Liver

•100-250x more common in patients with chronic Hepatitis B •3-4x more common in men¹ •hepatocellular carcinoma is uncommmon, it comprises only 2% of all malignancies •more common in Asia and sub-Saharan Africa due to high rates of infectious hepatitis² || •cirrhosis - about 80% of patients with newly diagnosed hepatocelluar carcinoma have preexisting cirrhosis •alcohol - 30% of cases are to be related to excessive alcohol use •Hepatitis B virus •Hepatitis C virus •hemochromatosis •aflatoxin exposure² || •pruritus •jaundice •splenomegaly •variceal bleeding •cachexia •increasing abdominal girth (portal vein occlusion by thrombus with rapid development of ascites) •hepatic encephalopathy •right upper quadrant pain (uncommon)² || •labs to include CBC, LFTs, blood chemistries, coagulation panel, serum AFP, hepatitis B/C panels •abdominal CT •fine needle aspiration¹ •ultrasound, CT or laparoscopically guided percutaneous biopsy² || G1 Well differentiated G2 Moderately differentiated G3 Poorly differentiated G4 Undifferentiated ||
 * Epidemiology: || Incidence of Disease:
 * Etiology: || Causes or risk factors include:
 * Signs & Symptoms: || Patients generally present with:
 * Diagnostic Procedures: || Workup:
 * Histology: || Hepatooblastoma is most common in patients younger than 2 years of age. Hepatocellular is most common in patients in their second decade of life.³ Cirrhosis of the liver is the major risk factor for hepatocellular carcinoma. About 80% of patients with newly diagnosed hepatocellular carcinoma have preexisting cirrhosis of the liver.² ||
 * Lymph Node Drainage: || "The regional lymph nodes are the hilar, hepatoduodenal ligament lymph nodes, inferior phrenic, and caval lymph nodes, among which the most prominent are the hepatic artery and portal vein lymph nodes."⁵ ||
 * Metastatic Spread: || The most common sites of distant metastatic spread is to the lungs and bones; however liver lesions may extend through the liver capsule to adjacent organs such as the adrenal, diaphragm, colon, or peritoneum. The main mode of spread is through the portal and hepatic veins.⁵ ||
 * Grading: || The grading scheme of Edmondson and Steiner is recommended.⁵
 * Staging: || AJCC/TNM⁵

Primary Tumor (T) TX: Primary tumor cannot be assessed T0: No evidence of primary tumor T1: Solitary tumor without vascular invasion T2: Solitary tumor with vascular invasion or multiple tumors none more than 5 cm T3a: Multiple tumors more than 5 cm T3b: Single tumor or multiple tumors of any size involving a major branch of portal vein or hepatic vein T4: Tumor(s) with direct invasion of adjacent organs other than the gallbladder or with perforation of visceral peritoneum

Regional Lymp Nodes (N) NX: Regional lymph nodes cannot be assessed N0: No regional lumph node metastasis N1: Regional lumph node metastasis

Distant Metastasis (M) M0: No distant metastasis M1: Distant metastasis

Anatomic Stage/Prognostic Groups Stage I: T N0 M0 Stage II: T N0 M0 Stage IIIA: T3a N0 M0 Stage IIIB: T3b N0 M0 Stage IIIC: T4 N0 M0 Stage IVA: AnyT N1 M0 Stage IVB: Any T Any N M1 ||
 * Radiation Side Effects: || With external irradiation doses of 55 Gy or less to the duodenum or stomach, the risk of severe gastrointestinal complications varied from 5% to 10%. At doses greater than 55Gy, one-third of patients developed severe problems. In patients who received external irradiation plus iridium, the dose to the external field was limited to 50.4 Gy, but most received additional irradiation dose to the duidenum or stomach from the iridium boost. There was a 30% to 40% incidence of severe complications in the duodenum or stomach in this group of patients.

Transhepatic catheters were previously left in place in these patients until the degree of stenosis stabilized or lessened on serial cholangiograms, which usually occurred within 12 to 18 months of treatment. Because of stent-related morbidity, attempts are now made to remove transhepatic catheters or endoscopic stents within 3 to 6 months of the brachytherapy boost, if imaging techniques of the biliary tree suggest this is mediclaly feasible.¹ || 26 percent are diagnosed after the cancer has spread to regional lymph nodes or directly beyond the primary site 22 percent are diagnosed after the cancer has already metastasized (distant stage) In 22 percent of cases, the staging information was unknown. ⁴
 * Prognosis: || The stage of liver cancer plays a role in the liver cancer survival rate as well. Based on historical data: 31 percent of liver cancer cases are diagnosed while the cancer is still confined to the primary site (localized stage)

The corresponding five-year relative liver cancer survival rates were: 19.0 percent for localized 6.6 percent for regional 3.4 percent for distant 3.3 percent for unstaged⁴ || ||  || || || Liver -- the whole liver can receive 20 to 30 Gy, with an upper threshold of 33 to 35 Gy. One-third to one-half of the liver volume can receive more than 40 Gy without complications. Kidney -- 1/3 can receive 50 Gy, 2/3 can receive 30 Gy, the whole kidney can receive 23 Gy. Spinal cord -- 45 Gy Stomach -- 1/3 can receive up to 60 Gy, 2/3 is 55 Gy, and the whole stomach tolerance is 50 Gy Small intestine -- 1/3 to 50 Gy and all to 40 Gy.⁶ ||
 * Treatments: || * Resection if the treatment of choice for primary liver tumors and solitary metastatic lesions, if technically feasible.
 * Infusion chemotherapy with implantable pumps can achieve significant palliation.
 * The major factor restricting irradiation to a palliative role is the inability of the liver to tolerate a dose of more than 25 to 30 Gy.
 * Small portions of the liver can receive 50 to 60 Gy without significant long-term morbidity.⁶ ||
 * TD5/5: || Dose to the following organs should be considered:
 * Planning Photos: || [[image:Liver_1_rev.jpg width="320" height="251" caption="Transverse View-Liver Plan"]]



|| 1. Millender L, Roach M. Hepatobiliary Cancer. In: Hansen EK, Roach M. //Handbook of Evidence-based Radiation Oncology,// 1st ed: 241-254. New York, NY: Springer, 2007. 2. eMedicine. Hepatic Cancer. []. Accessed January 18, 2010. 3. Washington CM, Leaver D, eds. //Principles and Practice of Radiation Therapy, 2 //nd ed: 844-847. Philadelphia, PA: Mosby Inc, 2004. 4. Emedtv. Liver Cancer Statistics. []. Accessed January 21, 2010. 5. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer; 2010: 191-199. 6. Chao KS, Perez CA, Brady LW. //Radiation Oncology Managment Decisions//. Lippincott Williams & Wilkins. 2002:393.
 * References**

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