fatty liver disease and cirrhosis.

Type 2 diabetes 
Type 2 diabetes has been linked with an increased risk of liver cancer, usually in patients who also have other risk factors such as heavy alcohol use and/or chronic viral hepatitis. This risk may be increased because people with type 2 diabetes tend to be overweight or obese, which in turn can cause liver problems.

Inherited metabolic diseases 
Certain inherited metabolic diseases can lead to cirrhosis.
People with hereditary hemochromatosis absorb too much iron from their food. The iron settles in tissues throughout the body, including the liver. If enough iron builds up in the liver, it can lead to cirrhosis and liver cancer.
Other rare diseases that increase the risk of liver cancer include:

• Tyrosinemia
• Alpha1-antitrypsin deficiency
• Porphyria cutanea tarda
• Glycogen storage diseases
• Wilson disease

 
Aflatoxins 
These cancer-causing substances are made by a fungus that contaminates peanuts, wheat, soybeans, ground nuts, corn, and rice. Storage in a moist, warm environment can lead to the growth of this fungus. Although this can occur almost anywhere in the world, it is more common in warmer and tropical countries. Developed countries such as the United States and those in Europe regulate the content of aflatoxins in foods through testing.
Long-term exposure to these substances is a major risk factor for liver cancer. The risk is increased even more in people with hepatitis B or C infections.

Vinyl chloride and thorium dioxide (Thorotrast) 

Exposure to these chemicals raises the risk of angiosarcoma of the liver. It also increases the risk of developing cholangiocarcinoma and hepatocellular cancer, but to a far lesser degree. Vinyl chloride is a chemical used in making some kinds of plastics. Thorotrast is a chemical that in the past was injected into some patients as part of certain x-ray tests. When the cancer-causing properties of these chemicals were recognized, steps were taken to eliminate them or minimize exposure to them. Thorotrast is no longer used, and exposure of workers to vinyl chloride is strictly regulated.

Anabolic steroids 

Anabolic steroids are male hormones used by some athletes to increase their strength and muscle mass. Long-term anabolic steroid use can slightly increase the risk of hepatocellular cancer. Cortisone-like steroids, such as hydrocortisone, prednisone, and dexamethasone, do not carry this same risk.

Arsenic 

Drinking water contaminated with naturally occurring arsenic, such as that from some wells, over a long period of time increases the risk of some types of liver cancer. 

Infection with parasites 

Infection with the parasite that causes schistosomiasis can cause liver damage and is linked to liver cancer. 

Tobacco use 

Smoking increases the risk of getting liver cancer. Former smokers have a lower risk than current smokers, but both groups have a higher risk than those who never smoked.

Factors with unclear effects on liver cancer risk 

 Birth control pills

In rare cases, birth control pills, also known as oral contraceptives, can cause benign tumors called hepatic adenomas. But it is not known if they increase the risk of hepatocellular cancer. Some of the studies that have looked at this issue have suggested there may be a link, but most of the studies were not of high quality and looked at types of pills that are no longer used. Current birth control pills use different types of estrogens, different estrogen doses, and different combinations of estrogens with other hormones. It is not known if the newer pills increase liver cancer risk.

 

Hepatocellular carcinoma (HCC) is the most common form of liver cancer. HCC can start as a single tumor that takes a long time to spread to other parts of the liver.

It can also manifest as many small cancerous nodules throughout the liver. This type of cancer is found most often in patients with cirrhosis (chronic liver damage).

Hemochromatosis

Hemochromatosis is a metabolic disease in which excess iron is absorbed from the digestive tract and deposited in tissues and organs through the body,

where it causes damage. Complications in the liver, heart, and pancreas can be life threatening.

Causes of Hemochromotosis

Hemochromotosis is most often caused by a genetic mutation to the HFE gene. Individuals who receive the genetic mutation from both parents have a 70% chance of developing the disease.

People who inherit one mutated gene do not develop hemochromotosis but carry the disease and may pass it on to their children.

