Hepatic tumors may be malignant or benign. Benign liver tumors were uncommon until oral contraceptives were in widespread use. Now benign liver tumors such as hepatic adenomas occur most frequently in women who are in their reproductive years and taking oral contraceptives. Few cancers originate in the liver. Primary liver tumors usually are associated with chronic liver disease, hepatitis B and C, and cirrhosis. Hepatocellular carcinoma (HCC), the most common type of primary liver tumor, usually cannot be resected because of rapid growth and metastasis elsewhere. Other types include cholangiocellular carcinoma and combined hepatocellular and cholangiocellular carcinoma. If found early, resection may be possible; however, early detection is unlikely.
Cirrhosis, chronic infection with hepatitis B and C, and exposure to certain chemical toxins have been implicated as causes of HCC. Cigarette smoking, especially when combined with alcohol use, has also been identified as a risk factor. Other substances that have been implicated include aflatoxins and other similar toxic molds that can contaminate food such as ground nuts and grains and may act as co-carcinogens with hepatitis B. Metastases from other primary sites, particularly the digestive system, breast, and lung, are found in the liver 2.5 times more frequently than tumors due to primary liver cancers.
Diagnosis is made on the basis of clinical signs and symptoms, history and physical examination, and results of laboratory and x-ray studies, PET scans, liver scans, CT scans, ultrasound, MRI, arteriography, laparoscopy, or biopsy. Leukocytosis, erythrocytosis, hypercalcemia, hypoglycemia, and hypocholesterolemia can also be seen on laboratory assessment. Elevated levels of serum alpha-fetoprotein (AFP) and carcinoembryonic antigen (CEA) may be found.
Radiation Therapy
- IV or intra-arterial injection of antibodies tagged with radioactive isotopes that specifically attack tumor-associated antigens
- Percutaneous placement of a high-intensity source for interstitial radiation therapy
Chemotherapy
- Systemic chemotherapy; embolization of tumor vessels with chemotherapy
- An implantable pump to deliver high-concentration chemotherapy to the liver through the hepatic artery in cases of metastatic disease
Percutaneous Biliary Drainage
- Percutaneous biliary or transhepatic drainage is used to bypass biliary ducts obstructed by the liver, pancreatic, or bile ducts in patients with inoperable tumors or those who are poor surgical risks.
- Complications include sepsis, leakage of bile, hemorrhage, and reobstruction of the biliary system.
- Observe patient for fever and chills, bile drainage around the catheter, changes in vital signs, and evidence of biliary obstruction, including increased pain or pressure, pruritus, and recurrence of jaundice.
Other Nonsurgical Treatments
- Laser hyperthermia has been used to treat hepatic metastases.
- Heat has been directed to tumors to cause necrosis of the tumors while sparing normal tissue through several methods: radiofrequency thermal ablation inserted into the liver tumor and radiofrequency energy, which causes tumor cell death from coagulation necrosis.
- Immunotherapy may be used: Lymphocytes with antitumor reactivity are given.
- Transcatheter arterial embolization results in ischemia and necrosis of the tumor.
- For multiple small lesions, ultrasound-guided injection of alcohol promotes dehydration of tumor cells and tumor necrosis.
Surgical Management
Hepatic resection can be performed when the primary hepatic tumor is localized or when the primary site can be completely excised and the metastasis is limited. Capitalizing on the regenerative capacity of the liver cells, surgeons have successfully removed 90% of the liver. The presence of cirrhosis limits the ability of the liver to regenerate. In preparation for surgery, the patient's nutritional, fluid, and general physical status are assessed, and efforts are undertaken to ensure the best physical condition possible.
- Lobectomy: Removal of a lobe of the liver is the most common surgical procedure for excising a liver tumor.
- Local ablation: For patients who are not candidates for resection or transplantation, ablation of HCC may be accomplished by chemicals such as ethanol or by physical means such as radiofrequency ablation or microwave coagulation.
- Immunotherapy: Interferon may be used after surgical resection for HCC to prevent recurrence of the lesion related to hepatitis B or C.
- Liver transplantation: Removing the liver and replacing it with a healthy donor organ is another way to treat liver cancer.
Outline
Nursing Management: Postoperative
See “Nursing Management” under Cancer for additional information.
- Provide close monitoring and care for the first 2 or 3 days.
- Assess for problems related to cardiopulmonary involvement, vascular complications, and respiratory and liver dysfunction.
- Monitor metabolic abnormalities (glucose, protein, and lipids).
- Instruct patient and family about care of the biliary catheter and the potential complications and side effects of hepatic artery chemotherapy.
- Educate patient about the importance of follow-up visits to permit frequent checks on the response of patient and tumor to chemotherapy, condition of the implanted pump site, and any toxic effects.
- Refer patient for home care.
- Encourage patient to resume routine activities as soon as possible, while cautioning about activities that may damage the pump or site.
- Provide reassurance and instruction to patient and family to reduce fear that the percutaneous biliary drainage catheter will fall out.
- Provide verbal and written instructions as well as demonstration of biliary catheter care to patient and family; instruct in techniques to keep catheter site clean and dry, to assess the catheter and its insertion site, and to irrigate the catheter to prevent debris and promote patency.
- Collaborate with the health care team, patient, and family to identify and implement pain management strategies and approaches to management of other problems: weakness, pruritus, inadequate dietary intake, jaundice, and symptoms associated with metastasis.
- Assist patient and family in making decisions about hospice care and initiate referrals. Encourage patient to discuss end-of-life care preferences with family and health care providers.
For more information, see Chapter 49 in Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth's textbook of medical-surgical nursing (14th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.