Transient elastography Fibroscan for non-invasive assessment of liver fibrosis

Author's objectives The aim of this report is to assess the available information on the use of transient elastography (FibroScan) for non-invasive assessment of liver fibrosis. Author's conclusions Liver fibrosis is associated with significant morbidity and mortality. The major cause is hepatitis C, which affects 240,000 Canadians. Assessing the degree of liver fibrosis is critical to its management. Liver biopsy, an invasive procedure, is considered to be the diagnostic gold standard. FibroScan is a rapid, non-invasive technology that uses low frequency vibration and ultrasound to assess the stiffness of liver tissue. The diagnostic performance of FibroScan is good for identifying severe fibrosis or cirrhosis, but it is less accurate for milder presentations. FibroScan is a promising technology, but large multi-centre trials comparing a range of emerging non-invasive fibrosis staging technologies are required. Structure abstract from Health Technology Assessment Database

Usefulness of radiofrequency ablation of liver tumors

Author's objectives The aim of this review was to assess the efficacy and safety of radiofrequency ablation (RFA) of liver tumors. Author's conclusions Most malignant liver tumors can not be surgically removed because of their extension, systemic involvement, comorbidities or tumor size. RFA is proposed as an alternative for patients with primary hepatocellular tumors or liver metastases of colorectal cancer, when surgery is not possible. When assessing the evidence, it is observed that in all cases tumor resection is the treatment of choice. When this is not possible, RFA shows more effectiveness than most alternative treatments. However, it is worth mentioning that the differences found are mainly in the rates of local recurrence and length of hospital stay, but there are no differences in survival. In addition, complications, although not evaluated by many authors, would be fewer than in other treatment alternatives (experts suggest a complication rate of 3% to 5%), with a mortality rate lower than 1%. To use this treatment, it is recommended that a multidisciplinary team including a liver surgeon performs a patient selection and that it is performed under ultrasound or topography guidance. The requirements that must be met to use RFA in patients with liver tumor are: - not candidates for surgical tumor resection (either because there is local involvement, or because of tumor location or comorbidities) - metastases of an isolated colorectal cancer or a hepatocarcinoma - no systemic or extrahepatic disease - identification images (ultrasound or computed tomography) - tumors less than 4 cm in diameter. Those tumors of other origins which are treated with RFA or which are treated for palliative treatment are considered investigational. Structured abstract from Health Technology Assessment Database

Surgical Treatment of Hydatid Disease of the Liver

Ahmet A. Balik, MD; Mahmut Basoglu, MD; Fehmi Çelebi, MD; Durkaya Ören, MD; K. Yalçin Polat, MD; S. Selçuk Atamanalp, MD; Müfide N. Akçay, MD

Arch Surg. 1999;134:166-169.

Hypothesis To review the results of different modalities of treatment of hydatid disease of the liver.

Design Retrospective study of 304 patients.

Setting A university hospital in Turkey.

Patients Three hundred four patients with hepatic hydatid disease who underwent operation between 1981 and 1996.

Main Outcome Measures Mortality and morbidity.

Results Two hundred thirty-eight patients had a cyst on the right lobe, 41 patients had a cyst on the left lobe, and 25 patients had a cyst on both lobes. Forty-five patients had multiple hepatic cysts and 18 patients had coexisting cysts in other intra-abdominal organs. Surgical procedures were tube drainage, capitonnage, omentoplasty, cystectomy, segmentectomy, and cystoenterostomy. Of the patients with tube drainage, 36 developed an infection of the remaining cavity, 10 developed long-lasting biliary fistula, 8 developed cholangitis, and 6 developed septicemia. Four patients died of unreleated complications. Of the patients with capitonnage, 7 developed cholangitis and 3 developed an infection of the remaining cavity. Of the patients with omentoplasty, 1 developed an infection of the remaining cavity and 1 developed cholangitis. One patient who underwent segmentectomy developed pulmonary complications. Of the patients with cystoenterostomy, 1 developed cholangitis, 1 developed septicemia, and 1 developed pulmonary complications.

Conclusion For management of hydatid disease of the liver, capitonnage, omentoplasty, cyst excision, segmentectomy, or cystoenterostomy are all superior to tube drainage.


From the Department of General Surgery, Atatürk University School of Medicine, Erzurum, Turkey.

Nexavar Granted FDA Priority Review For Treatment Of Liver Cancer

Bayer HealthCare Pharmaceuticals (NYSE: BAY) and Onyx Pharmaceuticals, Inc. (Nasdaq: ONXX) today announced that the supplemental New Drug Application (sNDA) for Nexavar(R) (sorafenib) tablets for the treatment of patients with hepatocellular carcinoma (HCC), the most common form of liver cancer, has been accepted for review and granted Priority Review status by the U.S. Food and Drug Administration (FDA). Nexavar is currently approved in more than 50 countries for the treatment of patients with advanced kidney cancer.

