Liver

Primary liver and bile duct cancers are the 5th most common cause of cancer death in men and 9th in women. 1 Incidence rates have increased in people of all races and in both sexes. Men are more than twice as likely as women to develop and die from liver and bile duct cancers. African Americans and Hispanics are almost twice as likely to develop these cancers as whites. || - Closely associated with hepatitis virus infections, especially hepatitis B 1 - Almost all cases of liver cancer in the U.S. occur in people who 1st had cirrhosis, usually resulting from hepatitis B or C or from heavy alcohol use - Ingestion of foods contaminated with aflatoxin and obesity may also increase liver cancer risk || More than 80% of patients show these common symptoms at diagnosis: 30% of patients have a sudden decrease in liver function. 2 || The main imaging modalities are ultrasound, intravenous contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI). X-rays of the chest, CT of the chest, abdomen, and pelvis, portal venography, and bone scans are all used selectively to assess the extent of local disease and possible metastases. 2 || The major types of primary carcinoma in the liver are hepatocellular carcinoma (HCC) and cholangiocarcinoma. Fibrolamellar HCC occurs in younger noncirrhotic patients and hepatoblastoma is seen in infancy and childhood. 3  Chronic infections like hepatitis B and or C can aid the development of HCC by repeatedly causing the body’s own immune system to attack the liver cells. || Lymph nodes involved in liver cancer are: 3 Primary liver cancer begins in the liver. 4 Metastatic liver cancer starts somewhere else in the body and spreads to the liver. The liver is the second most common site of metastases.. Its large size and high blood flow make it a prime target for tumor cells moving through the bloodstream. Colorectal, breast and lung cancers are the most common sources of metastatic liver cancer. || Grade is rarely used with liver cancer as all such cancers are usually aggressive. 5 || The following is the TNM staging for Liver cancers: 6 The main side effects on treating liver cancers with external beam radiation is complication with the stomach and duodenum. 6 When doses were held below 5040 centiGray (cGy), the complications were much lower. The bilary duct and hepatic artery must also be considered as critical structures in the treatment of liver cancer. 6 They are more at high for intraoperative radiation therapy, but should be monitored in external beam therapy as well. || There are several factors that impact a patient’s prognosis for liver cancer. These factors include a significant response to treatment, comorbidities (especially cirrhosis) and their general overall health. Survival rates are dependent upon the summary stage that a patient is diagnosed with. These stages include localized, regional and distant. Localized liver cancer patients have cancer that is strictly confined to the liver and have a 5-year survival rate of 28%. 7 Patients with regional disease have disease expanding beyond the liver to proximally located lymph nodes. These patients are equivalent to Stage 3C or 4A cancers that use TNM staging and their 5-year survival rate is 10%. 7 Finally, distant liver cancer is cancer that has spread to organs, tissues and/or lymph nodes throughout the body. These patients have a 3% 5-year survival rate. 7 For patients generally diagnosed with liver cancer, the average 5 year survival rate is 15%. 7 Quality of life and comorbidities have a more significant impact in liver cancer because several patients have chronic disease involving the liver other than cancer. Cirrhosis of the liver is usually a better indicator of each patient’s prognosis. || The treatment of liver cancer is divided into 3 sections: localized resectable, localized unresectable and advanced. 7 For patients with localized resectable disease, surgical removal of the infected liver (partial hepatectomy) is the route of treatment. 7 This surgery with curative intent is available to very few patients and depends directly on tumor size and if blood vessels are involved. If the tumor is large, the patients might see more of a benefit from a liver transplant. 7 Because the liver is an important organ in overall health, treating liver cancer aggressively poses severe risks. Localized unresectable liver cancer patients are treated with a liver transplant if the option presents itself. 7 This option cures liver cancer and removes difficult disease. A physician might also recommend therapies such as embolization (with or without chemotherapy or radiation therapy), targeted therapy with sorafenib, chemotherapy (systemic or by hepatic artery infusion), and/or radiation therapy. 7 In some cases, these therapies might be used to shrink the cancer enough to perform a partial hepatectomy or transplant. Unfortunately, it is unlikely that these treatments with cure liver cancer but can significantly improve the patient’s quality of life and increase life span. For advanced stage liver cancer, targeted therapy with sorafenib is the best option for patients to control the spread of cancer and prolong their life. 7 || Tissue dose associated with 5% injury rate within 5 years 8,9
 * **Epidemiolgy:** || Lindsey
 * **Etiology:** || Lindsey
 * **Signs & Symptoms:** || Kevin T.
