LIVER CANCER

Angel Maria cibichan

3rd year bsc .nursing
STCON
 ANATOMY
• Largest gland in the body.
• Weight: 1.5kg
• Position: Right
hypochondrium and
extend into epigastrium
and left hypochondrium.
• Shape : wedge shaped.
• Lobes : 2 lobes
Quadrate lobe
Caudate lobe
 INTRODUCTION

• Hepatocellular carciona (HCC) is relatively

uncommon in the United States but is one of the
most common malignancies in some parts of the
world, especially in areas of China and sub-Saharan
Africa., It is an aggressive tumor with an absence of
early symptoms and a poor prognosis.” Left
untreated, life expectancy is 3 to 6 months.
 DEFINITION

Tumors of the liver are either primary or metastatic .

primary liver Tumors may arise from hepatocytes
,connective tissues, blood vessels or bile duct. This tumors
are either benign or malignant. Metastatic malignant tumors
arise from the gastrointestinal tract, the breast and the
lungs.The majority of the primary liver cancers arise from
liver cells and is called hepatocellular cancer or carcinoma.
 EPIDEMIOLOGY

• Each year in the United States about

24,500 men and 10,000 women get
liver cancer and about 18,600 men and
9,000 woman died from the disease.
 ETIOLOGY AND RISK
FACTORS

• CIRRHOSIS
• ALCOHOLISM
• HEPATITIS B AND C VIRUS
• HEMOCHROMATOSIS
• AFLATOXIN B1
• ANABOLIC STEROIDS
• GENDER
 CLASSIFICATION
1. BENIGN HEPATIC TUMORS
Hepatic adenomas are benign tumors of the liver that
occur most commonly in women in their 30s and 40s nearly
90% of cases are associated with oral contraceptive use . The
fact that the tumor occur more commonly in women, especially
women who take oral contraceptives. Benign hepatic tumors
are associated with an excellent prognosis if they are removed
surgically before they rupture and cause death from
hemorrhage.
• There are number of benign liver tumors.
1. HEMANGIOMAS
are the most common benign tumor of the
liver, and occur when a benign, blood-filled tumor
forms within the liver.
1. ADENOMAS
benign tumors of the hepatocytes
1. FOCAL NODULAR HYPERPLASIA
a localized growth of several types of liver cells.
• 2. MALIGNANT HEPATIC TUMORS
1. CHOLANGIOCARCINOMA
represent 10- 20% of all liver cancers. These cancers
can arise from the bile ducts within the liver (intrahepatic
cholangiocarcinomas) or from in the bile ducts as they lead
away from the liver (extra- hepatic cholangiocarcinomas).
• Angiosarcoma and hemangiosarcoma (malignant blood-filled
tumors) starts in the blood vessels of the liver and grows
very rapidly. About 1% of adult primary liver cancers are
angiosarcomas.
2. PRIMARY HEPATOCELLULAR CARCINOMA
It is the most common type of primary liver
cancer. and account for around 70 percentage of all
liver cancer.
 STAGES OF LIVER C ANCER

• STAGE 1
This is the earliest stage of
hepatocellular carcinoma .The tumor
has not spread to the blood vessel
lymph nodes or other part of the body.
• STAGE 2
The tumor involves nearby blood
vessels but it has not spread to the nearby
lymph nodes or other parts of the body .
• STAGE 3 A
The cancer has not spread beyond the liver but the
area of the cancer is larger than stage 1 or 2
• STAGE 3 B
The cancer involves a major vein around the liver but
it has not spread to nearby lymph nodes or other parts of
the body
• STAGE 3 C
Any tumor that has spread to the organ near the liver
or if the tumor is present with perforation of the visceral
peritoneum.There is no spread to nearby lympnode or
other part of the body
• STAGE 4 A
Any tumor that has spread to the
regional lymph not but not to other part
of the body
• STAGE 4 B
Any tumor that has spread to other
part of the body.
 CLINICAL MANIFESTATIONS

Liver cancer is sometimes a silent disease because in an

early stage it often does not cause symptoms but us the
cancer grows symptoms made include:

• Pain in in the right upper abdomen

• Abdominal lump
• Swollen right abdomen
• Enlarged liver
• Unexplained weight loss
• Malaise
• Loss of appetite
• Yellow skin and eye,and dark urine
• Nausea and vomiting
• Liver damage
 PATHOPHYSIOLOGY

The risk factors like Hep B virus, Cirrhosis

Chronic liver injury (viral injury)

Cell death

Regeneration of hepatocytes
Cellular metabolic dysfunction

Release of inflammatory mediators

Increase the risk of transforming

mutation of hypocytes.

