LIVER CANCER

Group B2
Under Supervision: Dr/ Engy Elsayed

Sample Footer Text 3/22/2024 1

INTRODUCTION: -

• Liver cancer, specifically hepatocellular carcinoma (HCC), is a

complex and heterogeneous disease characterized by diverse
etiologies and clinical behaviors. While it predominantly arises
in fibrotic livers, with cirrhosis being a prominent predisposing
factor, the mechanisms driving its development can vary
significantly. Hepatitis B virus (HBV) and hepatitis C virus (HCV)
infections are common underlying causes, each potentially
influencing the carcinogenic process in distinct ways.
INTRODUCTION: -

• The variability in liver cancer's doubling time, ranging from a few

weeks to several months, underscores the dynamic nature of its
progression. Furthermore, the natural history of untreated disease
exhibits a wide spectrum of outcomes, influenced by factors such
as disease stage and the degree of underlying liver dysfunction.

• Untreated liver cancer carries a poor prognosis, even in cases of

early-stage disease. Advanced liver disease further complicates
the prognosis, highlighting the intricate interplay between liver
function and cancer progression.
ANATOMY
OF THE LIVER: -
• The liver is located behind the ribs in the upper
right portion of the abdominal cavity. It weighs
about 1,500 gm and is divided into four lobes. A thin
layer of connective tissue surrounds each lobe,
small units called lobules.

• The circulation of the blood into and out of the liver

is a major importance in its function. The blood that
perfuses the liver comes from two sources:
1. Approximately 75% of the blood supply
comes from the portal vein, which drains
the GI tract and is rich in nutrients.
2. The remainder of the blood supply enters by
way of the hepatic artery and is rich in
oxygen.
FUNCTION OF LIVER: -

• Metabolism: The liver metabolizes nutrients from food,

such as carbohydrates, proteins, and fats, converting
them into usable forms or storing them for later use. It
also synthesizes important molecules like cholesterol
and triglycerides.

• Detoxification: The liver filters and detoxifies harmful

substances, including drugs, alcohol, and metabolic
waste products. It converts these substances into less
toxic forms that can be eliminated from the body.
FUNCTION OF LIVER: -

• Bile Production: The liver produces bile, a digestive fluid that aids
in the breakdown and absorption of fats in the small intestine. Bile
is stored in the gallbladder and released into the intestines as
needed.

• Storage: The liver stores glycogen, a form of glucose used for

energy production, as well as vitamins (such as vitamin A, D, E, and
K) and minerals (such as iron and copper).

• Synthesis of Proteins: The liver synthesizes various proteins essential

for blood clotting (e.g., clotting factors), immune function (e.g., albumin),
and transport of substances in the blood (e.g., lipoproteins).
FUNCTION OF LIVER: -

• Regulation of Blood Glucose Levels: The liver helps

regulate blood glucose levels by storing excess glucose as
glycogen (glycogenesis) and releasing glucose into the
bloodstream when needed (glycogenolysis).

• Immune Function: The liver plays a role in immune function

by filtering and removing bacteria, viruses, and other
pathogens from the bloodstream. It also produces immune
factors involved in defending the body against infections.
DEFINITION: -

• Liver cancer, also known as hepatic cancer,

can be primary(originating in the liver) or
secondary (resulting from cancer spread to the
liver from elsewhere in the body). It involves the
abnormal growth of liver cells and can manifest
as primary hepatic malignancy or metastatic
liver disease.
PATHOPHYSIOLOGY: -

• The pathophysiology of liver cancer involves

the uncontrolled growth and division of liver
cells, leading to the formation of tumors.
Hepatocellular carcinoma (HCC), the most
prevalent type, originates from hepatocytes,
the primary liver cells.
PATHOPHYSIOLOGY: -

Several factors contribute to the development of liver cancer:

• Chronic liver inflammation: Persistent inflammation in the

liver, often triggered by conditions like viral hepatitis (hepatitis
B or C) or alcoholic liver disease, damages liver cells and
promotes abnormal cell growth.

• Genetic mutations: DNA mutations can disrupt the normal

regulation of cell growth and division in liver cells. These
mutations arise from factors such as chronic inflammation,
exposure to toxins, or genetic predisposition, leading to the
proliferation of mutated cells.
 PATHOPHYSIOLOGY: -
Several factors contribute to the development of liver cancer:

• Dysregulated cellular pathways: Aberrant activation of cellular

signaling pathways, including those involved in cell survival, blood
vessel formation (angiogenesis), and tissue invasion, fosters
tumor growth and spread. Genetic alterations and environmental
factors contribute to the dysregulation of these pathways.