Symptoms of Hemochromotosis

Hemochromotosis causes excess iron to accumulate in the joints and organs, where it may cause serious complications including:

• Cirrhosis and abnormal functioning of the liver
• Diabetes (from damage to the pancreas)
• Congestive heart failure, abnormal heart rhythm (arrhythmias), and  heart failure
• Disruption of the reproductive system including erectile dysfunction, loss of menstruation, loss of sex drive
• Skin changes (bronze or yellowing tint to the skin) resulting from deposits of iron in the skin

Symptoms often do not appear until age 50 to 60 in men, and after age 60 in women. Other common symptoms include:

• Lethargy
• Weakness
• Irritability
• Joint pain
• Depression
• Hair loss
• Infection
• Enlarged spleen

Diagnosing Hemochromotosis

Diagnosis may require testing including:

• Blood testing for iron overload, including tests to measure iron levels in the blood and in the liver
• Liver function tests
• MRI
• Genetic testing
• Liver biopsy

Treatment for Hemochromotosis

Treatments for hemochromotosis will depend on age, overall health, severity of disease, and other factors. Treatments can alleviate symptoms such as fatigue,

abdominal pain, and skin changes, but will not reverse damage such as cirrhosis or end joint pain. Primary therapies include:

• Phlebotomy: periodic removal of the blood from the body. Depending on age and severity of disease, patients may initially have a pint of blood removed once or twice per week.
• Once iron levels are normalized, blood may be removed monthly or every three to four months.
• Chelation therapy: Medication that binds to the excess iron and removes it from the body. Chelation medications may be administered via pill or intravenously.

Supplemental measures include:

• Avoidance of iron and vitamin C supplements
• Avoidance of alcohol
• Treatment for associated complications

Types of primary liver cancer and its treatment

Familial Amyloidosis

Amyloidosis is a disease in which the body produces abnormal proteins called amyloid. Deposits of these proteins build up in tissues and organs of the body and can cause a range of symptoms.

There are various types of amyloidosis, including primary amyloidosis, secondary amyloidosis, and familial amyloidosis.

Causes of familial amyloidosis

Familial amyloidosis, also called ATTR amyloidosis, is caused by an abnormal gene inherited from an affected parent. The most common form is caused by the transthyretin (TTR) protein,

and more than 100 mutations of this protein have been associated with the disease.

Familial amyloidosis is autosomal dominant, which means that a child has a 50% chance of inheriting the disease if just one parent carries the genetic trait for it.

Symptoms of familial amyloidosis

Although the abnormal gene is present at birth, symptoms do not appear until later in life, after amyloid deposits have accumulated. Familial amyloidosis often affects the liver, heart, kidneys, and nerves.
Symptoms may include:

• Neuropathy (numbness or tingling in the hands and feet)
• Cardiomyopathy (enlargement of the heart)
• Irregular heartbeat
• Diarrhea or constipation
• Weight loss
• Dizziness upon standing (orthostatic hypotension)
• Swelling of the legs and ankles
• Weakness
• Shortness of breath
• Severe fatigue
• Purplish patches around the eyes
• Enlarged tongue
• Skin changes such as easy bruising or thickening
• Protein in the urine

If the disease causes damage to the kidney, nerves, or heart, such damage can be life threatening.

Diagnosing familial amyloidosis

The following tests may be used to diagnose familial amyloidosis:

• Blood tests
• Urine tests
• Physical exam
• Tissue biopsy

Treatments for familial amyloidosis

The primary treatment for familial amyloidosis is liver transplantation. The abnormal TTR protein is made in the liver, but a newly transplanted liver will make only normal transthyretin protein.

In addition to liver transplantation, other supportive measures may be needed to address the effects of amyloidosis on other organs.

For instance if the kidneys are affected, patients may need to take diuretics, restrict dietary salt, wear compression garments, and elevate their legs to reduce swelling.

Dietary changes and medications may be needed to treat gastrointestinal effects.

Ex Vivo Surgery and Multivisceral Transplantation

Intestinal and Multivisceral Transplantation

By transplanting several organs at once, we can give patients with serious intestinal malformations or infections hope for a healthy future.

