Medical Surgical Department

Cancer Liver

Under supervision:-Lecturer/ Engy El-sayed

Prepared by : Group:- A2

2023-2024

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‫االسماء‬

‫احمد اشرف سعد عبده‬ ‫‪.1‬‬

‫احمد اکرامی فضل المظالی‬ ‫‪.2‬‬
‫احمد البكرى جمعه الزرقاني‬ ‫‪.3‬‬
‫احمد السيد احمد رزق‬ ‫‪.4‬‬
‫احمد السيد سعد عزب السعودي‬ ‫‪.5‬‬
‫احمد السيد عبد الحافظ محمد‬ ‫‪.6‬‬
‫احمد السيد عبد الرسول عبد الكريم‬ ‫‪.7‬‬
‫احمد بدوى السيد بدوى‬ ‫‪.8‬‬
‫احمد بسيونی عمر ابراهيم‬ ‫‪.9‬‬
‫‪.10‬احمد جمال عبد اللطيف الصيفي‬

‫‪.11‬احمد حاتم حافظ البرماوي‬

‫‪.12‬احمد ابراهيم حامد فارس‬

‫‪.13‬احمد صالح على عثمان‬

‫‪.14‬احمد على عبد اللطيف خليفة‬

‫‪.15‬احمد عيد عبد الغنى الديب‬

‫‪.16‬اسراء السيد عبد الجيد عفيفی‬

‫‪.17‬اسراء السيد محمود عبد العال محمد‬

‫‪.18‬اسراء ايمن محروس زکی‬

‫‪. 19‬اسراء ربيع عبد النبي عبد الدايم‬

‫‪.20‬اسراء رمضان على سيد‬

‫‪2‬‬
Outline
_ Introduction

_ Definition

_ Anatomy

_ Pathophysiology

_ Type

_ Risk factor

_ Causes

_ Clinical mainfstation

_ Diagnosis

_ Medical management

_ Nursing Management

_ Complication

_ Prevention

_ Refrance

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Introduction:
Liver cancer (hepatocellular carcinoma) not a homogenous
disease. In the majonty of patients, it develops in fibrotic livers
approximately 80%, and cinhosis, regardless of aetiology
represents the strongest predisposing factor for liver cancer The
behaviour of liver cancer is as variable as the known causes of
the disease Similarly mechanisms of carcinogenesis likely differ
between causes of liver cancer, even differing between common
causes such as hepatitis B virus (HBV)-and hepatitis C virus
(HCV) related cirrhosis Doubling time for liver cancer can vary
from a few weeks to several months, and the natural history of
untreated disease varies further depending on the stage at
presentation and the dearee of underlying liver disease. The

prognosis is poor for untreated liver cancer, even for early-stage

disease in some cases, particularly when the liver disease is
advanced and affect liver function.

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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:

• Approximately 75% of the blood supply comes from the portal

vein, which drains the GI tract and is rich in nutrients.

• The remainder of the blood supply enters by way of the hepatic

artery and is rich in oxygen.

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Functions of the Liver
1. Glucose Metabolism.

-After a meal, glucose is taken up from the portal venous

blood by the liver and converted into glycogen, which is
stored in the hepatocytes.

2. Ammonia Conversion.

-Use of amino acids for gluconeogenesis results in the formation

of ammonia as a byproduct the liver converts this metabolically
generated ammonia into urea.

3. Protein Metabolism.

-Itsynthesizes almost all of the plasma proteins (except gamma

globulin), including albumin, alpha and beta globulins, blood
clotting factors, specific transport proteins, and most of the
plasma lipoproteins.

4. Fat Metabolism.

-The liver is also active in fat metabolism. Fatty acids can be

broken down for the production of energy and the production of
ketone bodies.

5. Vitamin and Iron Storage.

-Vitamins A, B, and D and several of the B-complex vitamins

are stored in large amounts in the liver.

6. Drug Metabolism.

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-The liver metabolizes many medications, such as opioids,
sedative agents, anesthetics, and amphetamines.

7. Bile Formation.

-Bile is continuously formed by the hepatocytes and collected in

the canaliculi and bile ducts.

8. Bilirubin Excretion.

-Hepatocytes remove bilirubin from the blood and chemically

modify it through conjugation to glucuronic acid, which makes
the bilirubin more soluble in aqueous solutions. The conjugated
bilirubin is secreted by the hepatocytes into the adjacent bile
canaliculi and is eventually carried in the bile into the
duodenum.

