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Malignant tumors of a liver

Hepatocellular carcinoma — the malignant tumor developing from hepatocytes. Treats primary carcinomas of a liver. At a number of patients it is connected with a hepatitis B virus persistirovaniye. Quite often arises in cirrhotically the transformed liver.

Metastatic carcinoma of a liver — a malignant epithelial tumor which primary center is located out of a liver, for example in a stomach, a large intestine, the Lung, etc. In a liver only metastasises come to light. Treats secondary tumors of a liver.

Epidemiology
Meet metastatic (secondary) more often, is more rare — primary tumors of a liver. Among primary tumors the hepatocellular carcinoma prevails. Earlier in the developed countries the ratio of metastatic and primary tumors of a liver at for the first time made the hospitalized patients 50 — 30:1. Now this ratio decreased to 7 — 15:1. However at further supervision over the patients suffering from carcinomas of extrahepatic localization, metastasises in a liver reveal still very often.

Frequency of a hepatocellular carcinoma among all malignant tumors revealed at more often struck men fluctuates from 1 — 5% in the developed countries to 50 — 60% in Mozambique.

Etiology and pathogeny
The big part in development of a hepatocellular carcinoma is assigned to a carriage of a virus of hepatitis B at which the gene device of a virus can be associated with the gene device of a hepatocyte as if. DNA of a virus of hepatitis B is connected with hepatocyte chromosomes. Other cancerogenic factor is the aflatoxin — a product of an exchange of a yellow mold mushroom, eurysynusic in the equatorial Africa and Asia. Especially often meets on the foodstuff which is stored out of refrigerators. The aflatoxin injures a liver. Its cancerogenic action is represented proved, however the essence of cancerogenic effect is yet not quite specified. The hepatocellular carcinoma often meets in the countries where the hepatitis B virus carriage is widespread. In Uganda it is combined with a carriage in 40%. in Hong Kong — in 70%, on Taiwan — in 80%, in Senegal — in 93% of cases. In the countries with high incidence of a hepatocellular carcinoma a large number of an aflatoxin — in Thailand — 45 ng/kg in day, Mozambique — 222,1 ng/kg in day gets to food of the person. Frequency of development of a hepatocellular carcinoma in the developed countries correlates with a frequency of a carriage of a virus of hepatitis B and, apparently, with amount of the consumed alcohol. In particular, on our supervision, the hepatocellular carcinoma especially often develops against virus and alcoholic cirrhoses of a liver.

Classification
Morphological classifications of a hepatocellular carcinoma are generally offered. Division into nodal, massive and diffusion forms is most widespread. We developed the classification (1988) including the main clinical options of a disease: gepatomegalicheskiya (about 50% of patients), cystous (3 — 5%), tsirrozopodobny (about 25%), gepatonekrotichesky or abstsessovidny (6 — 10%), ikteroobturatsionny (6 — 10%), masked (6 — 10%).

Approximate formulation of the diagnosis:
1. The Tsirrozopodobny form of a hepatocellular carcinoma of the right hepatic lobe with moderate dysfunction of body. Portal hypertensia, persistent ascites.
2. An adenocarcinoma of the ascending gut. A large single metastasis in the right hepatic lobe with its kept function.

Preliminary diagnosis
The hypochondrium, fever (subfebrile is more often), weakness, abdominal distention, hepatomegalia are characteristic of the majority of options of a hepatocellular carcinoma pain in right. Anemia, a leukocytosis are revealed seldom. SOE is raised at 55 — 70% of patients.

Increase of activity of GGTF, alkaline phosphatase, ASAT, blood serum GDG and LDG is characteristic. Activity at least of one of these enzymes is increased at 98 — 99% of the patients suffering from clinically expressed forms of a hepatocellular carcinoma. 2 — 4 enzymes from listed above to five are patholologically changed a bowl.

Increase of concentration and - blood serum fetoprotein (determined by a radio immunological and immunoenzyme method) is revealed at 85% inspected. Direct diagnostic and differential and diagnostic sense has increase of concentration, eightfold in comparison with norm, and - blood serum fetoprotein.