MedWorld India has managed nearly many patients with devastating intestinal problems in recent years.

#MedWorld India works with the top hospitals in India with dedicated specialists in pediatric surgery and transplantation;

pediatric gastrointestinal medicine and nutrition; advanced practice nursing; and child life and social support services. This range of services,

essential to helping these children and their families cope with overwhelming health problems.

Intestinal or '#short bowel' transplantation is now recognized as a viable option for irreversible intestinal failure or short bowel syndrome.

Patients who develop intestinal failure can become candidates for intestinal transplantation if life threatening complications are present or if bowel rehabilitation is impossible due to the congenital nature of the intestinal disease.

Intestinal transplantation is frequently associated with liver transplantation. Certain diseases, such as biliary atresia, and the use of total parenteral nutrition (TPN) for conditions such as short bowel syndrome, can contribute to liver failure. If the child has both intestinal and liver failure, intestinal transplantation may be performed in conjunction with liver transplantation. If the patient does not have liver failure, isolated intestinal transplantation may be performed while leaving the liver in place. Multivisceral transplantation may be considered if the patient's condition involves failure of multiple abdominal organs, with or without transplanting the liver.

Ex vivo Surgery

Ex vivo transplant surgery entails the removal and re-implantation of as many as six abdominal organs in order to excise tumors that have grown to involve the organs and or blood vessels. In these complex operations, the surgical team removes affected internal organs and blood vessels, excises the tumor, and reimplants the organs. Some procedures require extensive surgical repair and grafting of blood vessels.

About the Procedures: Isolated Small Bowel or Multiorgan Transplantation

Intestinal transplant is a complex procedure that may entail an isolated intestinal transplant, multivisceral transplant, or a modified multivisceral transplant. Depending on the cause of your child's intestinal failure and overall medical condition, the transplant team will determine the type of surgery that best meets your child's medical needs.

Our pediatric transplant surgeons can perform small bowel transplantation for specific sections of the colon, such as the large bowel. We also can combine liver and small bowel transplantation, as well as liver, small bowel, and colon transplantation if necessary. For some patients, our surgeons rebuild the colon to avoid any permanent colostomy. They can also perform a multi-visceral transplantation-the transplantation of more than four organs: stomach, small bowel, pancreas, liver, and large bowel.

Types of Multivisceral Transplant Surgery

Multivisceral transplant surgical options include the following:

• Isolated Intestinal Transplant: an isolated intestinal transplant involves removing the diseased portion of the small intestine and replacing it with a healthy small intestine from a donor. This type of transplant is considered for patients with complications caused by intestinal failure, but who do not have liver failure.
• Multivisceral Transplant: a multivisceral transplant may be considered for patients who have multiple organ failure, including stomach, pancreas, liver, small intestine and/or kidney failure. This type of transplant involves removing the diseased organs and replacing them with healthy organs from a donor.
• Modified Multivisceral: a modified multivisceral transplant may be considered for patients who do not have liver disease/failure, but have organ failure of the stomach, pancreas, small intestine and/or kidney(s. This type of transplant involves keeping your own liver, and removing the remaining diseased organs and replacing them with healthy organs from a donor. Life-threatening complications include: loss, or impending loss of vascular access for total parenteral nutrition (TPN); development of TPN-induced liver failure with cholestatic disease (jaundice) and portal hypertension (which can lead to gastro-intestinal bleeding episodes); episodes of frequent sepsis from central venous line catheters and/or intestinal translocation; and recurrent, severe episodes of dehydration.