Definition
Liver cancer (also known as hepatic cancer, primary hepatic
cancer, or primary hepatic malignancy) is cancer that starts in the liver.
Liver cancer can be primary (starts in liver) or secondary (meaning
cancer, which has spread from elsewhere to the liver, known as liver
metastasis).

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 • pathophysiology

The pathophysiology of liver cancer involves the abnormal growth and

division of cells in the liver. There are different types of liver cancer, but
the most common one is hepatocellular carcinoma (HCC), which arises
from hepatocytes, the main cells in the liver.

* Several factors can contribute to the development of liver cancer,

including chronic liver inflammation, viral infections (such as hepatitis B
or C), cirrhosis (scarring of the liver), exposure to certain chemicals and
toxins, and genetic factors.

Here is a general overview of the pathophysiology of liver

cancer:

1. Liver injury and inflammation: Chronic liver injury and

inflammation can lead to ongoing cellular damage and regeneration. This
repeated process increases the risk of genetic mutations and abnormal cell
growth.

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2. Genetic alterations: Genetic mutations can occur in the DNA of liver
cells, disrupting the normal cell cycle control mechanisms. These
mutations can affect the regulation of cell growth and division, leading to
uncontrolled proliferation of the mutated cells.

3. Dysregulation of cellular pathways: Mutations in specific genes and

dysregulation of cellular signaling pathways can promote cell survival,
angiogenesis (formation of new blood vessels), and invasion of
surrounding tissues. These processes contribute to tumor growth and
spread.

4. Cirrhosis and fibrosis: Cirrhosis, often caused by chronic liver

diseases like hepatitis or alcohol abuse, leads to scarring and fibrosis in
the liver. The fibrotic tissue provides an environment that favors the
development of liver cancer.

5. Metastasis: Liver cancer can also spread to other parts of the body
through the bloodstream or lymphatic system. Metastatic liver cancer is
more common than primary liver cancer.

Type of Liver Cancer

1/Hepatocellular carcinoma (HCC)

-Hepatocellular carcinoma can have different growth patterns. Some

spread tentacle-like growths through the liver. This pattern is the most
common one in the United States. Some start as a single tumor that
spreads to other parts of the liver as the disease develops. Others develop
as nodules at several different places in the liver. Occasionally, a pattern
isn't clear.

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-Approximately 73% of primary liver cancers in adults are hepatocellular
carcinomas.

2/Cholangiocarcinoma

-A cholangiocarcinoma develops from cells in the bile duct of the liver.

The bile duct is a thin tube that extends from the liver to the small
intestine. The bile duct starts inside the liver as several smaller tubes that
join together.

-About 18% of primary liver cancers in adults are cholangiocarcinomas.

3/Angiosarcoma

-Angiosarcoma starts in the blood vessels of the liver and grows very
quickly.

-About 1% of primary liver cancers in adults are angiosarcomas.

Risk factors
1- Age /adult primary cancer occure often in people older than 60

2- Sex/Liver cancer is much more common in men than women

3- Viral hepatitis/long term infection with hepatitis Bvirus(HBV) Or

hepatitisC Virus or hepatitisDVirus lead tocirrhosis of the liver and
making cancer liver

4- Lifestyle factors

• Smoking passive or Active

• Alcohol excessive use acts as promoter by modifying the

metabolism of carcinogen in the liver

5- Metabolic factors/

• Obesity

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 • Non alcoholic fatty liver disease

• Diabetes mellitus/type 2diabetes tend to be over wight which in

turns can cause liver disease

6- Environment toxines such as exposure to certain chemicals or eating

food contaminated with aflatoxin B1

7- Genetic susceptibility and immuno suppression

8- Other conditions/certain are medical and gastric condition may

increase risk of liver failure

• Alpha-1-antitrypsin deficiency

-Alpha-1 antitrypsin deficiency is an inherited disorder that may

cause lung disease and liver disease .

-About 10 percent of infants with alpha-1 antitrypsin deficiency

develop liver disease, which often causes yellowing of the skin and
whites of the eyes (jaundice). Approximately 15 percent of adults
with alpha-1 antitrypsin deficiency develop liver damage
(cirrhosis) due to the formation of scar tissue in the liver. Signs of
cirrhosis include a swollen abdomen and jaundice. Individuals with
alpha-1 antitrypsin deficiency are also at risk of developing a type
of liver cancer called hepatocellular carcinoma

• Wilson's disease

-Wilson disease is a rare genetic condition that occurs when your

body accumulates too much copper, especially in the liver and
brain. Your body needs a small amount of copper from food to stay
healthy, but without treatment, Wilson disease can lead to high
copper levels that cause life-threatening organ damage

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 Wilson disease often develop symptoms of hepatitis
(inflammation of the liver) and can have an abrupt decrease in liver
function (acute liver failure).andSome people they develop
chronic liver disease and complications from cirrhosis. These
symptoms may include:

1/Fatigue and weakness.