 * Right upper abdominal pain
 * Weight loss
 * Anorexia
 * Malaise
 * Fever
 * **Diagnostic Procedures** || Kevin T.
 * **Histology:** || Jenn
 * **Lymph node drainage:** || Jenn
 * Celiac nodes
 * Portal nodes
 * Periportal nodes
 * Mediastinal nodes ||
 * **Metastatic spread:** || Rachel
 * **Grading:** || Rachel
 * **Staging:** || Brandon
 * Primary Tumor (T) **
 * TX: Primary tumor cannot be assessed
 * T0: No evidnce of primary tumor
 * T1: Solitary tumor without vascular invasion
 * T2: Solitary tumor with vascular invasion or multiple tumor non more than 5 centimeters (cm)
 * T3a: Multiple tumors greater than 5 cm
 * T3b: Single tumor or multiple tumors of any size involving a major branch of the portal vein or hepatic vein
 * T4: Tumor(s) with direct invasion of adjacent organs other than the gallbladder or the perforation of visceral peritoneum
 * Regional Lymph Nodes (N) **
 * NX: Regional lymph nodes cannot be assessed
 * N0: No regional lymph node metastasis
 * N1: Regional lymph node metastasis
 * Diastant Metastasis (M) **
 * MO: No distant metastasis
 * M1: Distant metastasis ||
 * **Radiation side effects:** || Brandon
 * **Prognosis:** || Ashley
 * **Treatments:** || Ashley
 * **TD 5/5:** || Amanuel
 * Stomach: 550cGy [Ulceration/perforation]
 * Small bowel: 5500cGy [Obstruction/perforation]
 * Bilary duct: 3000cGy [Bilary fibrosis] ||
 * **References:** || Amanuel
 * 1) National Cancer Institute Web Site. [] . Accessed June12, 2013.
 * 2) Lenhard RE, Osteen R, Gansler T. The American Cancer Society’s Clinical Oncology. Williston, VT: Blackwell Publishing, Inc; 2001.
 * 3) Hammett RJ, Gollan JL. Liver Cancer. In. The American Cancer Society’s Clinical Oncology. Atlanta, Georgia: 2001; 396-403.
 * 4) Liver Cancer. MD Anderson Center Web Site. []. Accessed June 13, 2013.
 * 5) Liver Cancer- symptoms, treatments and therapies. CANCERactive Web Site. [|http://www.canceractive.com/caner-active-page-link.aspx?n=162#10]. Accessed June 13, 2013.
 * 6) <span style="color: #800000; font-family: Arial,Helvetica,sans-serif;">American Joint Committee on Cancer. Cancer Staging Hanbook. 7th ed. Chicago, IL: Springer; 2010.
 * 7) <span style="color: #008000; font-family: Arial,sans-serif; font-size: 10pt; line-height: 1.5;">Liver Cancer. American Cancer Society Website. [] <span style="color: #008000; font-family: Arial,sans-serif; font-size: 10pt; line-height: 1.5;">. Updated January 18, 2013. Accessed June 13, 2013.
 * 8) <span style="color: #ff7100; font-family: Arial,sans-serif; font-size: 10pt; line-height: 1.5;">Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby-Elsevier; 2010
 * 9) <span style="color: #ff7100; font-family: Arial,sans-serif; font-size: 10pt; line-height: 1.5;">Clifford C, Perez C, Brady LW. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins;2011. ||

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