common type of primary liver tumor, usually cannot be resected because of rapid growth and metastasis elsewhere.
Other types include cholangiocellular carcinoma and com-bined hepatocellular and cholangiocellular carcinoma. If found early, resection may be possible; however, early detec-tion is unlikely.
Cirrhosis, hepatitis B and C, and exposure to certain chem-ical toxins have been implicated in the etiology of HCC. Cig-arette 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. 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.
Clinical Manifestations
• Early manifestations include pain (dull ache in upper right quadrant, epigastrium, or back), weight loss, loss of strength, anorexia, and anemia.
• Liver enlargement and irregular surface may be noted on palpation.
• Jaundice is present only if larger bile ducts are occluded.
• Ascites develops if such nodules obstruct the portal veins or if tumor tissue is seeded in the peritoneal cavity.
Assessment and Diagnostic Findings
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, ultra-sound, MRI, arteriography, laparoscopy, or biopsy. Leukocyto-sis (increased WBC counts), erythrocytoLeukocyto-sis (increased red blood cell counts), hypercalcemia, hypoglycemia, and hypoc-holesterolemia may also be seen on laboratory assessment. Ele-vated levels of serum alpha-fetoprotein (AFP) may be found.
Medical Management Radiation Therapy
• IV or intra-arterial injection of antibodies tagged with radioactive isotopes that specifically attack tumor-associated antigens
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Cancer of the Liver 173
• Percutaneous placement of a high-intensity source for inter-stitial radiation therapy
Chemotherapy
• Systemic chemotherapy; embolization of tumor vessels with chemotherapy
• An implantable pump to deliver high-concentration chemo-therapy to the liver through the hepatic artery
Percutaneous Biliary Drainage
• Percutaneous biliary 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 Treatment Modalities
• Hyperthermia: Heated by laser or radiofrequency energy is directed to tumors to cause necrosis of the tumors while sparing normal tissue.
• Radiofrequency thermal ablation (tumor cell death from coagulation necrosis).
• Immunotherapy: Lymphocytes with antitumor reactivity are administered.
• Embolization (ischemia and necrosis of the tumor occur).
• For multiple small lesions, ultrasound-guided injection of alco-hol 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 success-fully removed 90% of the liver. The presence of cirrhosis lim-its the ability of the liver to regenerate. In preparation for sur-gery, the patient’s nutritional, fluid, and general physical status are assessed, and efforts are undertaken to ensure the best physical condition possible.
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• Removal of a lobe of the liver is the most common surgical procedure for excising a liver tumor.
• In patients who are not candidates for resection or trans-plantation, ablation of HCC may be accomplished by chem-icals such as ethanol or by physical means such as radiofre-quency ablation or microwave coagulation.
• Removing the liver and replacing it with a healthy donor organ is another way to treat liver cancer.
Nursing Management: Postoperative
See “Nursing Management” under “Cancer” for additional information.
• Assess for problems related to cardiopulmonary involve-ment, vascular complications, and respiratory and liver dys-function.
• Give careful attention to metabolic abnormalities (glucose, protein, and lipids).
• Provide close monitoring and care for the first 2 or 3 days.
• Instruct patient and family about care of the biliary catheter and the potential complications and side effects of hepatic artery chemotherapy.
• Instruct 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.
• Encourage patient to resume activities as soon as possible, but caution patient to avoid activities that may damage the pump.
• Provide reassurance and instructions to patient and family to reduce fear that the percutaneous biliary drainage catheter will fall out.
• Provide verbal and written instructions as well as demon-stration 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.
• Refer patient for home care.
• Collaborate with the health care team, patient, and family to identify and implement pain management strategies and 174 Cancer of the Liver
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Cancer of the Lung (Bronchogenic Carcinoma) 175 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.
For more information, see Chapter 39 in Smeltzer, S. C., Bare, B. G., Hinkle, J. L, & Cheever, K. H. (2010). Brunner and Sud-darth’s textbook of medical-surgical nursing (12th ed.).
Philadelphia: Lippincott Williams & Wilkins.