2/Unexpected weight loss

3/Bloating from a buildup of fluid in the abdomen (ascites).

4/Swelling of the lower legs, ankles or feet (edema).

5/Itchy skin.

6/Severe jaundice

• Glycogen storage disease

-Is a metabolic disorder where the body is not able to properly

store or break down glycogen, a form of sugar or glucose. GSD
affects the liver, muscles and other areas of the body, depending on
the specific type.

Type of (GSD)

• type I (von Gierke's disease) Type Ia – liver, kidneys, intestines;

Type Ib – liver, kidneys, intestines, blood cells

• type II (Pompe's disease) – muscles, heart, liver, nervous system,

blood vessels

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 - type III (Forbes-Cori disease) – liver, heart, skeletal muscles,
blood cells

• type IV (Andersen's disease) – liver, brain, heart, muscles, skin,

nervous system

• type V (McArdle's disease) – skeletal muscles

• type VI (Hers' disease) – liver, blood cells

- type VII (Tarui's disease) – skeletal muscles, blood cells

• type IX (phosphorylase kinase deficiency) – liver

• type XI (Fanconi-Bickel syndrome) – liver, kidneys, intestines

The most common types of GSD are types I, II, III and IV,
accounting for nearly 90% of all cases. About 25% of patients with
GSD are thought to have type I. GSD types VI and IX have very
mild symptoms and may be erdiagnosed or not diagnosed until
adulthood.

9- liver cirrhosis in general associated with increase risk of

hepatocellular carcinoma

Overall,2%-4%of patient with cirrhosis develop hepatocellular carcinoma

each year.

Causes (carcinogenes):
Cancers can be caused by :

* DNA changes (mutations) that turn on oncogenes or turn off tumor

suppressor genes. For example,

1- liver cirrhosis related to hepatitis B virus (HBV) and hepatitis C virus

(HCV) account for more than half of cases.

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2- Certain chemicals that cause liver cancer, such as aflatoxin B1, are
known to damage the DNA in liver cells. For example, studies have
shown that aflatoxin B1

3- Nonalcoholic steatohepatitis (NASH):

NASH is a condition that can cause cirrhosis that may lead to liver
cancer. It is the most severe form of nonalcoholic fatty liver disease,
where there is an abnormal amount of fat in the liver.

4- Chronic alcoholism and smoking

Clinical manifestation of liver cancer

-
Weight loss

- Loss of appetite

- Upper abdominal

- Nausea , vomiting

- General weakness and fatigue

- Abdominal swelling

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- Jaundice (Yellowing of the skin and eyes)

- Fever

- Anemia

DIAGNOSIS:
Diagnosis of liver cancer is based on:

1-Health history

2-Physical examination

3-Laboratory and x ray results

* Health history
It include

- Any previous cancer that patient has

- Chronic disease like Hypertension and Diabetis mellitus

- Any medication that patient used to take

*Physical examination:

It include sign and symptoms of disease and general assessment of body

to determine any changes happened related to diseases

*Laboratory investigation
Alpha-fetoprotein (serve as a tumer marker) is elevated 80 to 90 % of
cases

Increase level of bilirubin

Alt - Ast elevated

Leukocytes (increase of WBC level) is present

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Hypocalcemia, hypercholesterolemia may be present

* Other investigation:

-Ultrasound may be used

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

-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.

Laparoscopy: This surgical procedure is done to look at the organs inside

the abdomen to check for signs of disease. Small incisions are made in
the wall of the abdomen and a laparoscope (a thin, lighted tube) is

16
inserted into one of the incisions. Another instrument is inserted through
the same or another incision to remove the tissue samples.

A biopsy is not always needed to diagnose liver cancer. Sometimes the

doctors can diagnose liver cancer based on the results of imaging tests
such as CT scans and MRI.

• Medical Management
Although surgical resection for the liver tumer is possible in some
patient, the underlying cirrhosis is so prevalent in cancer of the liver that
it increases the risks associated with surgery. Radiation therapy and
chemotherapy have been used to treat cancer of the liver with varying
degrees of success. Although these therapies may prolong survival and
improve quality of life by reducing pain and discomfort, their major
effect is palliative.

