Programs and Services
Diseases of the Liver and Treatment Options
Many diseases and disorders can cause the liver to function improperly or stop functioning. These include liver tumors, cirrhosis and hepatitis. Jaundice is often the first, and sometimes the only sign of liver disease. Jaundice is a yellow discoloration of the skin and whites of the eye due to high levels of bile pigment (bilirubin) in the blood.
Liver TumorsBecause the liver is made up of several different types of cells, several types of tumors can form within the liver. Some of these are cancerous and some are benign (not cancerous). These tumors have different causes and are treated differently.
Benign (non-cancerous) Liver Tumors
- Hemangioma — the most common benign tumor of the liver. The tumors are abnormal blood vessels that grow by dilating. Most of these tumors do not cause symptoms and need no treatment. Some may bleed or cause pain and need to be removed.
- Focal nodular hyperplasia (FNH) — a benign growth of several cell types — hepatocytes (liver cells), bile ductules (small ducts) and Kupffer cells (specialized cells that ingest or destroy bacteria and debris in the liver). These tumors do not bleed or become cancerous. The tumors can be removed if they are very large, cause symptoms, or are located in unfavorable areas of the body where growth would be problematic.
- Adenoma — a benign growth of hepatocytes (liver cells). Many of these tumors do not cause symptoms, but they can rupture and bleed and can become cancerous. Therefore, this tumor is usually removed when it is found.
- Cyst — a cavity in the liver that contains fluid. Single or multiple liver cysts are common, especially with advancing age. While liver cysts are usually benign, a cyst may become enlarged or infected and require treatment because of symptoms.
- Other types of benign tumors include hamartomas, regenerative nodules and lipomas, which do not require treatment.
Malignant Liver Tumors
Cancer that arises within the liver (vs. having spread to the liver from other sites) is called primary liver cancer.
Two forms of primary liver cancer are:
Cancer that has spread to the liver from other parts of the body — such as the lungs, breasts or colon — is called secondary or metastatic liver cancer. When cancer is found in the liver, most of the time it has spread to the liver from elsewhere in the body (i.e., colorectal, carcinoid and other neuroendocrine tumors). Common sources of metastatic tumors are colon/rectum, neuroendocrine (i.e., carcinoid and others), breast, stomach, pancreas and others.
- Hepatocellular carcinoma — a cancer that begins in the hepatocytes (liver cells). While this form of cancer is also referred to as “hepatoma,” the correct name is hepatocellular carcinoma. Approximately three out of four primary liver cancers are of this type. This type of tumor normally arises in a diseased liver and has become more prevalent in the United States due to the spread of the hepatitis C virus.
- Cholangiocarcinoma — cancer that starts in the bile duct, the tube that connects the liver and the gallbladder to the small intestine. About 10 percent to 20 percent of primary liver cancer is of this type. These tumors are classified as:
- Extrahepatic (the part of the bile duct outside the liver) or
About 90 percent of these tumors are extrahepatic tumors, and about 10 percent are intrahepatic tumors.
Treatment of Liver TumorsTreatment of liver tumors depends on the type of tumor, the number of tumors, and their size and location. Treatment may be local or systemic.
- Liver-directed treatment is done when the tumor is confined to the liver and cancer has not been found elsewhere in the body.
- Systemic treatment (chemotherapy) is used to kill cancer cells throughout the body.
What to Expect After Liver Surgery — Checklist for Patients
- Resection (surgical removal of liver tumors)
Many patients are candidates for surgical removal of their liver tumors (resection), which provides the best chance for a cure. The natural ability of the liver to regenerate (grow back) is used in determining a patient’s suitability for surgery.
Some patients may not be eligible for surgery because their cancer has spread to other organs that are untreatable, or the size or location of the tumor prevents safe removal. In other cases, cirrhosis or other medical conditions may make liver surgery unsafe. A multidisciplinary approach to treatment of liver tumors supports the decision to perform surgery vs. pursuing other types of treatment.
Liver surgery may be performed using laparoscopy (minimally invasive surgery) or open surgical methods. The choice depends on the type and location of the tumor and the presence/absence of cirrhosis or a fatty liver. Froedtert & The Medical College surgeons are highly skilled in performing a variety of open and minimally invasive surgeries to treat liver disease.
To remove a tumor in the liver, surgeons remove the tumor with a margin of normal liver. Surgical procedures include:
- Segmentectomy — removal of a defined segment of the liver
- Lobectomy — removal of a lobe of the liver
- Trisegmentectomy — an extensive surgery that can remove up to 80 percent of liver tissue
- Biopsy — a procedure in which small pieces of liver tissue are removed for testing to see if cancer cells are present. A tissue sample may be obtained in two ways:
- Needle biopsy — local anesthesia is used to numb the skin where a small incision is made. A needle is inserted through the skin and into the liver, where a tissue sample is obtained. This is done with ultrasound or CT guidance.
