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02.13 Liver Cancer

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Overview

Liver cancer impedes the function of the liver and can block the flow of blood and bile

Nursing Points

General

  1. In order to understand liver cancer it is important to understand the functions of the liver
    1. Synthesizes clotting factors
    2. Metabolizes fats, carbohydrates, and many medications
    3. Synthesizes proteins including albumin
  2. Cancer in the liver usually spreads from a different cancer 
  3. Hepatocellular carcinoma (HCC) is the most common cancer that does form in the liver 
  4. Cirrhosis from any cause is a HUGE risk factor for liver cancer
    1. Chronic inflammation and damage to liver cells leads to fibrosis and cellular changes that can cause HCC
  5. Very poor prognosis with advanced disease and cirrhosis
    1. HCC has a 5-year survival rate of 18.4% 
    2. Involve palliative care early in treatment to promote quality of life 

Assessment

 

  1. Pain- In the right upper quadrant or referred to right shoulder from enlarged liver
    1. Caution with medications →Impaired metabolism of opioids, but pain management is SO important
  2. Jaundice/ itching- from biliary obstruction/ bilirubin build up
    1. Treatment
      1. Percutaneous drain or stent to brain bilirubin
      2. Skin care- fragrance free soaps and lotions to reduce itching
  3. Fluid retention- ↑ pressure in portal vein, Na+ and water retention, ↓ albumin synthesis
    1. Treatment
      1. Diuretics- potassium sparing
      2. ↓ Na+ intake
      3. Elevate extremities to reduce dependent edema
  4. Ascites- fluid retention in the peritoneal cavity
    1. Treatment
      1. Paracentesis if symptomatic shortness of breath from increased pressure on lungs
  5. Encephalopathy- Altered LOC- ­↑ toxins traveling to the brain
    1. Nursing considerations
      1. Can be exacerbated with medications (opioids, benzos)
      2. Speed up the passage of food through the body to reduce toxin build-up
      3. Prevent opioid-induced constipation
    2. Treatment
      1. Lactulose- titrate to 2-3 soft bowel movements per day
  6. Bleeding- varices from ↑ portal vein pressure, ↓ liver synthesis of coagulation factors, ↓ platelets from splenomegaly
    1. Nursing Considerations
      1. Bleeding precautions, education
    2. Treatments
      1. Cauterization
      2. Blood product infusions

Therapeutic Management

  1. Liver resection/ transplantation- ideal but many are not eligible due to advanced disease at diagnosis 
  2. Direct therapy to cancer- kills cancer cells and/or cuts off blood supply to tumor 
    1. TACE- transcatheter arterial chemoembolization
    2. Brachytherapy
    3. Radioembolization
  3. Systemic treatment
    1. Chemotherapy/ biotherapy
  4. Palliative care

Nursing Concepts

  1. GI/Liver Metabolism
    1. Cirrhosis review- exacerbated with liver cancer 
  2. Fluid & Electrolyte
    1. Diet- ↓ Na+
    2.  Fluid restriction if ordered
  3. Coping
    1. Patient and family

Patient Education

  1. Pain management 
  2. Bleeding precautions 
  3. Palliative care education 
  4. No alcohol/ avoid Tylenol 

Reference Links

Study Tools

Video Transcript

Hi guys, I’m Stephanie. And today we will be talking about liver cancer. Okay. Now, in order to understand what liver cancer does in our body, we just need to review a couple of things about the liver. So the first thing I want to talk about is the blood flow to the liver. And we have to remember that the blood or the liver gets its blood from two different sources. So it comes from the portal vein and also from the hepatic artery. So this is important to remember when you’re talking about liver cancer, because cancer usually gets most of its blood from the hepatic artery where our liver gets most of its blood from the portal vein. So the portal vein produces 80% of the blood flow that the liver uses and the hepatic artery only produces 20% and it gives the liver 20% of its blood. And we’ll talk about that more later when we talk about treatments for liver cancer and then some important things that the liver does for us that are impacted when our patients have cancer. The liver will stop making proteins, specifically albumin, which if we remember that creates that oncotic pressure to pull fluids into the vasculature. So we won’t be making that. We won’t have the clotting factors, so of course we’ll be at risk of bleeding, right? And then the liver also helps us to process bilirubin so we’re going to have an increase in bilirubin. And remember the liver helps us process that and release it through the common bile duct here. So when these things are impacted, of course it affects everything in our body.