• Cirrhosis and fibrosis: Chronic liver diseases, such as hepatitis or

alcohol-related liver damage, can progress to cirrhosis,
characterized by extensive scarring and fibrosis in the liver tissue.
The altered liver environment associated with cirrhosis promotes
the development of liver cancer.
PATHOPHYSIOLOGY: -
Several factors contribute to the development of liver cancer:

• Metastasis: Liver cancer cells can metastasize to other

organs via the bloodstream or lymphatic system,
establishing secondary tumors. Metastatic liver cancer is
more prevalent than primary liver cancer and presents
additional challenges in treatment and management.
TYPES OF LIVER CANCER: -

1. Hepatocellular Carcinoma (HCC):

• Description: Hepatocellular carcinoma exhibits
different growth patterns, including tentacle-like
spread, single tumor progression, or nodular
development. It is the most common type of primary
liver cancer in adults, accounting for approximately
73% of cases.
• How Common: HCC represents the majority of primary
liver cancers in adults.
TYPES OF LIVER CANCER: -

2. Cholangiocarcinoma:
• Description: Cholangiocarcinoma arises from cells
in the bile ducts of the liver. It originates from the
thin tubes that carry bile from the liver to the small
intestine. Cholangiocarcinoma may develop from
the convergence of smaller bile ducts within the
liver.
• How Common: Cholangiocarcinoma accounts for
about 18% of primary liver cancers in adults.
TYPES OF LIVER CANCER: -

3. Angiosarcoma:
• Description: Angiosarcoma originates in the blood
vessels of the liver and tends to grow rapidly.

• How Common: Angiosarcoma is a rare type of

primary liver cancer, representing approximately
1% of cases in adults.
 RISK FACTORS: -
• Age: The incidence of liver cancer increases with age, with
a higher risk observed in older individuals.

• Gender: Liver cancer is more prevalent in males, with a

male-to- female ratio of more than 2:1.

• Smoking: Cigarette smoking has been associated with an

increased risk of liver cancer.

• Ethnicity: The highest incidence of hepatocellular

carcinoma is seen in East Asia and Africa, where chronic
hepatitis B infection is prevalent. In the United States,
racial minority groups have a higher incidence compared to
non-Hispanic White individuals.
 RISK FACTORS: -
• Alcohol: While alcohol itself is not directly carcinogenic
to liver cells, long-term excessive alcohol consumption
acts as a carcinogen when combined with chronic viral
hepatitis, increasing the risk of liver cancer.

• Diabetes: Individuals with diabetes have an elevated

risk of developing liver cancer compared to those
without diabetes.

• Obesity: Obesity is a significant risk factor for liver

cancer, particularly when associated with conditions
such as non-alcoholic fatty liver disease (NAFLD) and
metabolic syndrome.
 CAUSES OF LIVER CANCER: -
• Liver Cirrhosis: Liver cancer risk increases significantly in
individuals with cirrhosis, a condition characterized by the
replacement of healthy liver tissue with scar tissue. Cirrhosis
impedes liver function and increases the likelihood of cancer
development.

• Aflatoxin B1 Exposure: Consuming foods contaminated with

aflatoxin B1, a toxin produced by certain fungi, can elevate the
risk of liver cancer. Aflatoxin B1 contamination is most
prevalent in hot, humid regions such as sub-Saharan Africa,
Southeast Asia, and China.
 CAUSES OF LIVER CANCER: -
• Hepatitis B Virus (HBV) Infection:

• HBV can be transmitted through blood, semen, or other body

fluids.

• Transmission can occur from mother to child during

childbirth, through sexual contact, or by sharing needles
used for drug injection.

• Chronic HBV infection, particularly prevalent in Asia and

Africa, is a leading cause of liver cancer due to associated
liver inflammation and cirrhosis.
 CAUSES OF LIVER CANCER: -
Hepatitis C Virus (HCV) Infection:
• HCV is primarily transmitted through blood.

• Transmission commonly occurs through sharing needles for drug

injection or, less frequently, through sexual contact.

• Chronic HCV infection can lead to cirrhosis, increasing the risk of

liver cancer.

• Chronic Alcoholism and Smoking: Long-term excessive alcohol

consumption and cigarette smoking are associated with an increased risk
of liver cancer. These lifestyle factors contribute to liver damage and
inflammation, which can promote cancer development.
 CLINICAL
MANIFESTATION: -
Liver cancer symptoms are more likely to appear as the cancer
grows or becomes advanced.
Symptoms may include:
• weakness and tiredness
• pain in the abdomen
• swelling of the abdomen due to a build-up of fluid(ascites)
• pain in the right shoulder
• appetite loss and feeling sick
• weight loss
• yellowing of the skin and eyes (jaundice)
• pale bowel motions
• fever.
 DIAGNOSIS: -
Based on symptoms, lab investigations, medical history and physical
examination tests.