- Open biopsies — These types of biopsies are usually done as part of another surgical procedure. The surgeon may surgically remove a small wedge of liver tissue for the tissue sample, or a core biopsy may be done. A core biopsy involves inserting a small hollow needle into the liver. The needle is advanced within the cell layers to remove a sample or core. A core biopsy is typically performed under imaging guidance.
- Liver Transplant — a liver transplant is the surgical replacement of a diseased liver with a healthy donor liver. A transplant may be considered when a person has a high risk of death from liver disease (end-stage liver disease). A variety of liver diseases can lead to end-stage liver disease and the need for a transplant. The Froedtert & The Medical College Liver Transplant Program, established in 1983, performs 30 to 40 liver transplants each year.
- Surgical ablation (kills the liver tumor by freezing or heating the tumor until cell death occurs)
- Cryoablation — a procedure that kills a tumor by freezing it. A metal tube is placed into the tumor while the surgeon watches the process with ultrasound. The tube is cooled to -190° C (-360° F) and an ice ball engulfs the tumor, resulting in the death of the tumor cells.
- Radiofrequency ablation — a procedure that uses heat to destroy a tumor. A needle electrode is placed in the tumor under the guidance of imaging such as ultrasound or computed tomography (CT). A radiofrequency current is passed through the electrode to heat the tumor tissue near the needle tip and ablate or destroy it. The heat also closes up small blood vessels, minimizing the risk of bleeding.
Both of these procedures can be done as part of an open surgical procedure, a laparoscopic (minimally invasive) procedure, or as an outpatient procedure in the Radiology Department.
- Hepatic artery infusion — in this procedure, a pump that will hold a chemotherapy drug is implanted under the skin. A catheter (a thin tube) is placed into the hepatic (liver) artery. The pump is filled with a chemotherapy drug and connects to the catheter, so chemotherapy can be infused directly into the liver over a set period of time. This process lessens the side effects of systemic chemotherapy that affects the whole body. Hepatic artery infusion is an option in selected patients and is used with surgery or ablation to treat cancer that has spread to the liver.
Interventional Radiology TreatmentsInterventional radiologists specialize in performing minimally invasive procedures using imaging guidance, such as CT scanners, ultrasound and fluoroscopy (a “live” X-ray) to diagnose and treat conditions inside the body.
Interventional radiologists perform the following local treatments:
- Radiofrequency Ablation — a procedure that uses heat to destroy a tumor. A needle electrode is placed in the tumor under the guidance of imaging such as ultrasound or computed tomography (CT). A radiofrequency current is passed through the electrode to heat the tumor tissue near the needle tip and ablate or destroy it. The heat also closes up small blood vessels, minimizing the risk of bleeding. (This procedure may also be performed during liver surgery.)
- Cryoablation — a procedure that kills a tumor by freezing it. A metal tube is placed into the tumor while the surgeon watches the process with ultrasound. The tube is cooled to -190° C (-360° F) and an ice ball engulfs the tumor, resulting in the death of the tumor cells. (This procedure may also be performed during liver surgery.)
- Chemoembolization — a method of delivering chemotherapy directly into a tumor. A catheter is placed in a groin artery and guided into the artery that supplies blood to the tumor. A potent dose of a chemotherapy drug is infused through the catheter to the tumor, and the artery section is plugged to stop further blood flow to the area. This procedure may be done once or several times over several years, if indicated.
- Portal vein embolization (PVE) — a procedure that can make surgery possible in an otherwise inoperable liver. PVE is done in advance of surgery to shrink the diseased (cancerous) part of the liver that will be removed and cause the remaining liver to hypertrophy (grow). To do this, the portal vein on one side of the liver is blocked, causing the lobe on that side to shrink. Blocking the portal vein diverts blood flow to the opposite side of the liver, triggering that side to grow. This increases the volume and function of the “good” part of the liver that will remain after surgery. In a patient with metastases (cancer that has spread from another part of the body) in an otherwise healthy liver, the good part of the liver may grow enough in a few weeks to make surgery possible.
- TheraSphere® embolization — a procedure in which radioactive material is delivered directly to an inoperable liver tumor. This allows delivery of a much higher dose of radiation in a single administration, with minimal effect to the healthy tissue surrounding the tumor.