Liver cancer
 DIAGNOSTIC METHODS

• PHYSICAL EXAMINATION
• BLOOD TEST
•Alpha fetoprotein(AFP)
• Delta carboxylic
prothrombin(DCP)
• ULTRASOUND
CT
MRI
BIOPSY
• Fine needle Aspiration
or percutaneous
needle biopsy
ANGIOGRAM
 INDOCYANINE GREEN
• It critical to assess the functional hepatic
reserve to make a decision regarding surgery
for the patients.A common test used to assess
liver function uses chemicals that are normally
rapidly acquired and metabolized by
hepatocytes. Metabolism and clearance are
decreased in cirrhotic livers. Indocyanine green
(ICG) is given intrave- nously, and then blood
samples are drawn at timed intervals to assess
clearance from the plasma.
• Indocyanine Green (ICG) clearance is the most
common and easy - to - use test for the
perioperative dynamic assessment of liver
function in case of major liver surgery (resective
surgery and liver transplantation) .
• A Calculation is to arrive at the percentage of
clearance,values between 15% and 20% indicate
a lobectomy or two segment resection. Values
between 21% and 35% indicate a single
segment or Wedge resection.
 MANAGEMENT

MEDICAL MANAGEMENT

• 1. Radiation Therapy
The use of external beam radiation
for the treatment of liver tumors has been
limited by the radio sensitivity of normal
hepatocytes and the risk of destruction of
normal liver parenchyma
More effective methods of delivery
radiation to 2 most of liver include:
1. IV or Transarterial injection
2. Percutaneous placement of high
intensity sources.
2. CHEMOTHERAPY
1. Regional chemotherapy : It in involves infusion of
agents that are highly metabolized by the liver via the
hepatic artery .Tumor cells derive more than 80% of
their blood supply from the hepatic artery however
normal hepatocytes derive their supply from the portal
circulation .Thus administering chemotherapy through
the hepatic artery generally increases the dose of drug
deliver to the tumour but minimise the effect on the
hepatocytes and systemic toxicity.
• 2.INTRA-ARTERIAL THERAPY:
Drugs can be administered through temporary
catheters placed into the axillary or femoral arteries.
This method required the patient remain In the bed for
the duration of the infusion which may be up to 5 days .
the agent the use the most frequently for intra arterial
chemotherapy are
FLOXURIDIN(FUDR) and 5- FU include
cisplatin,doxorubincin,mitomycin c,
leucovorin,vincristine and interleukin 2.
• complications : of this method include
thrombosis of the hepatic and other
intra abdominal arteries, displacement,
sepsis and hemorrhage
• 3. IMPLANTABLE PUMP:
Drugs may also be administered via implantable
pump which offer the advantages allowing the patient
to remain Ambulatory and reducing catheter related
complications.
the most common problem associated with
implantable pump have been Gastroduodinal ulcer
and inflammation ,
3. Percutaneous biliary drainage
Biliary or transhepatic drainage is used
to bypass biliary duct obstructed by liver
tumor,pancreatic tumor or considered in
patient who have inoperable tumor under
fluoroscopy
• 4. EMBOLIZATION AND CHEMOEMBOLIZATION
• Embolization is the selective occlusion of hepatic ves-
sels by injecting nondegradable particles, typically Gel- foam
and Ivalon. Embolizations usually need to be repeated
because of the formation of collateral circula- tion.
• Chemoembolization involves occlusion by particles into
which chemotherapeutic agents have been adsorbed. Drugs
used in this application include FUDR, doxorubicin, cisplatin,
and mitomycin C, in different combinations
• Other nonsurgical treatment
1. Laser hyperthermia:
The use of local hyperthermia to treat cancer of the
internal organs has been limited by the difficulty of
controlling delivery of heat and limiting the effects to
the tumour
2. Cryosurgery :
It is a Procedure used treat multiple or
bilobar unresectable primary and
metastatic liver tumor . a prob is placed
inside the tumor ,liquid nitrogen is
circulated through the prob causing
Rapid freezing of the tumor cell.
• 3. Percutaneous Ethanol Injection (PEI)
involves the direct injection of 95% ethanol
into a tumor using ultra- sound guidance. It has
been used for patient with two to three lesions
less than 4 cm each and for patients with
cirrhosis who are ineligible for resection. The
treatment are repeated once or twice a week for
a total of six to eight treatments.
 IMMUNOTHERAPY