Indications for Intestinal Transplantation

Intestinal transplantation may be indicated for patients with the following conditions:

• Gastroschisis
• Volvulus
• Necrotizing Enterocolitis
• Intestinal Atresia
• Intestinal Pseudo-Obstruction
• Megacystis Microcolon Intestinal Hypoperistalsis Syndrome
• Microvillus Inclusion Disease
• Hirschsprung's Disease
• Gardner's Syndrome/Familial Adenomatous Polyposis
• Mesenteric Venous Thrombosis or Arterial Thrombosis 
• Crohn’s Disease
• Desmoid Tumor with Intra-Abdominal Infiltration
• Trauma:
• Multiple resections and explorations
• Vascular Abdominal Trauma such as Superior Mesenteric Artery (SMA) or Superior Mesenteric Vein (SMV) Injuries
• Endocrine Tumors
• Infiltrative Diseases leading to intestinal failure: Sarcoidosis/Amyloidosis
• Short Bowel Syndrome

Most patients needing a combined liver-intestine or multivisceral transplantation have:

• TPN Cholestasis that has progressed to irreversible liver injury (fibrosis/cirrhosis)
• End-Stage Liver Disease

Complications of Intestinal and Multivisceral Transplantation

Intestinal, multivisceral, or modified multivisceral transplantation is a life-saving therapy. However, your physicians cannot predict exactly how your child's body will respond to this transplant. The operation is extremely complex and the risks are significant.
The most common complications include postoperative hemorrhage, vascular leaks or obstruction, and biliary leaks or obstruction. Other potential complications include:

• bleeding
• infection
• bile leaks
• vascular complications
• intestinal leaks
• rejection of the transplanted tissue
• side-effects of immunosuppressant medications
• depression, anxiety, and mood-related disorders
• increased risk of skin and certain other cancers

 

Cystic Fibrosis

Cystic fibrosis (CF) is an inherited disease characterized by an abnormality in the body's salt, water- and mucus-making cells. It is chronic, progressive, and is usually fatal. In general, children with CF live into their 30s. 

Children with CF have an abnormality in the     function of a cell protein called the cystic fibrosis transmembrane regulator (CFTR). CFTR controls the flow of water and certain salts in and out of the body's cells. As the movement of salt and water in and out of cells is altered, mucus becomes thickened. The thickened mucus can affect many organs and body systems including:

• respiratory - sinuses and lungs
• digestive - pancreas, liver, gallbladder, intestines
• reproductive - more so in the male, where sperm-carrying ducts become clogged
• sweat glands

Many children with cystic fibrosis develop liver problems later in life.

Cystic Fibrosis Liver Disease

Cystic fibrosis affects the lungs, pancreas, liver, and other organs. Although the lung and pancreas are primarily affected in many patients with CF, fat in the liver is common and can be serious. In some patients, severe scarring, or cirrhosis, can develop.

In patients with CF, bile produced by the liver cells becomes stickier than normal and begins to block the small bile ducts. This causes damage and scarring to the surrounding liver tissue (called biliary fibrosis). Biliary fibrosis progresses and spreads through the liver, causing it to become hardened and unable to function optimally.

Symptoms of CF Liver Disease

Some patients have no symptoms, but those with advanced liver disease may have symptoms including:

• enlarged liver and spleen
• portal hypertension (high blood pressure in the vein leading to the liver)
• ascites (fluid accumulation in the abdomen)
• varices (bleeding from dilated veins) in the esophagus or stomach
• difficulty maintaining adequate weight
• jaundice
• bleeding problems 

Treatment for CF Liver Disease

Medications and nutritional changes can help to reduce the health problems associated with CF liver disease. Patients should avoid alcohol use.

Bile Duct Cancer (Cholangiocarcinoma)  

Cholangiocarcinoma is cancer located in one of the bile ducts, which carries bile from the liver to the small intestine. Bile duct cancer may occur anywhere in the ducts, either inside or outside the liver. Although they are slow growing, often they are not detected until in advanced stages when they block the bile duct and cause symptoms.
Also called biliary cancer, cholangiocarcinoma looks different under the microscope, often has different blood markers, and is treated differently than tumors originating in the liver tissue.  

 

Symptoms of cholangiocarcinoma

Symptoms may include:

• Jaundice
• Itchy skin
• Fever
• Abdominal pain
• Weight loss

Causes of cholangiocarcinoma

Cholangiocarcinoma is rare, occurring in only 2 out of 100,000 people. Risk factors include:

• Primary sclerosing cholangitis
• Inflammation to the liver from hepatitis C virus, NASH, and other liver disease
• In Asia and other regions, parasitic infection (biliary flukes)
• Bile duct cysts
• Ulcerative colitis

Treatment of cholangiocarcinoma

Treatments may include surgery, radiation therapy, and chemotherapy.

