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Forum Name: Liver Diseases

Question: Liver Cancer/Cirrhosis


 visheshsinghvi - Thu Dec 14, 2006 12:34 am

Dear Sir/Mam,

My father aged about 56 years is suffering from Hep. B and is on Adefovir (Hepsera) , recently he had undergone Sonography and MRI which reported as under :

MRI :

" The study shows ultered signal intensity of lvier parenchyma. Focal Lesion measuring 24x21 mm is seen in Segment 6 of right lobe of liver appearing Hypointense in T1W & hyperintense in T2WI with tiny hyper intense focus in T1WI. The lesion shows heterogenous enhancement post contrast study with small non-enhancing areas within. The intra hepatic biliary radicals are not dialated. The prota hepatis is normal, the spleen is normal "

The reports for other organs revealved normal except a small cyst on right kidney.

Sonography :

" Liver is normal in Shape with normal echotexture. There is an approx. 33x41x37 mm S.O.L. with hyoerechoic texture with breakdown with mildly hypoecoic Halo / Cronic(Residual) abscess / Mitotic Lesion- No Clarification "

ONE IMPORTANT THING ONE MONTH AGO ALSO HE HAD UNDERGONE A SONOGRAPHY WHICH REVEALED EVERYTHIN IS NORMAL IN LIVER AND THE VIRAL COUNT FOR HEP. B WAS ALSO UNDER NORMAL RANGE. BUT IN ONE MONTH VIRAL COUNT HAS ALSO INCREASED TO 5.82 AND THE MRI/SONOGRAPHY REVEALED AS ABOVE.

His other Liver Funcition tests like SGOT/SGPT/Albumin/Biliburin /Phosphate are slightly abnormal ranging to 50-100% higher than the normal values

MY FATHER'S CHILD SCORE IS 10.

Request you to guide me on the following points :

1. Whether he is suffering from Liver Cancer , if so can the stage of cancer be found out by the above reports ?

2. Whether he should go for liver transplantation or should go for RFAPI /Chemo Theraphy ?

3. What is the life expentancy in such cases ?

4. Do he continue Hepsera(Adefovir) or switch to Entacavir ?

5. Can this development takes place in only one month as the one month prior sonography revealed everything normal , do you suggest to undergo for retest ?

I know the questions are many but will be highly obliged and grateful if you can answer them ?

Thanks.
 Dr. Safaa Mahmoud - Thu Dec 14, 2006 2:56 pm

User avatar Hello,

An ultrasonographic examination of the liver is an excellent screening tool. But it can not be conclusive whether the lesion is malignant or due to another pathology.

MRIs, especially T2-weighted studies, are particularly good at detecting intrahepatic lesions. T2 W can help in distinguishing hemangiomas from carcinoma as carcinomas are of less intense signal at this level.

The characteristics you have mentioned can not be diagnostic for any pathological cause.

If malignancy is suspected there are other investigations to confirm the nature of this lesion.
Non invasive techniques are available and help in diagnosis.
Helical CT, study provides specific patterns of enhancement that help if differentiating malignant lesions from hemangioma and, to a lesser extent, focal nodular hyperplasia (FNH)

Other investigations include:
Serum AFP a tumor marker known to be high in liver carcinoma.
FNAC a cytological examination from suspicious lesions.

Having a chronic hepatitis B disease and being of old age make the need to exclude malignant nature of the lesion mandatory.

Before taking any decision in the treatment plan, the definitive diagnosis should be reached.
I advise you to follow with his doctor and discuss with him this information.

Keep us updated.
Best regards.
 visheshsinghvi - Sat Dec 16, 2006 8:02 am

Hi Dr. Safaa Mahmoud

Thanks for your reply, the Alfa Feto protein is 98.4 IU/ml the normal values given in the Test Report is as under :

Normal Value 0.5-5.5

Gest Ago in Weeks Normal Values Median (IU/ML)

15 Weeks 16.3-70.7 27.2
16 Weeks 21.2-92.0 35.4
17 Weeks 24.2-105.0 40.3
18 Weeks 27.7-120.0 46.2
19 Weeks 34.5-149.0 57.5
20 Weeks 39.0-170.0 65.5

The doctor here has refused for FNAC or Liver Biopsy as the same may be dangerous because of his Protrombin Time.

Can u further advice me on the questions posted previously like the liver cancer and its stage , which treatment option should we go for Transplant , Resection, Theraphy(Which Therapy) or any other possible treatment

Once again Thanks a lot , expecting reply to above query

Regards,
Vishesh Singhvi


The doctors has [/u]
 Dr. Safaa Mahmoud - Sat Dec 16, 2006 8:46 am

User avatar Hello,

Can you please inform us about the results for her liver function tests (total billirubin,SGPT, SGOT, Albumin, Alkaline phosphatase) as well as the prothrombin time and concentration.
Is her general condition good (her performance status)?