• Immunotherapy is another treatment modality

under investigation. In this therapy,
lymphocytes with antitumor reactivity are
given to the patient with hepatic cancer.
Tumor regression has been demonstrated in
patients with metastatic cancer for whom
standard treatment has failed.
SURGICAL MANAGEMENT

1.Wedge resection:
It is usually done for small lesions easily
accessible. Tumor located in one or two
different liver segment can be resected
by removing the involved segment.

2 . LOBECTOMY : major liver resection

involves the removal of atleast three
adjoining segments.
 • Right lobectomy:
Involves segment
5, 6, 7and 8.
• Left lobectomy:
Involves segment
2 , 3 and 4.
• Right trisegmentectomy
Involves segment 4 to 7
• Left lateral segmentectomy
involves segment 2 and 3.
• LOCAL ABLATION
Radiofrequency ablation (RFA) and
microwave ablation (MWA)
are treatments that use image
guidance to place a needle through
the skin into a liver tumor. In RFA,
high-frequency electrical currents
are passed through an electrode in
the needle, creating a small region
of heat.
LIVER TRANSPLANTATION
 LIVER TRANSPLANTATION

• A liver transplant is a surgical

procedure that removes a liver that no
longer functions properly (liver failure)
and replaces it with a healthy liver
from a deceased donor or a portion of
a healthy liver from a living donor.
• Liver transplant is usually reserved as a treatment
option for people who have significant
complications due to end-stage chronic liver
disease.
• Living-donor liver transplant is an alternative to
waiting for a deceased-donor liver to become
available. Living-donor liver transplant is possible
because the human liver regenerates and returns
to its normal size shortly after surgical removal of
part of the organ.
TYPES OF LIVER TRANSPLANTATION

• Living-donor liver transplant

• A living-donor liver transplant is a surgical procedure in
which a portion of the liver from a healthy living person is
removed and placed into someone whose liver is no longer
working properly.
• The donor's remaining liver regrows and returns to its
normal size, volume and capacity within a couple of
months after the surgery. At the same time, the
transplanted liver portion grows and restores normal liver
function in the recipient.
Deceased-donor liver transplant
• If you're notified that a liver from a deceased
donor is available, you'll be asked to come to the
hospital immediately. health care team will admit
you to the hospital, and you'll undergo an exam to
make sure you're healthy enough for the surgery
• The surgeon removes the diseased liver and
places the donor liver in your body. Then the
surgeon connects your blood vessels and bile
ducts to the donor liver. Surgery can take up to 12
hours, depending on your situation
Domino liver transplant
• Another, less common, type of living-donor liver
transplant is called a domino liver transplant. In a
domino liver transplant, you receive a liver from a
living donor who has a disease called familial
amyloidosis.
• Familial amyloidosis is a very rare disorder in
which an abnormal protein accumulates and
eventually damages the body's internal organs.
• The donor with familial amyloidosis receives a
liver transplant to treat his or her condition.
Then, the donor can give his or her liver to
you in a domino liver transplant because the
liver still functions well. You may eventually
develop symptoms of amyloidosis, but these
symptoms usually take decades to develop.
• Doctors usually select recipients who are 55
years old or older and who aren't expected to
develop symptoms before the end of their
natural life expectancy.
 AFT ER A LIVER T RANSPLANT

• The organ recipient is maintained in an environment

as free from bacteria, viruses, and fungi as possible,
because immunosuppressive medications reduce the
bodys natural defenses.
• In the immediate postoperative period, cardiovascular,
pulmonary, renal, neurologic, and metabolic functions
are monitored continuously.
 DIET AND NUTRITION

