Hepatocellular Carcinoma

HEPATOCELLULAR CARCINOMA Name: Course: Date: Case Study A 55-year old male patient, married with three children, has had the history of Hepatitis C that is now chronic, and in the recent past that same progressed into cirrhosis. In the 1960s the patient used intravenous drugs and late in the year 1975, he had several transfusion due to trauma, and this increased the risk factor of the hepatitis C (Clinical Key 2013). Due to bleeding of esophageal varices in the year 2001, the condition complicated cirrhosis, however this was later brought under control using the endoscopic banding that proved effective. Two months after the treatment, the patient developed the hepatic encephalopathy and ascites. Early March in 2001, a Computed Tomography Scan (CT), was carried out on the patient, to establish the severity of the condition. The CT scan showed the patient had a mass lesion on his liver in segment 7, within the dimensions of 7×7.4×6.8 in centimetres. After a period of one month, another CT scan was undertaken on the patient, from which it was established that the mass lesion had developed further to 11.5×12.3×10.5cm. The patient’s serum alpha-fetoprotein (AFP) was also established to have risen above 17,000ng/mL. In May of 2001, the patient was put under Chemoembolization using adriamycin, mitomycin as well as carboplatinum. By late September the same year, the CT scans indicated that the diameter of the mass has significantly reduced by 3 cm within segment 7. The AFP values too had reduced considerably compared to previous readings. In December of the same year, the patient underwent orthotopic transplant of the liver and the explants indicated that the cirrhosis was advanced and that there was hepatocellular carcinoma which was residual according to the histological evidence. Further Chemoembolization was administered on the patient, and after the second surgery, there were no residual hepatocellular carcinoma with regard to the histological evidence. Three months after the second liver transplant, chemotherapy was dropped, and the patient was put under 7 mg b.i.d. tacrolimus as well as 16mg q.d of medol, which followed after the patient has several counts of acute rejections. Although the patient was initially feeling fine, he was started on insulin after developing diabetes (Axelrod 2012). When his liver was examined again, there was evidence of grade 3 chronic hepatitis C and some mild signs of rejection. Three months later the patient was diagnosed with recurrent Hepatocellular carcinoma after a liver biopsy, and was now experiencing diarrhoea and was icteric. In the month that followed the patient deteriorated fast and finally succumbed. Anatomy of the liver At the weight of around 3 pounds which translates to around 1.66 kg in humans, the liver is the second largest organ in the human body, after the human skin, which covers the entire body making it the largest organ. However, within the human body the liver is the largest gland. It is reddish brown in colour, and generally meaty with a more or less triangular shape, sitting on the right upper side of the cavity in the abdomen. To touch, the liver feels rubbery, which is due to the fact that the liver is made of soft tissues that are interconnectivity and form a capsule3. Reinforcing this capsule is the peritoneum in the abdominal cavity, which forms its first layer of protection (Wright, 2013). Part of the peritoneal membrane acts as ligaments that connect to the right and the left triangular ligaments, falciform ligament and coronary ligaments (Jonathon, Hussain, Adusumilli and Marrero 2008, 328). The liver’s central superior part is connected to the diaphragm by the coronary ligament. While the superior right and the left part of the liver are connected to the diaphragm by the right and left triangular ligaments. The falciform ligament then connects it to the umbilicus, by running across the anterior edge and the inferior border from the diaphragm12. Within the human body, the liver is protected from injuries and held in place by the rib cage. The main features include the right, left, quadrate and caudate lobes while the gall bladder sits at the bottom where it aligns with the pancrease and the intestine. The right and the left lobes stand out as they are the largest of the four lobes and failciform ligament separates them (Axelrod,2012). While the left lobe is tapered, it is smaller than the right lobe by about 5-6 times. On the right lobe extends the caudate lobe on the posterior side, while the much inferior quadrate lobe extends from the right lobe on the posterior side and raps around the gall bladder. The liver sits right below the diaphragm and above the stomach and the right kidney. The lobes are formed of thousands of the lobules, which then connects to the small ducts. These small ducts are the same ones that connect up to form the hepatic duct in a binary tree shape. The lobules, which are hexagonal in shape, are the actual functional units in the liver. Six hepatic portal veins and six hepatic arteries surround the central vein of each of the lobule (Medline Plus, 2013). These blood vessels are also connected to other tiny tubes that are referred to as the sinusoids. These sinusoids pass through the Kupffer and Hepatocytes in the liver. The Kupffer cells are responsible for the breakdown of the worn out cells while the Hepatocytes carryout majority of functions, such as storage, bile production, metabolism and digestion. They are formed of millions of metabolic cells which are the hepatic cells. Bile is carried to the right lobe from the left lobe through the hepatic ducts7. When the hepatic ducts join up with the cystic ducts that are found at the gall bladder, they all form the bile duct, which moves the bile from the liver to the duodenum in the small intestine. Connected to the liver is the two blood vessels which are referred to as the portal vein and the hepatic artery. It is the hepatic artery that carries blood from the aorta of the heart. The portal vein on the other hand carries blood from the entire gastrointestinal tract, the pancreas and the spleen. Usually the blood that comes from the gastrointestinal tract contains nutrients that gas been obtained from the digestion process. As such one of the liver’s main and vital functions is filtering out the blood as it comes in from the digestive and out into the body (Jonathon, Hussain, Adusumilli and Marrero 2008, 320). Hepatocellular Carcinoma Pathology Hepatic carcinogensis experiments and humans studies indicate that the Hepatocellular Carcinoma (HCC) is actually a progression of stages, where dysplastic nodules develop from cirrhosis and eventually to the tumors. While the age of the persons that are diagnosed with HCC may vary from country to the next, the most common affected is around the 50 years mark. Countries that have shown a high rate of the tumours include Asia and Africa however, very rare in the United States as well as the other western countries such as Europe. Majority of the countries that have a high prevalence for the cancer, also have a history with chronic hepatitis among other liver diseases. HCC accounts for most of the cases of liver cancer, and is most prevalent in men than it is in women. Metastatic liver cancer is also related, but differs from HCC in that, it starts in other organs such as the colon or the breast and then spreads towards the liver (Kondo 2009, 19). Unlike other diseases, this cancer shows the symptoms in the late stages of development and most of the other time it is asymptomatic. The prognosis for the diseases is quite poor and less than 5% of patients diagnosed survive for more than two years. While the treatment options may vary from one patient to the next, the most common factors that are considered during these treatments are the size of the tumour, the stage and the grade (Medline Plus 2013). Where the tumour has a high grade, the prognosis tends to be very poor, such that the patients last up to a few months of diagnosis. If the grade is low, however the prognosis improves, and patients may live for years without noticing any of the symptoms. Risk factors Majority of the cases, are triggered by liver scarring, which is generally referred to as cirrhosis. On the other hand, liver cirrhosis may be caused by a myriad of factors which include; both hepatitis B and C, iron overloading in the body, aflatoxins, hemochromatosis, diabetes type 2, alcoholism and chronic liver inflammation among others. These risk factors widely vary among the various countries and regions. In parts of Asia such as china, there are prevalent cases of hepatitis B which in most of the cases is chronic (Tan, Low, and Thng 2011, 3). As such, this is the most common causal agent of the HCC in China and the surrounding regions. In the united state and the majority of the western countries, vaccination against the hepatitis strain is quite high and thus very few patients can be diagnosed with the same. This therefore means that the majority of the cases of HCC are caused by cirrhosis which directly relates to the alcoholism cases. The patient in the case study had developed the cancer in the liver after having a long history with hepatitis C. In addition, cirrhosis also complicated the patient...