Surgery

If found early enough that the tumor can be removed, surgery is curative. The bile duct and part of the liver may need to be removed.  If the tumor is blocking the bile duct, a small tube called a stent may be placed to allow bile to drain more easily to the intestine.
There are also local approaches to treat the tumor using endoscopic retrograde cholangiopancreatography (ERCP). During ERCP, an endoscope is inserted into the patient’s mouth and threaded into the bile ducts to relieve obstruction and to deliver various therapies, which may include photodynamic therapy (PDT) and local ablation.

#MedWorld India offers liver transplantation complete review and advise for patients with biliary cancers which are considered unresectable. 

Radiation Therapy

Radiation therapy may include external beam radiation (SBRT, protons), and radiolabelled beads such as Y90. There are few data yet for these treatments in biliary cancers, but they are under active investigation. Similarly, there are few data yet for chemoembolization in this disease, but it is sometimes used.

Chemotherapy

Chemotherapy is the use of medication to destroy cancer cells. It is usually given intravenously but may be administered orally. If cholangiocarcinoma is advanced, the standard first-line treatment is a chemotherapy combination of gemcitabine and cisplatin. Side effects of these treatments include fatigue, lowering of the blood counts, occasionally kidney dysfunction and hair thinning.
Chemotherapy drugs may be given alone or in combination. Other commonly-used chemotherapy medications for cholangiocarcinoma include: 5FU, capecitabine, irinotecan and oxaliplatin.

Large randomized trials have not yet been completed to determine whether chemotherapy is effective in preventing recurrences after surgery to remove cholangiocarcinomas. The base the treatment of biliary tumors from pancreatic cancer literature. Chemotherapy alone is often recommended, while chemotherapy and radiation is often used if there is a positive margin (cancerous cells remaining after surgery). Sometimes chemotherapy is administered for those with a positive margin, allowing time for the liver to regenerate, and surgery can be re-attempted in order to clear the margin.

Molecular and targeted therapies

Targeted agents under study include:

• MEK inhibitors
• Immunotherapies
• IDH inhibitors
• DNA demethylating agents
• Antiangiogenic therapies

Gallbladder Cancer

About one percent of people have cancer in their gallbladders that is found incidentally (during testing for some other reason). In patients who are diagnosed with cancer of the gallbladder, it is very important to check the pathology of these tumors. Many patients need more extensive surgery with resection of part of the liver and hepatic lymph nodes. This has been shown to improve survival significantly.
The primary risk for gallbladder cancer is gallstones. The following risk factors for gallstones are the most common: being overweight, being female, and age around 40. Because gallstones are related to fat intake, ethnicity and diet are important risk factors. Among Pima Indians in Peru, 80% of women develop gallstones at some point in their lives. Virtually all native Indian women in Chile and Peru develop gallstones. In some parts of the world such as India, the incidence of gallstones is high due to the prevalence of salmonella.

Alpha-1 Antitrypsin Deficiency

Alpha-1 antitrypsin is one of many proteins that the liver produces from food and circulates into the bloodstream. People with alpha-1 antitrypsin deficiency make a slightly abnormal form of this protein, which becomes trapped in the liver.
Inability to make proper alpha-1 antitrypsin is inherited from both parents.

Symptoms of alpha-1 antitrypsin deficiency

Some people have no visible symptoms. Some are healthy for many years, but later in life develop emphysema and lung damage. Yet other children develop inflammation of the liver and display signs of liver damage within the first four months of life. In such cases, symptoms may include:

• Jaundice
• Persistently yellow urine
• Poor weight gain
• Abnormal bleeding from the nose or umbilicus
• Enlargement of the liver and or spleen

Older children with alpha-1 antitrypsin deficiency may experience symptoms including:

• Jaundice
• Ascites  (accumulation of fluid in the abdomen)
• Portal hypertension (increased blood vessel pressure in the portal vein)

Treatments for alpha-1 antitrypsin deficiency

Although there is no cure for this condition, treatments can help to reduce symptoms associated with alpha-1 antitrypsin deficiency. Treatments include regular monitoring in order to recognize and treat changes in the liver promptly, as well as dietary recommendations, which may include extra calories, vitamins or other.

