Hepatic Neoplasms

Gastroenterology (12%) Core Clinical Conditions

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Definition Aetiology Pathophysiology Sign and Symptoms Investigations Management

Hepatic neoplasms, also known as liver tumours or hepatic tumours, refer to abnormal growths that develop in the liver tissue. As one of the largest organs in the body, the liver plays a crucial role in various bodily functions, including metabolism, detoxification, and production of essential proteins. However, like any other organ, the liver is also susceptible to the development of both benign and malignant neoplasms.

1. Chronic viral infections: Chronic viral infections, particularly with hepatitis B virus (HBV) and hepatitis C virus (HCV), have been identified as major risk factors for hepatic neoplasms. These viruses can lead to persistent inflammation in the liver, increasing the likelihood of malignant transformations over time.

2. Cirrhosis: Cirrhosis, a condition characterised by the replacement of normal liver tissue with scar tissue, is strongly associated with the development of hepatic neoplasms. Common causes of cirrhosis include chronic alcohol abuse, non-alcoholic fatty liver disease (NAFLD), chronic viral hepatitis, and autoimmune liver diseases.

3. Environmental factors: Exposure to various environmental factors can contribute to the development of hepatic neoplasms. These include aflatoxins, a type of toxin produced by the fungus Aspergillus that commonly contaminates poorly stored grains and nuts. Occupational exposure to certain chemicals, such as vinyl chloride and arsenic, has also been linked to an increased risk of liver cancer.

4. Non-alcoholic fatty liver disease (NAFLD): NAFLD, characterised by excessive accumulation of fat in the liver, has emerged as a significant risk factor for hepatic neoplasms in recent years. Prolonged NAFLD can progress to non-alcoholic steatohepatitis (NASH), which in turn can lead to the development of liver cancer.

5. Genetic factors: Genetic predisposition plays a role in the development of hepatic neoplasms. Several hereditary conditions, such as hereditary hemochromatosis, alpha-1 antitrypsin deficiency, and Wilson's disease, increase the risk of liver cancer. Additionally, certain gene mutations, such as in the TP53 gene (p53 tumour suppressor gene), can contribute to the development of hepatic neoplasms.

6. Lifestyle factors: Unhealthy lifestyle choices can also have a significant impact on the risk of hepatic neoplasms. Excessive alcohol consumption, obesity, poor diet, and smoking have been associated with an increased likelihood of developing liver cancer.

7. Diabetes: Diabetes, especially type 2 diabetes, has been identified as a risk factor for hepatic neoplasms. The mechanisms underlying this association are not fully understood, but chronic hyperinsulinemia, insulin resistance, and inflammation are believed to contribute to the development of liver tumours.

1. Primary Hepatic Neoplasms: Primary hepatic neoplasms are those that originate within the liver itself. The most common types include hepatocellular carcinoma (HCC) and cholangiocarcinoma. HCCs typically develop from hepatocytes, which are the main functional cells of the liver. Cholangiocarcinomas, on the other hand, arise from the bile ducts within the liver.

2. Secondary Hepatic Neoplasms: Secondary hepatic neoplasms, also known as metastatic liver tumours, occur when cancer cells from other parts of the body spread to the liver. Many cancers can metastasize to the liver, including colorectal, breast, and lung cancers. The liver's rich blood supply and its role in filtering and processing blood make it a common site for metastasis.

3. Pathogenesis: The pathogenesis of hepatic neoplasms involves multiple molecular alterations in liver cells. In primary hepatic neoplasms like HCC, chronic liver inflammation resulting from viral infections or other causes leads to continuous hepatocyte injury, regeneration, and genetic alterations. These genetic changes often involve oncogenes (genes promoting cell growth) and tumour suppressor genes (genes inhibiting cell growth), leading to uncontrolled cell proliferation and tumour

1. Abdominal Pain: Persistent and unexplained pain in the upper right side of the abdomen is a common symptom of hepatic neoplasms. The pain is typically dull or achy but can occasionally be sharp or stabbing.

