Dr. Keith E. Stuart is a medical oncologist specializing in the study and treatment of cancers involving the gastrointestinal tract, with a special interest in tumors involving the liver. He was educated at Harvard University (graduating magna cum laude) and Albert Einstein College of Medicine and did his medical training at the New England Deaconess Hospital.
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
Imaging studies play a very important role in the diagnosis of liver
cancer. A good
study can provide information as to the size of the tumor, the number of tumors,
and whether the tumor has involved major blood vessels locally or spread outside
of the liver. There are several types of studies, each having its merits and
disadvantages. In practice, several studies combined often complement each
other. On the other hand, a plain X-ray is not very helpful, and therefore, is
not routinely done in the diagnostic work-up of liver cancer. Further, there is no
practical role for nuclear medicine scans of the liver and spleen in the workup
for liver cancer. Such scans are not very sensitive and they provide no additional
information beyond that provided by the other (ultrasound, CT, and MRI) scans.
Ultrasound examination is usually the first study ordered if liver cancer is suspected
in a patient. The accuracy of an ultrasound depends very much on the technician
and radiologist who perform the study (operator dependent). Studies from Japan
and Taiwan report that ultrasound is the most sensitive imaging study for
diagnosing and characterizing liver cancer. But in these studies,
highly experienced individuals performed the scans and spent up to one hour
scanning each patient suspected of having liver cancer. An ultrasound has the advantages
of not requiring intravenous contrast material and not involving radiation.
Moreover, the price of an ultrasound is quite low as compared to the other types
of scans.
Computerized axial tomography (CT scan) is a very common study used in the
U.S. for the workup of tumors in the liver. The ideal CT study is a
multi-phase, spiral CT scan using oral and intravenous contrast material.
Pictures are taken in three phases:
Without intravenous contrast
With intravenous contrast (enhanced imaging) that highlights the arterial system (arterial phase)
When the contrast is in the venous phase
The pictures are taken at very frequent intervals (thin slices) as the body
is moved through the CT scanner. Many radiologists use a specific protocol that
determines how the contrast is infused in relation to how the pictures are
taken. Therefore, CT is much less operator-dependent than is ultrasound.
However, CT is considerably more expensive. Furthermore, CT requires the use of
contrast material, which has the potential risks of an allergic reaction and
adverse effects on kidney function.
There are several variations to CT scanning. For example, in a CT angiogram,
which is a highly invasive (enters a part of the body) study, intravenous
contrast is selectively infused through the hepatic artery (artery to the
liver). The purpose is to highlight the vessels for better visualization of them
by the CT scan. Also, in Japan, an oily contrast material called Lipiodol, which
is selectively taken up by liver cancer cells, has been used with CT. The purpose of this
approach is to improve the sensitivity of the scan. That is to say, the goal is
to increase the percentage of abnormal CT scans in patients who have liver
cancer.
Magnetic resonance imaging (MRI) can provide very clear images of the body.
Its advantage over CT is that MRI can provide sectional views of the body in
different planes. The technology has evolved to the point that the newer MRIs
can actually reconstruct images of the biliary tree (bile ducts and gallbladder)
and of the arteries and veins of the liver. (The biliary tree transports bile
from the liver to the duodenum, the first part of the intestine.) MRI studies
can be made even more sensitive by using intravenous contrast material (for
example,
gadolinium).
MRI scans are expensive and there is tremendous variability in the quality of the images. The quality depends on the age of the machine and the ability of the patients to hold their breath for up to 15 to 20 seconds at a time. Furthermore, many patients, because of claustrophobia, cannot tolerate being in the MRI scanner. However, the current open MRI scanners generally do not provide as high quality images as the closed scanners do. MRI sometimes finds lesions that are smaller than can be seen on a CT scan and can tell the radiologist more about the blood vessel (vascular) characteristics of the tumor; more importantly, there is no radiation risk, which becomes important if the screening test is to be repeated many times over a person's lifetime.
Advances in ultrasound, CT, and MRI technology have almost eliminated the need for angiography. An angiography procedure involves inserting a catheter into the femoral artery (in the groin) through the aorta, and into the hepatic artery, the artery that supplies blood to the liver. Contrast material is then injected, and X-ray pictures of the arterial blood supply to the liver are taken. An angiogram of liver cancer shows a characteristic blush that is produced by newly formed abnormal small arteries that feed the tumor (neovascularization).