  Acute Liver Failure  

In most cases of liver failure, decrease in function occurs gradually over years. In acute liver failure, the liver rapidly loses function within days. Acute liver failure can develop suddenly in an otherwise healthy person and requires immediate medical attention.

Acute liver failure is a medical emergency that can cause complications including excessive bleeding, pressure in the brain (cerebral edema), kidney failure, infection, and death.

 

 

Causes of acute liver failure

• Acute liver failure is most commonly caused by:
• Tylenol (acetaminophen) overdose
• Hepatitis A, B, and C viruses
• Reactions to prescription or herbal medications
• Toxins such as poisonous wild mushrooms
• Autoimmune hepatitis
• Vascular diseases such as Budd-Chiari syndrome which block the veins in the liver
• Metabolic diseases such as Wilson’s disease
• Cancer

Symptoms of acute liver failure 

Symptoms may be difficult to detect initially because they can be present with many conditions. They may include:

• Jaundice  (yellow skin and eyes)
• Abdominal pain
• Nausea
• Vomiting
• General malaise
• Disorientation, confusion, inability to concentrate
• Sleepiness

Acute liver failure may be diagnosed with blood tests, imaging with ultrasound, and biopsy of liver tissue.

Treatment of acute live failure

Medications

If the cause of acute failure is acetaminophen overdose or a toxin such as a poisonous mushroom, medications to reverse the toxic effects may be administered. If the cause is viral, medical care may allow the patient to heal and the liver to recover.

Complications caused by acute liver failure may be treated with medications and blood transfusion.

Treatment of Hepatocellular carcinoma (HCC) depends on the stage of the cancer and other factors. It may be treated with surgery (transplantation and resection), local therapies, systemic treatments, or combinations of these approaches.

Surgery: Resection

If the tumor is detected at an early stage, when it is typically a single lesion, and there is no significant liver disease, surgeons may be able to surgically remove the tumor. This is called resection. For tumors which are very small, typically less than 2-3 cm, sometimes the tumor can be ablated, or destroyed, most often using radiofrequency ablation. 

Surgery: Liver Transplantation

Because most patients with primary hepatocellular carcinoma have underlying liver disease, liver transplantation allows the best chance for cure. MedWorld India offers liver transplantation patients with bile duct cancers. For patients whose bile duct cancer can not be removed surgically, transplantation can offer an unprecedented chance for cure.

The Milan Criteria is the internationally accepted guideline used to select patients for liver transplantation. According to these criteria, patients may be eligible for liver transplantation if they have a single tumor 5 cm or smaller, or 3 or fewer tumors that are each 3 cm or less in size, and no obvious invasion of the blood vessels on imaging before the transplant.  Patients who have more than one tumor above the sizes specified by these criteria are usually not eligible for transplantation unless the tumor can be “downsized” or shrunk. In some cases, tumors can be reduced sufficiently through chemoembolization, radiation, or other approaches.

Liver Transplantation 

#MedWorld India boasts one of the largest and most experienced team of consultants advising on liver transplantation in collaboration with the leading hospitals in India, offering living donor liver transplantation and employing minimally invasive surgical approaches whenever possible.

Liver transplant procedures the take advantage of the most sophisticated medical knowledge and surgical technology available today, including living donor transplantation, partial liver transplantation, advanced organ preservation techniques, liver transplantation in HIV- and Hepatitis C co-infected individuals, and antiviral therapy to prevent or treat recurrent hepatitis C after liver transplantation.

Our program routinely achieves excellent outcomes for donors and recipients.  Additionally, nearly all donors are very satisfied or satisfied with the experience of donating a portion of their liver. After surgery, we also offer specialized nursing, nutritional support, smoking cessation, weight loss and pain management.