• Eating at least five servings of fruits and vegetables

each day
• Avoiding grapefruit and grapefruit juice because of their
effect on a group of immunosuppression medications
• Having enough fiber in your daily diet
• Choosing whole-grain foods over processed ones
• Drinking low-fat or fat-free dairy products, which
is important to maintain optimal calcium and
phosphorus levels.
• Eating lean meats, poultry and fish
• Following food safety guidelines
• Staying hydrated by drinking adequate water
and other fluids each day
 NURSING MANAGEMENT

• For patient with the liver cancer anticipating surgery

support, education and encouragement are provided
to help them prepare psychologically for the surgery
.
• After the surgery the potential problems related to
cardiopulmonary involvement may include vascular
complications and respiratory and liver disfunction.
• The nurse educate the patient to recognise and report
the potential complications and side effects of the
chemotherapy and the desirable and undesirable effect
of specific chemotherapy regimen.
• The nurse also Emphasis the importance of follow up
visit to assess the response to chemotherapy and
Radiation therapy.
• Patient at home with a billiary drainage system in place
typically fear the catheter will become dislodged,
reassurance and instructions can help reduce their fear
that the catheter will fall out
• Patient with the implantable port are
instructed about the chemotherapy Regimen
,types of medication, affect and the side effects
that may occur and appropriate management
strategies if problem occur.
• The patient physical and psychological status
are assessed as well as a adequacy of pain
relief, nutritional status and the presence of
symptoms indicating complications of
treatment or progression of disease.
• The nurse reminds the patient that
preventing rejection and infection is
essential and increase the chance for
survival and a more normal life than
before transplantation.
 COMPLICATIONS

• 1.BLEEDING
• Bleeding is common in the postoperative
period and may result from coagulopathy, portal
hypertension and fibrinolysis caused by ischemic
injury to the donor liver. Administration of
platelets, fresh frozen plasma or other blood
products maybe necessary
• INFECTION
Infection is the leading cause of death after liver
transplantation bacterial and the fungal infection are
common susceptibility to infection is increased by the
immunosuppressive therapy.
Bacteria: enterococcus, streptococcus, Staphylococcus
aureus, and members of the Enterobacteriaceae family
• REJECTION
A transplanted liver is perceived by
the immune system as a foreign antigen
this triggers T lymphocytes that attack
and destroys the transplanted liver.
SURGERY RELATED:
• Hemorrhage
• Coagulopathy
• Liver insufficiency/failure
• Ascites
• Portal vein thrombosis
• Pleural effusion
HEPATIC ARTERY INFUSION RELATED:
• Catheter occlusion
• Arterial thrombosis
• Biliary sclerosis
• Drug toxicity:Gastritis, nausea/vomiting,
ulcer.
CHEMOEMBOLIZATION RELATED:
• Fever
• Abdominal pain
• Anorexia
• Cholecystitis
RADIATION THERAPY RELATED:
• Nausea
• Anorexia
• Fatigue
• Occasional vomiting
 NURSING DIAGNOSIS

• Imbalanced nutrition less than body

requirements
• Risk for impared skin integrity.
• Disturbed body image.
• Deficient knowledge
• Risk for complication .
 PREVENTION

• Keep a healthy weight

• Get vaccinated against Hepatitis B. The Hepatitis
B vaccine is recommended for all infants at birth
and for adults who may be at increased risk
tested for Hepatitis C, and get medical care, if you
have it.
• Avoid smoke.
• Avoid drinking too much alcohol
CONCLUSION
 BIBLIOGRAPHY

• 1. Shirley .E. Otto ,Oncology nursing, 4th edition, Elsevier

publication, 2004,pg: 195-202.
• 2. Javed ansari, Comprehensive medical surgical nursing, 3rd
edition, Pv publication, pg : 905-909
• 3. Joyce m Black, textbook of medical surgical nursing, 1st South
Asian edition, Elsevier publication, 2009,pg : 1175.
• 4. American cancer society textbook of oncology nursing, 2nd
edition, 269-279.
• 5 .Brunner and sudharth textbook of medical surgical nursing, 1st
South Asian edition, Walter kluwer,pg no:978-986.