So the cancer usually spreads from another area. And that makes sense, right? It’s a secondary cancer. Remember that portal vein, it comes from other organs. So cancer, if it was in those organs is going to come right directly to the liver. If it is a primary liver cancer forming within the liver, it can form in the liver cells, or it can be a bile, duct cancer.

And those take on a bunch of different types of cancers, but they all pretty much present the same. Today we’re mostly going to be talking about hepatocellular carcinoma or HCC, which makes up 75% of primary liver cancers. So all of the cancers pretty much present in similar ways, but this is the main one that we will be discussing today. A huge, huge, huge risk factor is cirrhosis. Many patients who have liver cancer first have cirrhosis from any cause. So what are those causes? Hepatitis B or C, alcohol or drug use, and then also Nash, right? That nonalcoholic steatohepatitis. I forgot how to say it, but what causes, this? That is diabetes, obesity, and hypertension so this puts people at risk for cirrhosis. And then that also puts them at risk for unfortunately, hepatocellular carcinoma. This has a very poor prognosis. We’re talking about 18.4%, five-year survival. 

So it is very important to get palliative care involved early with these patients. Now, we’re not saying they’re giving up if they get palliative care involved, but we want to make sure their quality of life is best that it can be while they’re going through these very aggressive treatments. We want palliative care to be following them.

Now we’re going to talk about symptoms and management. So how these patients present, they have pain usually in the right upper quadrant, sometimes shoulder, if it’s referred pain from the enlarged liver cells causing this pain right now, pain is difficult to manage for these patients, especially in late stages. Some, not all, some have a history of opioid abuse or substance abuse, right? So they’re needing higher doses of medications, but guess what? The liver also is responsible for metabolizing several different medications. So it’s just a delicate balance for pain management. Also jaundice. We often see these patients present with jaundice, right? And that’s the case also with any liver failure, right? And this is from the increase in bilirubin. Both of these actually are, but we’re talking about jaundice first. So that increase in bilirubin. It causes these patients to the yellow- their eyes and their skin guys. These patients can be as yellow as a highlighter. It’s very significant. And then itching that buildup of bilirubin also makes their skin really itchy. We can sometimes get medications for this, or we just talk to them about skincare using fragrance-free soaps and lotions to reduce that itching can sometimes help a little bit. Although getting rid of this, bilirubin is the most important thing. So sometimes these patients have drains- bili drains to get rid of the bilirubin. 

You’ll see that often. And then another huge way these patients present is with fluid retention. Now we’re going to talk a little bit about why this is. So when we have the increased pressure in the portal vein, because the liver isn’t functioning properly, right? We have to push more. We have to work hard or basically to push the blood in, right? So that’s causing the portal, hypertension. The rest of the body is going to respond to that. It’s gonna tell us to increase sodium and water retention. Our body’s gonna tell us to increase sodium and water retention. Now let’s talk about this. So we have this extra fluid in the body, right? But remember we have our veins, our albumin should be there pulling the fluid in that our body’s retaining, right. But it’s not because our liver is not working. So we’re having all this extra fluid retained by the body and it’s not going into the vasculature, it’s escaping. 

So we have this edema, very significant. It’s usually dependent. So we tell these patients to elevate their legs. And then we treat it with diuretics, usually, potassium-sparing, cause we’re not processing our electrolytes properly. Right. So we don’t want to lose all of our potassium. And then also we reduce the sodium intake so that our body doesn’t have the sodium to absorb, to absorb more water. So we reduce sodium intake and then elevate the legs. so more severe complications of that fluid buildup can go into the abdomen. Right? So really big fluid buildup. And that ascites is that fluid within the abdomen, in the peritoneal cavity. So as this abdomen continues to swell, the lungs in here are not able to expand cause there’s too much pressure. So that can cause shortness of breath with significant anxieties. 