ERCP for Management of Bile Duct Obstruction

Blockage of the bile duct is a potential complication of liver tumors, liver surgery, and bile duct cancer. Our interventional endoscopists often utilize endoscopic retrograde cholangiopancreatography (ERCP) to relieve bile duct obstructions. During this procedure, a physician inserts a stent into the duct to relieve the obstruction and allow drainage to proceed into the intestine, sparing the patient from having to wear an external bag on the abdomen to drain fluids. This approach improves the patient’s quality of life and relieves symptoms associated with jaundice.

Local Therapy

Localized therapy, also called locoregional therapy, includes the following approaches:

• Radiofrequency or Microwave Embolization

  The tumor is destroyed with highly targeted radiowave or microwave energy.

• Radio arterial embolization

  Tiny spheres of a radioactive substance (yttrium-90) are delivered to the tumor site via the hepatic arterial system. The radioactive substance then kills cancer cells at the tumor site.

• Radiation Therapy

  Several hospitals are also examining new forms of targeted external beam radiation, particularly for trying to shrink the tumor out of the portal vein. This also looks very promising, potentially with less toxicity than with Y-90.

• Chemoembolization

  Chemotherapy (injected into the hepatic artery via a catheter) may be used to target larger tumors. The chemotherapy is combined with a substance that temporarily blocks off the hepatic artery, trapping much of the chemotherapy near the tumor. This approach spares nearby healthy tissue from the toxic effects of chemotherapy.
  In some cases, chemotherapy can reduce the size of a tumor enough that it can be surgically removed. Most often, this is delivered locally using beads treated with different types of chemotherapy agents, a therapy called chemoembolization. By inserting them into the tiny blood vessels that feed the tumor, the radiation effectively targets the cancer cells without affecting the whole body. Chemoembolization therapies most commonly include drug-eluting beads labelled with doxorubicin or irinotecan.

Systemic Chemotherapy

Chemotherapy (systemic therapy) is offered to patients who are not good candidates for surgery or locoregional therapy. Chemotherapy drugs are designed to kill cancer, and are generally given in cycles, with a period of treatment followed by a period of rest. These drugs can be administered before surgery, after surgery, or both. When given before surgery, chemotherapy is called neoadjuvant. When given after surgery, chemotherapy is called adjuvant. Chemotherapy can be administered orally, by injection, or intravenously depending on the regimen and the drug. The best course of therapy is selected after considering the specific characteristics of the patient's cancer to maximize the results of the treatment and increase survival.

Traditional chemotherapy medications historically have not been very successful in HCC patients because many are metabolized in the liver, which is not functioning normally in many patients, and because many HCCs have “pumps” which can get the chemotherapy out of the cancer cells, and thus make them resistant.

Adjuvant chemotherapy is usually administered after surgery or liver transplantation, although there adjuvant therapy in HCC has not yet been proven effective. 

For advanced liver cancer with blood vessel invasion or metastatic disease, the standard of care now is a drug called sorafenib (nexavar), which has been shown to improve survival for patients with advanced liver cancer, kidney cancer, and thyroid cancer. It acts by blocking pathways that cause blood vessels to grow. As such, it is considered a “targeted” therapy.  Given in pill form, it is usually taken twice a day on an empty stomach. Side effects include redness of the hands and feet (which can be lessened by using urea cream twice a day while on the drug), diarrhea, fatigue, and high blood pressure.

Molecular and targeted therapies

Many other targeted agents are being studied in clinical trials. These include MET-inhibitors, mTOR inhibitors, demethylating agents, and immunotherapies, among many other types of targeted therapies.  We now have the capability to identify novel targets in each cancer patient’s tumor, so that we can try to identify new therapies which might not have ordinarily been considered for them.

The following blood tests may be ordered to determine if a mass found in the liver is cancerous.

Liver function tests (LFTs)

A series of blood tests can help assess how well the liver is working.