Priority Review designation is intended to expedite the regulatory review process for investigational agents or uses that address unmet medical needs. Based on this designation, the FDA reviews the application with a goal of taking action within six months of the date on which they received the sNDA.

“This Priority Review underscores the potential of Nexavar to be a significant advance in the treatment of liver cancer,” said Susan Kelley, M.D., vice president, Therapeutic Area Oncology, Bayer HealthCare Pharmaceuticals. “If approved, Nexavar would be the first FDA-approved therapy for patients battling this devastating disease.”

The sNDA submission, completed in June 2007, was based on data from the Phase 3 SHARP trial which demonstrated that Nexavar extended overall survival by 44 percent in patients with HCC (HR=0.69; p=0.0006) versus placebo. There were no significant differences in serious adverse event rates between the Nexavar and placebo-treated groups with the most commonly observed adverse events in patients receiving Nexavar being diarrhea and hand-foot skin reaction. Based on this data, the companies also submitted a Marketing Authorization Application (MAA) to the European Medicines Agency (EMEA) in June.

“The incidence of liver cancer continues to rise in the United States and around the world, highlighting the significant need for new therapies,” said Hank Fuchs, executive vice president and chief medical officer of Onyx. “Our comprehensive development program continues to identify new areas where Nexavar’s unique combination of multi-targeted activity, tolerability and oral dosing may meet additional unmet needs in cancer.”

HCC, the most common form of liver cancer, is responsible for about 90 percent of the primary malignant liver tumors in adults.(1,2) Liver cancer is the sixth most common cancer in the world and the third leading cause of cancer-related deaths globally.(3) Over 600,000 cases of liver cancer are diagnosed globally each year(3) (about 19,000 in the United States(4) and 32,000 in the European Union(5)) and in 2002 approximately 600,000 people (about 13,000 Americans and 57,000 Europeans) died of liver cancer.(6)

Treatment options for nonalcoholic fatty liver disease

Shivakumar Chitturi

Australian National University Medical School, Gastroenterology and Hepatology Unit, Canberra Hospital, Australian Capital Territory, Australia, shiv.chitturi@act.gov.au

Nonalcoholic fatty liver disease comprises a range of disorders from steatosis and steatohepatitis through to cirrhosis. Nonalcoholic steatohepatitis can progress to cirrhosis and liver-related death. Therefore, managing this common disorder is becoming an important public health issue. Lifestyle measures are commonly suggested but robust data are lacking. Trials with antioxidants (vitamin E, betaine) as well as cytoprotectants (ursodeoxycholic acid) have been disappointing. While data for insulin sensitizers such as metformin are less conclusive, thiazolidinediones appear promising. However, not all patients respond to thiazolidinediones. Moreover, issues related to weight gain, cardiovascular risk need to be addressed. The use of endocannabinoid antagonists and insulin secretagogues are novel strategies to combat this disorder.

Key Words: fatty liver • insulin sensitizers • nonalcoholic steatohepatitis • nonalcoholic fatty liver disease • endocannabinoids • thiazolidinediones • ursodeoxycholic acid • vitamin E • lifestyle intervention • physical activity

treatment of liver disease

Southwest College of Naturopathic Medicine: 2140 East Broadway Rd. Tempe, AZ 85282, USA. lupers@cwix.com

Botanicals have been used traditionally by herbalists and indigenous healers worldwide for the prevention and treatment of liver disease. Clinical research in this century has confirmed the efficacy of several plants in the treatment of liver disease. Basic scientific research has uncovered the mechanisms by which some plants afford their therapeutic effects. Silybum marianum (milk thistle) has been shown to have clinical applications in the treatment of toxic hepatitis, fatty liver, cirrhosis, ischemic injury, radiation toxicity, and viral hepatitis via its antioxidative, anti-lipid peroxidative, antifibrotic, anti-inflammatory, immunomodulating, and liver regenerating effects. Picrorhiza kurroa, though less well researched than Silybum, appears to have similar applications and mechanisms of action. When compared with Silybum, the hepatoprotective effect of Picrorhiza was found to be similar, or in many cases, superior to the effect of Silybum.