And that’s usually when we will treat that ascites specifically and that procedure is called a paracentesis. So they stick a needle directly into that abdomen and pull out the fluid. And I mean, we get bottles, huge bottles, liters of fluid off at a time from these patients. And unfortunately, it will come back unless we treat the cause- in this case, the liver cancer. Also, encephalopathy- that’s the buildup of toxins in the brain. Our liver is not processing toxins properly, right. So they’re going to build up. So to treat this, we want to make those toxins pass through the body quicker. So we give a medication called lactulose and that is a laxative. It pulls the toxins out and excretes them quicker. We usually titrate this to two to three bowel movements per day, but we also have to remember to prevent constipation. 

And remember that these patients are also in significant pain, right? And they’re being treated with opioids and what can that cause?- constipation. So it’s important to titrate this lactulose. They might not be on the same dose of the actual dose that they were on before because of this opioid-induced constipation. They might need to take more lactose to keep these two to three BMs per day. And these opioids can also contribute to this encephalopathy. So we just need to be careful with the pain management and make sure that that’s not making things worse, right. Because opioids can change our level of consciousness if we’re giving too much. So just be careful about that. And then bleeding, we kind of briefly discussed this at the beginning. So they’re at risk of bleeding because they have decreased clotting factors, right? So we’re educating them about bleeding precautions. Sometimes we have to give something called FFP, fresh frozen plasma. 

If we’re going to do a procedure to this helps the blood clot and treatment for these patients. So surgery is number one, that’s the first, most important treatment with the best outcome. So we’re talking about a complete liver resection or they can take out part of it, right? The liver is amazing and it can regrow or complete liver transplantation. Now a lot of patients are not candidates for surgery because the tumor has to be less than five centimeters and no cirrhosis. So many patients are not eligible for surgery, unfortunately. So we have different local targeted treatments. This can be with the goal of just doing this treatment for liver cancer, or also just trying to reduce the tumor burden so that they can get surgery. And some of the ways that we treat this is with a procedure called TACE, and this is a really cool procedure. 

It’s transcatheter, arterial chemoembolization. So this is really specific to liver cancer. So in the cath lab, they’ll go in through this femoral artery up here through the hepatic artery directly to the liver, pretend like this is our tumor. So we’re going to be giving chemo directly to that tumor right here, but also embolization agents to block off this hepatic artery and guess what the liver can handle that because we also have that blood flow from the portal vein coming, remember that’s 80% of that blood flow. So the liver can usually compensate, but cancer usually cannot. The cancer usually relies on that 20% of blood flow from the hepatic artery. So if we embolize it, stop that blood flow, sometimes that treats the cancer. Also, we can do radiation directly to the tumor through that femoral artery and hepatic artery. Also sometimes, sometimes we do radiation.

Also this other drawing here is for hepatic artery infusion. So sometimes without embolization, we just give chemo directly through the hepatic artery. Again, this is really specific for liver cancer, so they can have a device outside of their abdomen, a pump and that’s delivering chemo directly into the hepatic artery. So you’ll see this pump. Now, if you are in a unit where you have these, you will know exactly what you need to do with them. Sometimes they have to be on complete bed rest. It really depends on the physician, but just know if you see something like this, you need to ask someone to make sure you know how to manage it. Then also we have systemic treatment. So we have the chemo and immunotherapies available now with any systemic treatment, we’re going to have systemic side effects. 

So just be aware of that. Now we’ll talk about these key points.  Remember cirrhosis is the main risk factor. So they already have damage and fibrotic liver cells, right?  Pain management is also very important. We talked about education, making sure that we’re being safe with the amount of medication were administering and complications and symptoms are all related to liver failure. So if you understand liver failure, you’re, you’re going to understand liver cancer and the way these patients present and then suggest palliative care early. Now, remember they’re not giving up if they seek palliative care, they’re looking for support throughout the continuum of their treatment. Palliative care is different than hospice. Palliative care is with them throughout the whole treatment. And we want to encourage this because we know that this is a devastating diagnosis. All right, guys, we covered a lot today. I hope you learned a lot about liver cancer. Go out and be your best self today. And as always happy nursing.

 

 

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