The radionuclide stsintigrafiya and ultrasonography of a liver at the first research allow to reveal symptoms of a tumor (focal defeat) at 75% inspected. Both methods give 10 — 20% of false positive results. Most often hyper diagnosis is allowed concerning patients with macronodular cirrhoses of a liver and focal fatty dystrophy of a liver.

At this stage differential diagnosis is carried out with metastatic carcinomas of a liver (see below), and also benign tumors. At benign tumors unlike a hepatocellular carcinoma reveal clear equal boundary of focal defeat. Activity of GGTF, alkaline phosphatase, ASAT, blood serum GDG, LDG at benign tumors of a liver is not changed. Differential and diagnostic value of this test at the patients having at the same time cirrhosis and an alcoholic hepatopathy is reduced. Eightfold and bigger increase of concentration and - fetoprotein at benign tumors is never observed practically. At benign tumors of growth of the sizes of a tumor within 3 months it is also not observed. Contrary to it at clinically expressed forms of a hepatocellular carcinoma this interval of supervision is sufficient for identification of strong indications of progressing of a disease.

It is necessary to differentiate a hepatocellular carcinoma from other reasons of significant increase in the sizes of a liver also: 1) at alcoholic hepatopathies, as a rule, there are no signs of focal damage of a liver, concentration and - it is normal of fetoprotein or is slightly raised; 2) congestive hepatomegalias of a cardial origin are often combined with other signs of a circulatory unefficiency — short wind, tachycardia, peripheral hypostases; electrocardiographic, X-ray inspection and ultrasonography of heart allow to specify character of a disease.
The known diagnostic value has the reduction of the sizes of a liver observed at strict observance of the mode of abstinence, and also restriction of the motive mode.

At a metastatic carcinoma of a liver results of research GGTF, an alkaline phosphatase, ASAT, GDG, LDG are close to those at a hepatocellular carcinoma. High concentration and - fetoprotein are observed as an exception. At 30 — 45% of patients concentration of carcinoembryonic antigen of blood serum is increased.

When carrying out a radionuclide stsintigrafiya and ultrasonography of a liver reveal the data close to those at patients with a hepatocellular carcinoma. For confirmation or an exception of metastatic character of a malignant tumor of a liver conduct careful examination of a number of bodies for an exception of possible primary localization of a tumor (gastroscopy, a kolonoskopiya or a rektoromanoskopiya in combination with an irrigoskopiya, a X-ray analysis of a thorax, ultrasonography of a pancreas and kidneys, survey of mammary glands and mammography at women).

The special attention is paid to a possibility of primary localization in a prostate (at men) and in ovaries (at women) as metastasises of these localizations are represented rather kurabelny.

Final diagnosis
In the course of verification of the diagnosis use also computer tomography which allows to reveal liver more than 3 cm in size tumors at 80% inspected. At a tumor tseliakografiya
the similar sizes reveal at 60 — 65% inspected. As final confirmation of the diagnosis serve the tumors given morphological research.

Verification of a metastatic tumor is carried out by the same principles. An important role is played by detection of primary localization of a tumor and morphological confirmation of malignant character it.

Treatment
The hepatocellular carcinoma is subject to surgical removal. More often it feasible at tumors of the left share. The liver transplantation is in some cases possible. However in general among all reasons of a liver transplantation malignant tumors make 5 — 10%. More than 50% are the share of cirrhosis.

At impossibility of surgical treatment expediency of chemotherapy is discussed. Various combinations of adriamycin, a ftoruratsil, Bleomycinum and Carminomycinum of usually noticeable effect do not give, side effects of chemotherapy are considerable.

Single, rather small sizes metastasises of carcinomas of a colon (its especially right half) in some cases subject to operational treatment — a resection of a segment or a share. The chemotherapy is carried out generally by the principles of treatment of primary localizations of carcinomas. Efficiency of treatment increases at administration of drug (like a ftoruratsil, Phthorafurum) in a hepatic artery.

 
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