History
1.Diagnostic suspicion is typically prompted by abnormal findings on
screening imaging
2.Patients often have no additional symptoms beyond those of their
chronic underlying liver disease, which is typically cirrhosis or
chronic viral hepatitis
 DIAGNOSIS: -
History
3.Sudden decompensation of previously compensated cirrhosis (eg,
onset of ascites, variceal bleeding, hepatic encephalopathy) may
indicate tumor macrovascular invasion

4.Jaundice occurs with biliary obstruction

5.Bulky tumor growth may cause early satiety, weight loss, and local

pain over liver

6.Localized bone pain may signal bony metastatic foci

 DIAGNOSIS: -
Physical examination
1. Findings reflect underlying liver disease.

2. In early cirrhosis, may be relatively normal.

3. In decompensated cirrhosis, the following are often present:

jaundice, spider angiomas, palmar erythema, gynecomastia, ascites,

testicular atrophy, and edema.

4. Tumor growth is occasionally visible and palpable in right upper

quadrant
 DIAGNOSIS: -
Laboratory Investigation

Alpha-fetoprotein (serve as a tumor marker) is elevated 80 to

90 % of cases

Increase level of bilirubin

Alt - Ast elevated

Leukocytes (increase of WBC level) is present

Hypocalcemia, hypercholesterolemia may be present

 DIAGNOSIS: -
Other Investigation
• Ultrasound: Is important not only for surveillance but also
characterization of hepatocellular carcinoma (HCC)
• CT scan: is used to determine site, size of cancer. CT scan
may indicate whether cancer has spread to other organs in
the abdomen or chest.
• MRI: Is used as a second‐line diagnostic imaging modality
to confirm the presence of focal liver lesions suspected as
hepatocellular carcinoma
• PET (positron emission tomography): is used to evaluate a
wide range of metastatic liver cancer
 DIAGNOSIS: -
Liver Biopsy
During a biopsy, cells or tissues are removed so they can be
viewed under a microscope by a pathologist to check for
signs of cancer. Procedures used to collect the sample of
cells or tissues include the following :

• Fine-needle aspiration biopsy: A sample of fluid, tissue, or

cells is removed using a thin needle.

• Core needle biopsy: A sample of cells or tissue is removed

using a slightly wider needle.
 DIAGNOSIS: -
Liver Biopsy

• Fine-needle aspiration biopsy: A sample of fluid, tissue, or

cells is removed using a thin needle.

• Core needle biopsy: A sample of cells or tissue is removed

using a slightly wider needle.
 TREATMENT: -
Medical Management: -

-Tumor ablation: is used mostly for small primary liver

cancers. It is rarely used for secondary cancer in the liver.
The most common types of tumor ablation treatments use
radio waves and microwaves to heat and destroy cancer
cells. This treatment is administered by either a needle
inserted through the skin (percutaneous ablation) or a
surgical cut (ablation with surgery).
 TREATMENT: -
Medical Management: -

-Chemotherapy: can be given systemically, via tablets or

intravenously(through a drip), which means it goes
throughout the whole body. This may be given following
other treatment, such as surgery or cryotherapy, to get rid
of any remaining cancer cells. It is not usually used to treat
primary liver cancer unless the cancer has spread to other
parts of the body.
 TREATMENT: -
Medical Management: -

-Chemotherapy can also be given directly into the tumor,

which is called chemo-embolization (or TACE). As it is
targeting the tumor directly, stronger drugs can be used.
TACE is more commonly used for primary liver cancer.

-Systemic chemotherapy can also be used as palliative

treatment to slowdown the cancer growth and reduce pain.
 TREATMENT: -
Medical Management: -

Radiotherapy: is where radiation is used to kill cancer cells. A

type of radio therapy called selective internal radiation
therapy (SIRT) is some times used to treat liver cancer. This
is where radioactive beads are injected into the patient's
liver's blood supply to stop the cancer growing. Patient
may have SIRT for liver cancer if he is an adult and his liver
has not been too badly damaged, and the cancer cannot be
removed by surgery.
 TREATMENT: -
Medical Management: -