Froedtert & The Medical College are one of only about 30 hospitals in the United States using TheraSphere®. In an outpatient procedure, a catheter is placed into the femoral artery at the groin. The catheter is guided with fluoroscopy (a type of x-ray) to the hepatic (liver) artery and into the branch that feeds the tumor. Tiny radioactive glass beads are infused through the catheter into the blood that supplies the tumor. The blood carries the beads directly into the tumor, with minimal injury to surrounding tissue. This allows a more concentrated dose of radiation precisely where it’s needed.
Radiation OncologyExternal beam radiation uses high-energy rays to kill cancer cells and shrink tumors. Radiation may be used on its own to treat localized cancer that cannot be removed with surgery or treated by other means.
Chemotherapy is the use of drugs to kill cancer cells. These drugs work by interfering with the growth of cancer cells, leading to cell death. Chemotherapy is often used with other treatments such as radiation and/or surgery. As a systemic treatment, chemotherapy drugs flow through the bloodstream to nearly every part of the body.
Medical oncologists at Froedtert & The Medical College work with other team members to determine if chemotherapy is an appropriate treatment option for a patient.
- People with colon cancer that has spread to the liver (secondary liver cancer) often receive chemotherapy as part of their treatment. While secondary liver cancer cannot be cured with chemotherapy, it may slow the growth of the cancer and reduce symptoms.
- Chemotherapy is sometimes recommended to try to shrink a tumor that cannot be removed with surgery in order to control symptoms or possibly allow surgery to remove the tumor after shrinking it.
Cirrhosis Cirrhosis is an irreversible scarring of the liver that may be caused by many conditions, including:
- Viral hepatitis B and C
- Excessive use of alcohol
- Non-alcoholic fatty liver disease (the build-up of excess fat in the liver cells)
- Bile duct injuries
- Metabolic conditions including iron and copper overload (a buildup of iron or copper in the body’s organs)
- Autoimmune inflammatory conditions (diseases in which the body’s immune response is directed against its own tissues, causing prolonged inflammation and tissue destruction)
Cirrhosis typically results from many years of disease. A person may have compensated or decompensated cirrhosis, depending on the type of complications.
- In compensated cirrhosis, the liver is heavily scarred but can still perform many important functions.
- In decompensated cirrhosis, the liver is extremely scarred and unable to function properly.
Complications include bleeding in the intestine or varices (dilated blood vessels in the esophagus), jaundice, fluid accumulation in the abdomen (ascites) and accumulation of waste products (leading to mental confusion). Patients with cirrhosis are also at increased risk of developing liver cancer.
Treatment of CirrhosisOnce cirrhosis occurs, it is irreversible. Treatment can stop or delay further disease progression and reduce complications. Treatment depends on the cause of cirrhosis and the complications a person may be having. The first part of treatment is to treat the underlying cause of the liver disease. For example, hepatitis B and C can be treated with antiviral drugs and autoimmune diseases can be treated with steroids. Preventive approaches are also used to avoid further injury to the liver. These include alcohol avoidance, hepatitis vaccination, avoiding medications that can be toxic to the liver, and a low-fat diet.
The second part of treatment is to monitor the person for complications and, if they are present, begin treatment to manage them.
Patients with decompensated liver disease (the liver is unable to function properly) usually have a poor long-term survival and should be evaluated for liver transplantation.
HepatitisHepatitis is a condition characterized by inflammation of the liver. Hepatitis can be the result of many causes, the most common being viral hepatitis B and C. These blood-borne infections can lead to advanced liver disease in some people.
- The Hepatitis B virus is found in the blood and certain body fluids. It is spread when a non-immunized person contacts the blood or body fluid from an infected person. It is commonly spread through unprotected sex with an infected person, sharing needles with an infected person, needle stick exposures on the job (as in health care), or from an infected mother to her baby during birth. Immunization is available for hepatitis B.
- Hepatitis C virus is found in the blood and certain body fluids. It is spread in similar ways as hepatitis B, when blood or body fluid from an infected person enters another person’s body. There is no vaccine for hepatitis C.
Treatment of HepatitisEffective therapy is available for viral hepatitis. Hepatitis B can be treated with interferon-based therapies as well as medications that prevent the virus from reproducing. Treatment results depend on the patient, the amount of virus present and the extent of liver damage.
Hepatitis C usually is treated with a combination of the drugs interferon and ribavirin. More than 50 percent of patients are able to clear the virus from their body with these drugs.
Author: Marla Fraunfelder
|Medical Reviewer: ||Kathleen Christians, MD|
|Edward Quebbeman, MD, PhD|
Last Review Date: Dec. 26, 2007
Online Editor(s): Christopher Sadler