2. Abdominal Swelling: As liver tumours grow, they can cause the liver to enlarge, leading to abdominal swelling or distension. This swelling can sometimes be accompanied by a feeling of fullness or tightness in the abdomen.

3. Weight Loss: Unexplained weight loss is a general symptom of many cancers, including hepatic neoplasms. If you have unintentionally lost a significant amount of weight without any changes in diet or physical activity, it is important to investigate the underlying cause.

4. Jaundice: Yellowing of the skin, eyes, and mucous membranes (jaundice) is a common symptom of liver problems, including hepatic neoplasms. As liver tumours can obstruct the bile ducts, it can cause a buildup of bilirubin, resulting in jaundice.

5. Changes in Stool and Urine: Liver tumours can affect the production and processing of bile, which can lead to changes in stool colour. You may notice that your stool becomes pale, clay-coloured, or dark. Additionally, hepatic neoplasms can cause the urine to become darker in colour.

6. Fatigue: Persistent fatigue and weakness are common symptoms experienced by individuals with hepatic neoplasms. The liver plays a vital role in various bodily processes, and when affected by tumours, it can lead to energy depletion and fatigue.

7. Loss of Appetite and Nausea: People with hepatic neoplasms may experience a decrease in appetite, leading to weight loss. Nausea and vomiting can also occur due to liver enlargement or compression of surrounding structures.

1. Medical History and Physical Examination: The initial step in diagnosing hepatic neoplasms involves taking a detailed medical history and conducting a comprehensive physical examination. A PA should check risk factors, symptoms, and signs associated with liver tumours.

2. Laboratory Tests: Commonly used blood tests include liver function tests (LFTs), alpha-fetoprotein (AFP) levels, carcinoembryonic antigen (CEA), and carbohydrate antigen 19-9 (CA 19-9).

3. Imaging Studies:

• Ultrasound (US): Ultrasound is often the first-line imaging technique used to evaluate liver tumours due to its wide availability, cost-effectiveness, and ability to identify the location and size of a hepatic mass.

• Computed Tomography (CT) Scan: CT scans provide detailed cross-sectional images of the liver, enabling the evaluation of tumour characteristics such as size, shape, and vascularity. Contrast-enhanced CT scans are particularly useful in establishing the diagnosis.

• Magnetic Resonance Imaging (MRI): MRI is useful in providing detailed information about the liver parenchyma, adjacent structures, and the vascularity of hepatic masses. It can be especially helpful in differentiating malignant from benign tumours.

• Positron Emission Tomography (PET) Scan: PET scans are useful for assessing the metabolic activity of liver lesions, thus aiding in distinguishing between benign and malignant tumours. This imaging modality is often used to evaluate the extent of disease and assess metastasis.

4. Biopsy and Histopathological Examination: A liver biopsy may be performed to confirm the diagnosis of hepatic neoplasm and determine its histopathological classification (e.g., hepatocellular carcinoma, cholangiocarcinoma).

1. Surgical Intervention:

Surgery is often considered the primary treatment for localised hepatic neoplasms. The goal of surgical intervention is to remove the tumour while preserving as much healthy liver tissue as possible.

2. Systemic Therapies:

Systemic treatments are aimed at managing hepatic neoplasms that have spread beyond the liver or those that cannot be adequately treated with local therapies. They include:

• Chemotherapy: Chemotherapy drugs can be administered intravenously or orally to target and kill cancer cells throughout the body. However, the effectiveness of chemotherapy for hepatic neoplasms varies depending on the tumour type.

• Targeted Therapy: Certain liver tumours have specific genetic mutations or overexpressed proteins. Targeted therapies aim to block the growth and spread of cancer cells by selectively targeting these specific alterations.

• Immunotherapy: Immunotherapy enhances the body's immune system to recognize and attack cancer cells. It can be used in specific cases of hepatocellular carcinoma (HCC) that meet certain criteria.

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