Palliative care: aims to improve your quality of life by

alleviating symptoms of cancer. As well as slowing the
spread of liver cancer, palliative treatment can relieve pain
and help manage other symptoms. Treatment may include
radiation therapy, chemotherapy or other drug therapies.
 TREATMENT: -
Surgical Management: -
Surgical Resection: Surgery can involve removing part of the liver, or
a liver transplant, where the whole liver is replaced by a donor
liver.
-Surgery is suitable for a small number of people with liver cancer,
and it will depend on the size, number and position of the tumors.
-Surgery to remove part of the liver is called a partial hepatectomy.
Following surgery, the remaining part of the liver can usually repair
itself if it is not damaged and grow back to normal size over a few
months.
-If there are tumors in both sides of the liver, surgery may be
conducted over two stages, to allow the liver to regrow following
the first operation.
 TREATMENT: -
Surgical Management: -

Liver Transplantation: Removing the liver and replacing it with a

healthy donor organ is another way to treat liver cancer.
Studies have shown decreased recurrence rates of the primary
liver malignancy after transplantation, with improvement in 5-
year survival rates to consistently greater than 70% Metastasis
and recurrence may be enhanced by the immunosuppressive
therapy that is needed to prevent rejection of the transplanted
liver.
 NURSING MANAGMENT: -
Nursing management for liver cancer involves providing holistic
care to patients throughout the continuum of the disease, from
diagnosis through treatment and palliative care. Here are key
components of nursing management for liver cancer:

• Assessment and Monitoring: Nurses conduct comprehensive

assessments to evaluate the patient's physical, psychological,
and social needs. This includes monitoring liver function tests,
assessing pain levels, nutritional status, and psychosocial well-
being.
 NURSING MANAGMENT: -
• Symptom Management: Nurses play a crucial role in managing
symptoms associated with liver cancer, such as pain, nausea,
fatigue, and jaundice. This may involve administering medications,
providing comfort measures, and implementing non-
pharmacological interventions to alleviate symptoms and improve
quality of life.

• Education and Support: Nurses provide education to patients and

their families about liver cancer, treatment options, potential side
effects, and self-care strategies. They offer emotional support,
address concerns, and connect patients with resources and
support groups to help them cope with the challenges of living with
cancer.
 NURSING MANAGMENT: -
• Nutritional Support: Nurses collaborate with dietitians to
assess nutritional status and develop individualized dietary
plans for patients with liver cancer. They provide guidance on
maintaining adequate nutrition, managing symptoms that affect
appetite and digestion, and preventing malnutrition.

• Pain Management: Nurses assess pain levels, administer

analgesics as prescribed, and monitor the effectiveness of pain
management interventions. They also employ non-
pharmacological pain relief techniques such as relaxation
techniques, massage, and positioning to help alleviate pain and
discomfort.
 NURSING MANAGMENT: -
• Psychosocial Support: Nurses address the psychological and
emotional needs of patients and their families by providing
counseling, supportive listening, and referrals to mental health
professionals when necessary. They promote coping mechanisms,
encourage open communication, and foster a supportive
environment for patients and families.

• Coordination of Care: Nurses collaborate with the interdisciplinary

healthcare team to coordinate care and ensure continuity across
different settings, including hospitals, clinics, and home care. They
facilitate communication between healthcare providers, advocate
for patients' needs, and assist with care transitions.
 NURSING MANAGMENT: -
• End-of-Life Care: For patients with advanced liver cancer or
those receiving palliative care, nurses provide compassionate
end-of-lifecare. They focus on symptom management, comfort
measures, and psychosocial support to ensure a peaceful and
dignified end-of-life experience for patients and their families
 COMPLICATIONS: -
• Liver Failure: As liver cancer progresses, it can impair the liver's ability to
function properly, leading to liver failure.

• Ascites: Ascites is the accumulation of fluid in the abdominal cavity. It can

develop as a result of liver cancer obstructing the flow of blood through the
liver or causing inflammation that leads to fluid buildup.

• Portal Hypertension: Liver cancer can cause an increase in pressure within

the portal vein, which carries blood from the digestive organs to the liver This
condition, known as portal hypertension, can lead to complications such as
varices (enlarged veins in the esophagusor stomach) that may rupture and
cause severe bleeding.
 COMPLICATIONS: -
• Hepatic Encephalopathy: Liver cancer can impair the liver's
ability to detoxify substances in the blood, leading to a buildup
of toxins such as ammonia. Hepatic encephalopathy occurs
when these toxins affect brain function, causing symptoms
such as confusion, difficulty concentrating, and personality
changes.