Best regards.
 visheshsinghvi - Sun Dec 17, 2006 1:45 am

Hello Dr. Safaa Mahmaud

Thanks for helping, his(my father's) general condition is good, he goes to office , generally he feels burns in stomach and has got a bit amount of bleeding from his gums and nose in past few days. The frequency of bleeding is only once a day in morning when he wakes up. And the bleeding is also not daily sometimes he does not have bleeding for 2-3 days also.

His liver function test results as on 11.Dec.2006 are as under :

Test Patient Value ( Normal Value)

Serum Bilburin Total 3.2 mg/dl ( 0.0-1.0)

Serum Biliburin Direct 1.7 mg/dl (0.0-0.05)

Serum Biliburin Indirect 1.5 mg/dl ( 0.0-0.3)

Serum Alk. Phosphate 348 U/L ( 60-171)

SGOT 98 U/L ( 0--50)

SGPT 86 U/L ( 0--50)

Serum Protein 8.3 gm/dl ( 6.6.-8.3)

Serum Albumin 3.0 gm/dl (3.5-5.5)

Serum Globumin 5.3 gm/dl ( 2.0-3.5)

A: G Ratio 0.5

The Protrombin Test result is as under as on 11.Dec.2006

Bleeding Time 2.40 MIN. ( Normal 1-3 MIN)

Clotting Time 5.02 MIN. (Normal 3-8)

Protrombin Time

Test 18.1 Sec. (Normal 10-16 Sec.)

Control 13.0 Sec.

INR 1.5

PTTK (Partial Thromboplastin)

Test 39.9 Sec. ( Normal 30-45 Sec.)

Control 32

IMPRESSION : NORMOCYCTIC NORMOCHROMIC BLOOD PICTURE WITH THROMBOCYTOPENIA.

Thanks a lot, please reply.

Best regards,

Vishesh Singhvi
 Dr. Safaa Mahmoud - Wed Dec 20, 2006 8:54 pm

User avatar Hello,

Although the level of (alpha feto proteins) is higher than normal, it is not conclusive for malignancy, in fact in patients with chronic liver disease have high level of this marker but generally less than 400 IU/ml.

Being at high risk for developing HCC ( chronic hepatitis B infection), and his MRI results makes malignant nature of the lesions is to be considered.

However, the decision for further approaches assuming that the lesions represent Hepatic carcinoma, should be taken by an oncologist after complete physical examination and work up evaluating his liver condition and his general medical status.

Surgical resection and liver transplantation are the only chances of cure in patinets with limited disease .

Indications for respectability include tumor size (less than 5 cm) and adequate liver function ( normal billirubin, albumin, etc).

From his results, his liver condition may not make surgery an appropriate approach.

But transplantation is still an option, however, opportunities for liver transplantation are limited thus doctors keep it as second option after surgery.

Other alternative local therapies are radiofrequency ablation, cryoablation, and radiotherapy.

Keep us updated.
Best regards.
 visheshsinghvi - Thu Dec 21, 2006 2:59 am

Hello Dr Safaa Mahmaud
Thanks for help,our doctors here have suggested us for angiography with chemoembolization.what is your opinion inthis regard.Are there any side effects of the same.can you pls suggest us any other tests except liver biopsy and FNSCwhich can confirm the malignancy
can u also pls tell me the maximum span for which the treatment can be delayed.
thanks a lot . please reply
 Dr. Safaa Mahmoud - Thu Dec 21, 2006 6:01 am

User avatar Hello,

Patients with localized (less than 5 cm) tumor but unresectable due to other medical considerations (e.g. cirrhosis), the site of the lesion in the liver or even limited bilateral tumors are candidates for local therapy like:
chemoembolization,
cryosurgery,
percutaneous ethanol injection, or
radiofrequency ablation

Reports indicated survivals equivalent to resection in some early cases.

A randomized trial in patients with cirrhosis and a small hepatocellular carcinomas showed an improved local recurrence-free survival in patients underwent radiofrequency ablation as compared to percutaneous ethanol injections as their
only form of treatment, but overall survival was not changed.(2)

Other approaches like embolization of the hepatic artery with chemotherapy (adriamycin) although result in central tumor necrosis, reduction in tumor size, pain relief, benefits are usually transient. Any interference with arterial blood supply (including infusion chemotherapy) is contraindicated in the presence of portal hypertension, portal vein thrombosis, or clinical jaundice. 3)

Follow up with your doctor is essential, you can discuss with him this information, Direct clinical examination is essential to decide the better approach for each patient.