Type of Medical management of liver cancer

A- Non-surgical B-surgical

A /Non-surgical

1- Radiation therapy
The use of external-beam radiation for the treatment of liver tumors has
been limited by the radiosensitivity of nor- mal hepatocytes and the risk
of destruction of normal liver parenchyma. Internal radiotherapy can
result in reduction in tumor size, but its effect on survival.

2- chemotherapy
Typically, studies of patients with advanced cases of liver cancer have
shown that the use of systemic chemothera- peutic agents leads to poor

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outcomes. For patients with stable hepatic function (Child class A).
Systemic chemotherapeutics are not routinely used in HCC, although
local chemotherapy may be used in a procedure known as transarterial
chemoembolization (TACE).

3- Percutaneous Biliary Drainage or Transhepatic Drainage:

It is a medical procedure where a thin tube, known as a catheter, is

inserted through the skin into the bile ducts to relieve obstruction or
excess fluid buildup.Is used to dypass biliary ductobstructed by liver,
pancreatic, or bile duct tumers in patient who have inoperable tumers or
are consedered poor sergical risks.

4-Other non surgical treatments

-Laser hyperthermia

-Radio freqency thermal ablation

-Immunotherapy

-Transcatheter arterial

-Ultrasound-guided of alcohol for multiple small lesions

B- Surgical Management

Surgical resection is the treatment of choice when HCC is cinfined to one

lobe if liver and function of the remaining liver is considered adequate for
postoperative recovery.

1- Lobectomy

Removal of lobe of the liver is the most common surgical procedure for
excising a liver tumer.

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2- Local Ablation

_Ablation is the removal or destruction of a body tissue or part,

usually by surgery, radiation, or other procedures.
Patients who are not candidates for resection or transplantation,
ablation of HCC may be accomplished by chemical such as ethanol or by
physical means such as radiofrequency ablation (most frequently used
local ablative therapy) or microwave coagulation. These techniques may
be performed under ultrasound or CT guidance laparoscopically or pet
cutaneously.

3- Liver Transplantation

-Liver transplantation is a surgical procedure in which a

diseased or damaged liver is replaced with a healthy liver from a
donor. It is typically recommended for patients with end-stage
liver disease or acute liver failure. After the surgery, patients
require close monitoring and lifelong immunosuppressive
medication to prevent rejection of the new liver. It is a complex
procedure that can significantly improve quality of life and
increase long-term survival for eligible patients ..

Nursing Management
Assessment:

➢ Nursing assessment focuses on the onset of symptoms and the history

of precipitating factors, particularly long term alcohol abuse, as well as
dietary intake and changes in the patient's physical and mental status. It is
also important to document any exposure to toxic agents encountered in
the workplace or during recreational activities. The nurse reports

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exposure to potentially hepatotoxic substances such as medications, and
inhalants or general anesthetic agents.

o The Nurse assesses: The patient's relationships with family, friends, and
coworkers may give some indication about incapacitation secondary to
alcohol abuse and cirrhosis. Abdominal distention and bloating, GI
bleeding, bruising, and weight changes are noted.

o The Nurse assesses: nutritional status, which is of major importance in

cirrhosis, by daily weights and monitoring of plasma proteins, transferrin,
and creatinine levels.

▪ The Surgical patient: Support, explanation, and encouragement are

provided to help the patient prepare psychologically for the surgery.

▪ After surgery, potential problems related to cardiopulmonary

involvement may include vascular complications and respiratory and liver
dysfunction.

• Metabolic abnormalities require careful attention.

• A constant infusion of 10% glucose may be required in the first 48

hours to prevent a precipitous fall in the blood glucose level that results
from decreased gluconeogenesis. Because extensive blood loss may occur
as well, the patient receives infusions of blood and IV fluids.

• The patient requires constant, close monitoring and care for the first 2 or
3 days, similar to postsurgical abdominal and thoracic nursing care. If the
patient is to receive chemotherapy or radiation therapy in an effort to
relieve symptoms, he or she may be discharged home while still receiving
one or both of these therapies.

• The patient may also go home with a biliary drainage system or hepatic
artery catheter in place. In most cases, the hepatic artery catheter has been

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inserted surgically and has a prefilled infusion pump that delivers a
continuous chemotherapeutic dose until completed.

An hepatic artery port may also be inserted to provide access for

intermittent chemotherapy infusion. This port dwells under the skin, but,
because it provides direct arterial access, it is not used for continuous
infusion therapy in the home environment; the access line is discontinued
once the chemotherapeutic agent has infused.

• The patient and family require teaching about care of the biliary catheter
and the effects and side effects of hepatic artery chemotherapy. This
teaching is necessary because of participation of the patient and family in
patient care in the home setting.