• Metastasis: If liver cancer spreads to other parts of the body

(metastasis), it can cause additional complications depending
on the location of the metastases. For example, if the cancer
spreads to the lungs, it can cause difficulty breathing, coughing,
and chest pain.
 PREVENTION: -
Primary Prevention: Primary prevention focuses on preventing the
development of liver cancer by addressing risk factors and
reducing exposure to carcinogens.

• Immunization against Hepatitis B and C: Immunization against

hepatitis B virus (HBV) and hepatitis C virus (HCV) is a primary
prevention strategy aimed at preventing chronic viral hepatitis,
a major risk factor for liver cancer. Vaccination programs target
individuals at risk, including infants, healthcare workers, and
individuals with high-risk behaviors.
 PREVENTION: -
• Promotion of Safe Injection Practices: Primary prevention efforts
include promoting safe injection practices to reduce the risk of
hepatitis virus transmission. Education of healthcare providers and
the public on proper injection techniques and the use of sterile
needles helps prevent the spread of viral hepatitis and subsequent
development of liver cancer.

• Screening of Donated Blood: Screening donated blood for hepatitis

viruses is essential to prevent transfusion-associated hepatitis
infections. By using sensitive assays to detect hepatitis B and C
viruses in donated blood, transfusion-related transmission of these
viruses is virtually eliminated in industrialized countries, reducing
the risk of liver cancer.
 PREVENTION: -
• Education on Tobacco and Alcohol Cessation: Primary prevention includes
education on the risks of tobacco and alcohol use, which are associated
with an increased risk of liver cancer. Tobacco cessation programs and
support for reducing alcohol consumption are vital components of primary
prevention efforts to promote liver health and reduce the incidence of liver
cancer.

• Promotion of Healthy Lifestyle: Encouraging individuals to maintain a

healthy lifestyle through diet, weight management, and regular exercise is
crucial for primary prevention. A balanced diet rich in fruits, vegetables,
and whole grains, along with maintaining a healthy weight and engaging in
regular physical activity, can help reduce the risk of liver cancer
associated with obesity and metabolic syndrome.
 PREVENTION: -
Secondary Prevention: Secondary prevention focuses on early
detection and intervention to prevent the progression of liver
disease to cancer.
• Chemoprevention Strategies: Secondary prevention efforts
include chemoprevention strategies aimed at reducing the risk
of liver cancer development in high-risk individuals. Compounds
such as chlorophyllin and oltipraz have shown promise in
attenuating the consequences of exposure to aflatoxin B1, a
potent carcinogen associated with liver cancer.
 PREVENTION: -
• Increased Consumption of Leafy Green Vegetables: Encouraging
the consumption of leafy green vegetables containing
isothiocyanates may help inhibit tumor formation and reduce the
risk of liver cancer. Isothiocyanates found in cruciferous
vegetables have demonstrated anti-carcinogenic properties in
animal studies and may play a role in cancer prevention.

• Iron Reduction Therapy: Secondary prevention strategies include

iron reduction therapy for individuals with iron storage diseases
such as hereditary hemochromatosis. By reducing excess hepatic
iron levels and preventing the development of fibrosis and
cirrhosis, iron reduction therapy may help reduce the risk of liver
cancer associated with iron overload.
 PREVENTION: -
Tertiary Prevention: Tertiary prevention focuses on managing
liver cancer and its complications to improve patient outcomes
and quality of life.

• Anti-HBV/HCV Treatment: Tertiary prevention includes the

treatment of chronic hepatitis B and C infections to reduce the
risk of liver cancer development. Anti-viral therapies aimed at
suppressing viral replication and reducing liver inflammation
can help prevent the progression of liver disease to cancer in
infected individuals.
 PREVENTION: -
• Comprehensive Measures for HCC Management: Tertiary
prevention efforts involve comprehensive measures to reduce
hepatocellular carcinoma (HCC) recurrence, mortality, and improve
survival rates. This includes a multidisciplinary approach to HCC
management, incorporating surgery, chemotherapy, radiotherapy,
and targeted therapies tailored to individual patient needs.

• Regular Monitoring for HCC Recurrence: Tertiary prevention

includes regular monitoring for HCC recurrence and metastasis
following treatment. Surveillance strategies such as imaging
studies and tumor marker tests are used to detect recurrent
disease early, allowing for timely intervention and improved
outcomes.
 PREVENTION: -
• Detection of Circulating HR-HPV DNA: Tertiary prevention
efforts may also involve the detection of circulating high-risk
human papillomavirus (HR-HPV) DNA in blood samples for
surveillance purposes. Monitoring for HR-HPV DNA may help
identify individuals at risk of developing HPV-related liver
cancer and guide clinical management decisions.
THANK YOU