Blood clotting tests

A damaged liver may not make enough of the proteins that allow the blood to clot and therefore prevent bleeding.

Tests for viral hepatitis

Infection with hepatitis B virus (HBV) or hepatitis C virus (HCV) is linked both to cirrhosis of the liver (see above) and to liver cancer.

Kidney function tests

A series of blood tests can help assess the how well the kidneys are working.

Complete blood count (CBC)

This test measures levels of red blood cells, white blood cells (which fight infections), and platelets (which help the blood clot). It also shows how well the bone marrow, where new blood cells are made, is functioning.

Blood chemistry tests and other tests

Blood chemistry tests check the levels of a number of minerals and other substances in the blood, some of which might be affected by liver cancer.

Alpha-fetoprotein blood (AFP) test

The AFP level can help determine what treatment options might be appropriate. Also ordered during treatment, to find out how well the therapy is working, or find out if the cancer has come back.

The diagnosis of liver cancer is usually confirmed through imaging studies. These include:

CT scan

Computed Tomography (CT) scans take many different x-rays to produce detailed, cross-sectional images of the liver and other organs.

Magnetic resonance imaging (MRI)

MRI scans use radio waves and strong magnets instead of x-rays to take pictures of the body. MRIs map the location, size, and sometimes even the type of tissue contained in the tumor, and are useful tools for planning biopsies.

Ultrasound

This diagnostic technique uses sound waves to take create images of parts of the body. A small instrument called a transducer emits sound waves and picks up the echoes as they bounce off the liver. A computer converts these sound wave echoes into an image that is displayed on monitor.

Endoscopy

An endoscope is a long, lighted tube that is passed through the patient’s esophagus, stomach and beginning of the lower intestine, allowing the physician to explore these areas without surgery. This technique, along with ERCP (described below) is used to evaluate cholangiocarcinomas.

Endoscopic Retrograde Cholangiopancreatography (ERCP)

A smaller tube or catheter is passed through the endoscope and into the bile ducts. Dye is injected into the ducts, and the physician takes X-rays to discover whether a tumor is present in the bile ducts.

The physician may also need to take a biopsy of the tissue to be examined under a microscope. This tissue can be obtained in the following procedures:

Laparoscopy

In this procedure, the physician inserts a thin, lighted tube with a small video camera on the end through a small incision in the front of the abdomen to examine the liver and other internal organs. This procedure is done in the operating room usually under general anesthesia.

Laparoscopy can help doctors confirm the stage (extent) of the cancer and decide upon a treatment plan.

Laparoscopy is usually done at an outpatient surgery. Because the surgeon only makes a small incision to insert the tubes and there is no need for general anesthesia, the patient can expect less pain and faster recovery time.

Needle biopsy

A hollow needle is placed through the skin in the abdomen and into the liver. The skin is first numbed with local anesthesia.

During a fine needle aspiration (FNA) biopsy, tumor cells are sucked into a very thin needle with a syringe.
During a core needle biopsy, a slightly larger needle is used to take a bigger sample from the liver.

Often a patient has no symptoms until the disease has reached its later stages. Many of these complaints may be caused by other illnesses, so it is important to be evaluated by a physician.

• Unexplained weight loss or loss of appetite
• Feeling very full after eating very little
• Nausea or vomiting
• An enlarged liver
• An enlarged spleen
• Pain in the abdomen or near the right shoulder blade
• Swelling or fluid build-up in the abdomen
• Itching
• Yellowing of the skin and eyes (jaundice)
• Fever
• Enlarged veins on the belly that are visible through the skin
• Abnormal bruising or bleeding

People who have chronic hepatitis or cirrhosis may feel worse than usual and produce excess hormones that cause:

• High blood calcium levels (hypercalcemia), and symptoms of nausea, confusion, constipation, weakness, or muscle problems
• Low blood sugar levels (hypoglycemia) and symptoms of fatigue or fainting
• Breast enlargement (gynecomastia) and/or shrinking of the testicles in men
• High red blood cells counts (erythrocytosis) causing redness and flushed skin
• High cholesterol levels

 

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