Hepatic Tumors – Vocabulary Flashcards

Hepatic Tumors – General Overview

• Tumors arising in the liver can be malignant (cancerous) or benign.

• Cancerous lesions are further divided into:

  • Primary hepatic malignancies (originate in the liver itself)

  • Metastatic (secondary) tumors

• Benign tumors include hepatic adenomas, focal nodular hyperplasia, and hemangiomas.

Classification of Malignant Hepatic Tumors

• Hepatocellular carcinoma (HCC) / “Hepatoma”
  • Most frequent primary liver cancer.
  • Arises from hepatocytes.

• Cholangiocarcinoma
  • Originates from epithelial lining of intra- or extra-hepatic bile ducts.
  • Distinct biology and usually different risk profile (e.g. primary sclerosing cholangitis).

• Mixed epithelial–mesenchymal tumors
  • Contain both hepatocellular elements and stromal/mesenchymal cells.

• Primary mesenchymal malignancies
  • Angiosarcoma – arises from hepatic blood-vessel endothelium (rare; linked to vinyl-chloride & thorotrast exposure).
  • Hepatoblastoma – pediatric tumor; may secrete hormones triggering precocious puberty.

Risk Factors for Hepatocellular Carcinoma

• Chronic viral hepatitis: HBV & HCV (integration of viral DNA, chronic inflammation, cirrhosis).

• Alcohol-induced cirrhosis – repeated hepatocellular injury → regenerative nodules → dysplasia.

• Exposure to hepatotoxins (e.g. aflatoxin B1, vinyl chloride, thorium dioxide, arsenic).

• Anabolic-androgenic steroids – prolonged use linked to adenoma → malignant transformation.

• Non-alcoholic fatty liver disease (NAFLD) / NASH – emerging risk, even without cirrhosis.

• Age – incidence rises after 60\text{ yrs} but can occur younger.

• Sex – men ≈ 2:1 risk vs women (partly hormonal, lifestyle, HBV carrier rates).

• Race/ethnicity – highest rates in Asian (endemic HBV); rising in Western nations due to HCV & NAFLD.

• Smoking – carcinogen synergy.

• Genetic / familial syndromes (e.g. hereditary hemochromatosis, α-1 antitrypsin deficiency, glycogen-storage dz).

Metastasis Pattern (to & from the Liver)

• Primary tumors that commonly spread TO liver:
  • Colon & rectum
  • Neuroendocrine / carcinoid
  • Breast
  • Ovary
  • Lung
  • Kidney (renal cell)
  • Prostate
  • Pancreas
  • Stomach

• Liver primaries can spread OUTWARD to lung, regional lymph nodes, bone.

Clinical Presentation – Signs & Symptoms (often late)

• Frequently asymptomatic in early stage; detected on surveillance imaging for cirrhosis.

• Pain – dull ache R-upper quadrant, right shoulder, back, epigastrium (Glisson capsule stretch).

• Fever (non-infectious cytokine release) – consider malignancy if no infection source.

• Jaundice – only when tumor obstructs bile ducts.

• GI & constitutional: indigestion, anorexia, weight loss, nausea, early satiety, generalized weakness.

• Fluid shifts: abdominal ascites, peripheral leg edema.

• Palpable mass / hepatomegaly – enlarged, nodular liver edge on exam.

Diagnostic & Laboratory Evaluation

• Abdominal ultrasound (US)
  • First-line; distinguishes solid vs cystic lesions.

• CT / MRI (arterial & venous phases)
  • Defines size, number, vascular invasion; guides resectability.

• Arteriography
  • Dye injection into hepatic artery → maps tumor vascular supply; aids surgical/embolization planning.

• Biopsy
  • Fine-needle (FNA) or core; confirms HCC vs metastasis.
  • Post-procedure nursing: patient positioned on affected side \ge 2\text{ h}; monitor VS for bleeding (↑HR, ↓BP, ↑RR), check site for hematoma, provide analgesia.

• Laboratory trends
  • CBC may show anemia (blood loss) or erythrocytosis (paraneoplastic).
  • LFTs ± abnormal; can be normal even in advanced cases.
  • Coagulation – prolonged PT/PTT in cirrhosis or tumor factor consumption.

• Tumor markers (not in transcript but clinically relevant): AFP, DCP.

AJCC TNM Staging System (8th ed.)

• T (Primary Tumor)
  • T0 – no tumor.
  • T1 – single lesion, no vascular invasion.
  • T2 – single lesion w/ vascular invasion OR >1 lesions, each <5\text{ cm}. • T3 – multiple lesions >5\text{ cm} OR involvement of major branch of portal/hepatic vein.
  • T4 – direct invasion of adjacent organ (≠ gallbladder) or perforation of visceral peritoneum.

• N (Regional Nodes)
  • N0 – none.
  • N1 – regional node metastasis.

• M (Distant Metastasis)
  • M0 – none.
  • M1 – metastasis to distant node/organ (lungs, bone most common).
  • MX – cannot be assessed.