Another potential test used for many other cancers is a PET (positron emission tomography) scan, which involves the injection of radioactive sugar to light up actively growing cells, as in cancers. However, this is not very useful in liver cancer.
What, then, is the best imaging study for diagnosing liver cancer? There is no simple
answer. Many factors need to be taken into consideration. For example, is the
diagnosis of liver cancer known or is the scan being done for screening? What is the
expertise of doctors in the patient's area? What is the quality of the
different scanners at a particular facility? Are there economic considerations?
Does the patient have any other conditions that need to be considered, such as
claustrophobia or kidney impairment? Does the patient have any hardware, for
example, a
pacemaker or metal prosthetic device? (The hardware would make doing an MRI
impossible.)
If you live in Japan or Taiwan and have access to a radiologist or
hepatologist with expertise in ultrasound, then it may be as good as a CT scan.
Ultrasound is also the most practical (easier and cheaper) for regular screening
(surveillance). In North America, a multiphase spiral CT scan is probably the
most accurate type of scan. However, for patients with impaired renal function
or who have access to a state-of-the-art MRI scanner, the MRI may be the
diagnostic scan of choice. Finally, keep in mind that the technology of
ultrasound, CT, and MRI is ever evolving with the development of better machines
and the use of special contrast materials to further characterize the tumors.
Abdominal pain is pain in the belly and can be acute or chronic. Causes include inflammation, distention of an organ, and loss of the blood supply to an organ. Abdominal pain can reflect a major problem with one of the organs in the abdomen such as the appendix, gallbladder, large and small intestine, pancreas, liver, colon, duodenum, and spleen.
Cirrhosis of the liver refers to a disease in which normal liver cells are replaced by scar tissue caused by alcohol and viral hepatitis B and C. This disease leads to abnormalities in the liver's ability to handle toxins and blood flow, causing internal bleeding, kidney failure, mental confusion, coma, body fluid accumulation, and frequent infections. Symptoms include yellowing of the skin, itching, and fatigue.
Hepatitis C is an inflammation of the liver due to the hepatitis C virus (HCV), which is usually spread by
blood transfusion, hemodialysis, and needle sticks, especially with intravenous
drug abuse. Chronic hepatitis C may be treated with interferon, usually in combination with anti-virals.
Cholesterol is naturally produced by the body, and is a building block for cell membranes and hormones. Low-density lipoprotein (LDL) cholesterol is the "bad" cholesterol, conversely, high-density lipoprotein (HDL) cholesterol is the "good" cholesterol. High cholesterol treatment includes lifestyle changes (diet and exercise), and medications such as statins, bile acid resins, and fibric acid derivatives.
Jaundice is a yellowish staining of the skin and whites of the eyes (sclerae) with bilirubin, the pigment found in bile. Jaundice can be an indicator of liver or gallbladder disease, or it may result from the rupture of red blood cells (hemolysis).
Alcoholism is a disease that includes alcohol craving and continued drinking despite repeated alcohol-related problems, such as losing a job or getting into trouble with the law.
The hepatitis B virus is a unique, coated DNA virus belonging to the Hepadnaviridae family of viruses. The course of the virus is determined primarily by the age at which the infection is acquired and the interaction between the virus and the body's immune system. Successful treatment is associated with a reduction in liver injury and fibrosis (scarring), a decreased likelihood of developing cirrhosis and its complications, including liver cancer, and a prolonged survival.
Ascites, the accumulation of fluid in the abdominal cavity is most commonly caused by cirrhosis of the liver. Some of the other causes of ascites include portal hypertension, congestive heart failure, blood clots, and pancreatitis. The most common symptoms include increased abdominal girth and size, abdominal bloating, and abdominal pain. Treatment depends on the cause of ascites.
Polycythemia (elevated red blood cell count) causes are either primary (aquired or genetic mutations) or secondary (diseases, conditions, high altitude). Treatment of polycythemia depends on the cause.
Cancer is a disease caused by an abnormal growth of cells, also called malignancy. It is a group of 100 different diseases, and is not contagious. Cancer can be treated through chemotherapy, a treatment of drugs that destroy cancer cells.