Complications of Liver cancer

*
Liver cancer results in several complications as liver is the source of
metabolism, enzyme activation, the storage of minerals and glucose, etc.
Any abnormality in the liver leads to altered functions. Liver cancer may
be caused by tumour pressure on the bile duct or other organs, hormones

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released by cancer cells, and liver malfunction resulting in a build-up of
toxins in the body.

* Common complications of liver cancer, include: ·

- Anaemia (lack of healthy red blood cells)

- Obstruction of bile duct

- Increase in portal blood pressure (portal hypertension)

- Hypercalcemia (high blood calcium)

- Hepatorenal Syndrome (occurrence of kidney disease due to the

presence of liver disease)

- Hepatic Encephalopathy

Prevention of liver cancer

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Prevention of liver cancer

Primary prevention

Primary prevention, defined as preventing the etiological agent from

initiating the carcinogenic process .

. Immunization against hepatitis B virus infection: Since 1991 the WHO

has recommended that HBV vaccine be included in the routine infant
immunization program in all countries.

. Immunization against hepatitis C virus infection .

. Safe injection practices: These are based on education of medical,

paramedical, and dental practitioners to avoid the use of unnecessary
injections and to improve the safety of their injection and infusion
techniques.

. Screening of donated blood for the presence of hepatitis viruses:

Transfusion-associated hepatitis C and B virus infections have been
virtually eliminated in industrialized countries by screening of all donated
blood with very sensitive assays for detecting these viruses

. Passive immunization: Passive immunization with HBIG is useful in

preventing transmission of HBV, but it is expensive and its effect is of
limited duration.

. Anti-viral agents: Treatment with currently used anti-viral agents has

limited efficacy in the sustained eradication of hepatitis B and C viruses,
and so achieves relatively little in preventing the spread of these viruses.
Nevertheless, in those patients with HCV or HBV infection who respond
to treatment with anti-viral drugs the risk of HCC development is reduced
or delayed.

. Tobacco cessation program.

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. Smoking cessation.

. Maintaining a healthy lifestyle ( diet ,weight, exercise).

Secondary prevention

Secondary prevention of HCC, defined as early disease detection or

preventing it from reaching its target or interacting with tissue
nucleophiles, especially DNA, currently provides a limited number of
opportunities only.

. Chemoprevention of aflatoxin B1- induced hepatocellular carcinoma:

Chemoprevention of AFB1-induced malignant transformation is based on
the principle of attenuating the consequences of currently unpreventable
dietary exposure to the toxin.

. Chlorophyllin. Sodium copper chlorophyllin, a water soluble derivative

of natural chlorophylls, is a potent anti-carcinogen in a number of
experimental models,53 including AFB1-induced HCC. Chlorophyllin
acts as an “interceptor molecule”, forming tight molecular complexes
with a number of chemical carcinogens, including aflatoxins, thereby
reducing their bioavailability and hence their carcinogenic capability.

.Oltipraz. A second approach is to modify the detoxification pathway of

AFB1 in such a way as to render its reactive metabolite innocuous. The
anti-schistosomal drug, oltipraz (a substituted 1,2-dithiole-3-thione) is
structurally similar to the dithiolethiones found in cruciferous vegetables
that may play a role in cancer prevention.

.Other chemoprevention possibilities: A decrease in the risk of HCC

correlates with an increased consumption of leafy, green
vegetables.63Plants belonging the family Cruciferae and the genus
Brassica (including broccoli, cauliflower, and Brussel sprouts) contain

24
large quantities of isothiocyanates, mostly in the form of their
glycosinolate precursors. Some of these isothioc-yanates have been
shown to inhibit tumor formation in rats.

. Iron storage diseases: Whether or not excess hepatic iron is proved to be

directly hepatocarci-nogenic, ‘de-ironing’ of patients with HH by
repeated venesection would be expected to have a secondary preventive
effect against HCC formation, both by reversing the accumulation of iron
and preventing the development of fibrosis and cirrhosis.

Tertiary Prevention

Tertiary prevention targets both the clinical and outcome stages of a

disease. It is implemented in symptomatic patients and aims to reduce the
severity of the disease as well as any associated sequelae. While
secondary prevention seeks to prevent the onset of illness, tertiary
prevention aims to reduce the effects of the disease once established in an
individual. Forms of tertiary prevention are commonly rehabilitation
efforts.

. Anti HBV/HCH and other etiological treatment.

. Comprehensive measures to reduce HCC recurrence and mortality, and

improve survival.

. Monitoring for HCC recurrence and metastasis.

. Detection of circulation HR -HPV DNA in blood samples.

25
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