• Numbers 0\text{–}4 appended to T/N/M denote increasing severity.

Stage-Specific Clinical Groups (Simplified)

• Localized – Resectable
  • Confined to resectable segment/lobe; adequate residual liver function; potential cure.

• Localized – Unresectable
  • Vessel encasement, multifocal disease, or poor hepatic reserve (Child-Pugh B/C).
  • Symptoms: ascites, jaundice, edema.

• Advanced / Metastatic
  • All lobes or extra-hepatic spread.

Curative & Palliative Treatment Modalities

Surgical Options

• Partial hepatectomy / lobectomy
  • Treatment of choice if \le 1 lobe, tumor-free margins feasible, and synthetic liver function intact.
  • Relies on remarkable hepatic regenerative capacity (limits: underlying cirrhosis).

• Liver transplantation
  • Ideal in patients w/ \le 3 tumors each <5\text{ cm} or single <5\text{ cm} without major vascular invasion & no HBV.
  • Provides new liver, removes cirrhotic microenvironment; lifelong immunosuppression required.

• Cryosurgery
  • Argon/CO₂ probe → freeze tumor; useful for localized disease not amenable to resection.

• Radiofrequency Ablation (RFA) / Microwave coagulation
  • Heat-induced coagulative necrosis via percutaneous or laparoscopic applicator.

• Ethanol Injection (percutaneous) – dehydrative necrosis.

Non-Surgical / Locoregional

• Trans-arterial Chemoembolization (TACE)
  • Delivers chemotherapy (e.g. doxorubicin) mixed w/ lipiodol + embolic particles → ischemic plus cytotoxic effect.

• TARE / SIRT – ^{90}\text{Y} microspheres (investigational).

• External-beam Radiation Therapy (EBRT)
  • Limited by liver tolerance; role mainly palliative for bone pain or large mass.

• Systemic Chemotherapy
  • Single-agent Adriamycin (doxorubicin) or 5-FU; combos with cisplatin ± α-interferon studied; overall limited survival benefit.

• Clinical trials / novel targeted agents
  • Derivatives of doxorubicin, 5-FU, multikinase inhibitors (sorafenib) under investigation.

Supportive / Adjunctive Measures

• Percutaneous biliary drainage – relieves obstructive jaundice when ducts compressed.

• Implantable hepatic-artery infusion pumps – deliver high-dose chemo with lower systemic toxicity.

Nursing Management & Post-Op Monitoring

• Surgery:
  • Monitor for hypoglycemia (liver is glucose reservoir).
  • Hypovolemia & blood loss (large vascular organ) – manage with IV fluids/transfusions.
  • Maintain normothermia; large open surgeries risk hypothermia.
  • Assess drains: T-tube (bile duct), closed-suction drains.
  • Watch for bile leakage → peritonitis (↑bilirubin in drain, abdominal pain, fever).
  • Prevent infection (aseptic technique, early ambulation, pulmonary hygiene).
  • Serial labs: CBC, LFTs, coagulation profile.

• Biopsy after-care – discussed above; vigilance for hemorrhage & pain control.

• Port-a-cath/chemo port care – flush protocol, infection prevention.

Patient & Family Education

• Explain operative plan, expected drains/tubes, dietary progression (high-protein unless encephalopathic).

• Prepare for chemo/radiation side-effects; provide psychosocial support, resources, counseling.

• Clarify follow-up schedule: imaging surveillance Q3-6 months, labs (AFP), transplant clinic if applicable.

• Stress infection signs (fever, chills, incision erythema) given immunosuppression post-transplant.

• Reinforce lifestyle changes: alcohol abstinence, HBV vaccination for family, weight control for NAFLD.

Benign Hepatic Tumors

• Hepatocellular Adenoma
  • Women of child-bearing age, strongly associated with oral contraceptive use (>5\text{ yrs}).
  • Usually solitary; risk of rupture/hemorrhage; rare malignant transformation.

• Focal Nodular Hyperplasia (FNH)
  • Hyperplastic response to anomalous artery; females 20\text{–}30\text{ yrs}.
  • Central scar on imaging; generally asymptomatic; no malignant potential.

• Hemangioma
  • Most common benign liver lesion; up to 5\% adults have micro-hemangiomas.
  • Cavernous vascular channels; usually <5\text{ cm} and incidental.
  • Giant lesions may cause pain, rupture risk; avoid biopsy (bleeding).

Clinical Pearls & Connections

• Underlying cirrhosis simultaneously raises surgical risk and baseline cancer risk – must weigh resection vs transplant.

• No single therapy has demonstrated survival superiority in advanced HCC; multidisciplinary evaluation & clinical-trial enrollment are key.

• Ethical consideration: resource allocation for transplant, given organ scarcity; strict listing criteria (e.g. Milan criteria) aim for equitable, best-outcome use.

• Real-world relevance: Rising NAFLD epidemic predicts future upswing in HCC incidence independent of viral hepatitis—public-health focus on obesity and diabetes may indirectly curb liver-cancer burden.