References:
2) Lencioni RA, Allgaier HP, Cioni D, et al.: Small hepatocellular carcinoma in cirrhosis: randomized comparison of radio-frequency thermal ablation versus percutaneous ethanol injection. Radiology 228 (1): 235-40, 2003. [PUBMED Abstract]


3) A comparison of lipiodol chemoembolization and conservative treatment for unresectable hepatocellular carcinoma. Groupe d'Etude et de Traitement du Carcinome Hepatocellulaire. N Engl J Med 332 (19): 1256-61, 1995. [PUBMED Abstract]

Best regards.
 visheshsinghvi - Tue Jan 02, 2007 6:40 am

Dr. Safaa Mahmoud,

First of all thanks for the reply and sorry for my delay in reverting. Now the doctors are suggesting looking to the Liver Function Tests following course of treatment in order of preference :

1. RFA
2. Transarterial Radio Embolization (Therasphere & Yetrium 90)
3. TACE

Can u please guide me telling what are the side effects and risk factors, success rates in general of these treatments.

Your advices is as valuable as always.

Thanks a lot

Vishesh Singhvi
 visheshsinghvi - Tue Jan 23, 2007 5:54 am

Dear Dr.Safaa Mahmoud,

We have got RF ablation of liver tumors of my father, in the CT scan taken just before the RF ablation doctors told that there are three lesions in Segment IV, VI & VIII segment.

They have abalated lesions in Segment IV & VI , post RF my father's general conditions is ok and there is no bleeding and water in abdomen.

Regarding the third lesion your help is required on following doubts :

1. Recently one week after RF we got my father's ultrasound done which shows that there is no lesion in Segment VIII of Liver . Shall we get another CT Scan/MRI done before taking decision for any treatment .

2. Which test CT Scan/MRI is better for finding whether lesion is present or not ? When it can be done I mean after RF will it be harmful ?

3. If the third lesion is there Doctors are saying that it is very near to lungs for which RF would be difficult, should we go for RF / Chemo Embolization/ Surgery?

Thanks a lot , your opinion counts as always

regards,

vishesh singhvi
 Dr. Safaa Mahmoud - Mon Jan 29, 2007 5:52 pm

User avatar Hello,

Sorry for the delay in replying. Good news that your father has improved on RF.

If I understand well you said these results are obtained by US and A CT Scan or MRI will be done to confirm results.

A very important information while choosing the technique for reevaluation, is the initial one used in patient diagnosis and staging, and as I remember your father MRI showed all the lesions clearly, thus it is reasonable to repeat the MRI study for comparison and reevaluation.

In some countries a multi-phase spiral CT scan is the scan of choice and in others MRI scan is the most preferred.

- As for Chemoembolization versus R, or surgery F this will depend on his general condition, his lab results (liver function tests), and the Scan results.

If it is still possible to treat (the remaining lesion if any) with RF, It will be reasonable approach since he responded well and his general condition was improved on this type of treatment.

Best regards.
Keep us updated.
 visheshsinghvi - Mon Jan 29, 2007 10:40 pm

Hello Dr. Safaa Mahmoud,

Thanks for valuable opinion, the doctors here will do the CT Scan / MRI on 3rd Feb.,2007 , I will update you on the same.

One thing as I mentioned earlier his general condition post RF ablation is good, but after stopping pain killer medicine ( Tramazac 50 mg) he is feeling pain at a particular point in right side of abdomen , the doctor here are saying that sometimes it may happen because of the track they burn along with the tumor and it will go by time.

I wish to know that is something like this is normal (as sometimes the pain becomes unbearable and even by touch of finger tip he feels pain) , he is having no other symptoms of abnormality like fever etc. and his liver functions tests have also improved in comparision to tests done immediately after RF Ablation.

Your advices is as valuable as always.

Thanks a lot

best regards,

Vishesh Singhvi
 visheshsinghvi - Tue Feb 06, 2007 10:40 pm

Dear Doctor,

As discussed earlier last month on 11.01.2006 my father's liver tumors in Seg.IV & VI were ablated by RFA (Radio Frequency Ablation) and now he is having tumor of around 2.3 cms in Seg. VII which has also spread in Seg. IV around 1.8 cms . Doctors are saying this time RFA is not possible as the tumor is very near to lungs . My questions are :

1. Whether RFA is possible ?

2. If not whether we should go for Therashpere treatment ( TARE ) of Chemoembolization (TACE) , his liver functions are elevated albumin < 3 & biliburin > 2.7 and is also having Hep. B and Liver Cirrhosis



Please advice


Thanks a lot

Vishesh Singhvi

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