Nonalcoholic fatty liver disease (NAFLD) refers to a wide spectrum of liver disease ranging from simple fatty liver (steatosis), to nonalcoholic steatohepatitis (NASH), to cirrhosis (irreversible, advanced scarring of the liver). All of the stages of NAFLD have in common the accumulation of fat (fatty infiltration) in the liver cells (hepatocytes).
Insulin resistance is the diminished ability of cells to respond to the action of insulin in transporting glucose (sugar) from the bloodstream into muscle and other tissues. Causes of insulin can include conditions such as stress, obesity, metabolic syndrome, and steroid use. Some of the risk factors for insulin resistance include fatty liver, heart disease, strokes, peripheral vascular disease, high cholesterol, and smoking. Treatment for insulin resistance are lifestyle changes and if necessary, medication.
Hepatitis is most often viral, due to infection with one of the hepatitis viruses (A, B, C, D, E, F (not confirmed), and G) or another virus (such as those that cause infectious mononucleosis, cytomegalovirus disease). The main nonviral causes of hepatitis are alcohol and drugs. Many patients infected with hepatitis A, B, and C have few or no symptoms of illness. For those who do develop symptoms of viral hepatitis, the most common are flu- like symptoms including: loss of appetite, nausea, vomiting, fever, weakness, tiredness, and aching in the abdomen. Treatment of viral hepatitis is dependant on the type of hepatitis.
Hereditary hemochromatosis (iron overload) is an inherited disorder in which there is excessive accumulation of iron in the body. Individuals may have no symptoms or signs, or they can have severe symptoms and signs of iron overload. The most effective treatment for hemochromatosis is therapeutic phlebotomy.
Primary Biliary Cirrhosis is a chronic disease characterized by progressive inflammation and destruction of small bile ducts within the liver. The bile ducts transport bile from the liver to the intestine for the absorption of fat and elimination of waste products. The causes of Primary Biliary Cirrhosis may involve autoimmunity, infection, or genetic predisposition, acting alone or in combination. There are many medications and treatment options available for those with this and other associated diseases of Primary Biliary Cirrhosis.
The liver is the largest solid organ in the body, and is actually an gland. The liver has a wide variety of critical functions such as manufacturing proteins and metabolizing fats and carbohydrates. The liver also eliminates harmful biochemical waste products from the body (alcohol, drugs, toxins). The liver secretes bile that aids in digestion. Examples of diseases of the liver include cirrhosis, hepatitis, cancer, and fatty liver. Symptoms of liver disease include bleeding, easy bruising, edema, fatigue, and jaundice.
Mold exposure may cause symptoms in people who are sensitive to molds. Symptoms of mold allergy include sneezing, runny nose, wheezing, coughing, redness of the eyes, and rash. Prevent mold growth by keeping indoor humidity low, between 30%-50%, using bathroom fans when showering, repairing plumbing leaks quickly, and using an air conditioner during humid seasons.
Primary sclerosing cholangitis (PSC) is a chronic, progressive disease of the bile ducts that channel bile from the liver into the intestines. There is an association between primary sclerosing cholangitis and ulcerative colitis and Crohn's disease. Symptoms of primary sclerosing cholangitis include abnormal liver blood tests, itching, fatigue, and jaundice. Primary sclerosing cholangitis is treated with medications and in some cases, liver transplant.
Anabolic steroids are synthetic substances that are related to testosterone and promote skeletal muscle growth and the development of male sexual characteristics in both men and women. In the 1930s, it was discovered that anabolic steroids could promote skeletal muscle growth in lab animals, which lead to anabolic steroid abuse by bodybuilders and weight lifters.
Digestion is the complex process of turning food you eat into the energy you need to survive. The digestive process also involves creating waste to be eliminated, and is made of a series of muscles that coordinate the movement of food.
Alpha-1 antitrypsin deficiency is an inherited disorder that may cause liver and lung disease in adults. Signs and symptoms include shortness of breath, wheezing, weight loss, respiratory infections, fatigue, vision abnormalities. Advanced lung disease from alpha-1 antitrypsin deficiency include emphysema. Liver damage from alpha-1 antitrypsin deficiency causes a swollen abdomen, swollen legs or feet, and jaundice.
Hepatitis A and hepatitis B are the two most commnon viruses that infect the liver. Hepatitis A and Hepatitis B can be prevented and treated with immunizations (vaccinations) such as Havrix, Vaqta, Twinrix, Comvax, Pediarix, and hepatitis b immune globulin (HBIG).
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