Treatment of Colorectal Liver Metastases

Liver metastases from colorectal cancer (CRC) have a poor prognosis. Despite recent advances in the management of advanced disease with chemotherapy, liver resection remains the only hope for cure for patients with colorectal liver metastases. Approximately 15% of patients with stage IV CRC referred to specialist centers have metastatic liver disease deemed to be resectable at presentation. Over the last five years, combination chemotherapeutic regimens, namely 5-fluorouracil/folinic acid with irinotecan or oxaliplatin and, more recently, integrating targeted monoclonal antibodies, have been shown to downsize the tumour burden to an extent that sometimes allows initially unresectable metastases to be excised. Five-year survival rates following liver resection range between 25% and 55% compared with 0% and 5% for non-operated patients. Beyond liver resection, the rationale for “pseudo-adjuvant” chemotherapy lacks scientific evidence, despite some promising data. However, perioperative chemotherapy for resectable lesions is gaining ground in current practice. In this article we review the state of the art treatment for CRC liver metastases and, considering the results of recent trials, try to determine the appropriate role of chemotherapy.

Liver Cancer Prognosis - Treatment

Can your liver cancer prognosis be improved? Karon Beattie, a cancer survivor, has compiled a cancer treatment reference book detailing over 350 alternative cancer treatments that have been used by thousands of people who beat cancer. Although liver cancer is not highly responsive to conventional cancer treatments, Beattie gives numerous accounts of people surviving liver cancer by alternative treatments. She states that these treatments are not covered by the FDA and usually not patentable by drug companies, resulting in poor knowledge among doctors.

Specifically in relation to liver cancer, Beattie's book, "Natural Cancer Treatments That Work", describes a treatment that heats tumors without damaging surrounding tissue. She cites survival rates of 78.1% at four years after diagnosis of liver cancer with cirrhosis of the liver, for patients who had failed to respond to chemotherapy and radiation. This seems an astonishing outcome for a cancer given a poor prognosis by oncologists.

Beattie goes on to detail a Stanford University study that found a common antibiotic was successful in eliminating liver cancer. In 2004, Stanford scientists were able to "turn off" a cancer-causing gene in mice suffering liver cancer, turning cancer cells back to normal. In addtion, the author provides 104 first-hand accounts of people who beat liver cancer using natural and alternative treatments. If stories like this are true, why are they not a standard treatment for liver and other cancers?

According to Beattie, the creators of the gentle and non-toxic treatments detailed in her book, are respected Nobel Prize winners, doctors, biochemists, scientists and Ph.D.'s pre-eminent in their fields. She believes that many doctors may not be aware of these treatments because they can only prescribe, and indeed are trained to prescribe treatments that are regulated by the FDA. Many of the alternative treatments she lists involve herbs and vitamins that are outside the jurisdiction of the FDA.

Cancer sufferers and their loved ones will find these compelling accounts hard to ignore in their quest to survive cancer and reclaim their lives.

MESOTHELIOMA INFORMATION - ABOUT MESOTHELIOMA"Mesothelioma (cancer of the mesothelium) is a disease in which cells of the mesothelium become abnormal

"Mesothelioma (cancer of the mesothelium) is a disease in which cells of the mesothelium become abnormal and divide without control or order. They can invade and damage nearby tissues and organs. Cancer cells can also metastasize (spread) from their original site to other parts of the body. Most cases of mesothelioma begin in the pleura or peritoneum." - National Cancer Institute

Mesothelioma is a serious cancer that occurs in individuals exposed to asbestos. Mesothelioma victims have either inhaled or swallowed asbestos fibers which then travel through the lung and become lodged in the pleura (the thin, saran wrap-type membrane lining the lungs). Mesothelioma can also develop in the abdominal (peritoneal) area of the body. Each year 2,500 to 4,000 patients in the U.S. are diagnosed with mesothelioma.

The only known cause of mesothelioma is exposure to asbestos. Even small amounts of asbestos and infrequent exposure can cause injuries.

Exposure to asbestos fibers usually occurs in at-risk workplace environments. Those at the highest risk for developing mesothelioma include workers handling or installing insulation, roofers, electricians, miners, and others (more about occupational hazards).

Asbestos fibers are so toxic, that industrial and trade worker’s families may be exposed to mesothelioma through particles that cling to the worker’s clothing, shoes, skin and hair. This type of “second-hand” exposure to asbestos is known as Para occupational exposure.

Exposure to asbestos can also occur in the home. Asbestos exposure in the home could have occurred when renovation or repair work was performed. The majority of building products manufactured today do not contain asbestos, however those frequently used prior to 1970 do carry exposure risks. Products such as joint compounds, wallboards, gaskets, fireproofing, pipe covering, cements, floor tiles, ceiling tiles and boiler insulation often contained asbestos. If these products were mixed, grinded, cut, sawed, sprayed, removed or otherwise manipulated, banged or damaged, they could have released significant asbestos fibers into your home. The inhalation of these airborne fibers can create the risk of developing mesothelioma, even 15-30 years later.

Mesothelioma Was Preventable
Scores of corporations that manufactured and profited from the sale of asbestos-containing products knew the health hazards as early as the 1920's. If you worked in a high-risk industry and have been diagnosed with mesothelioma, or you have lost someone to an asbestos-related illness, it is your right to seek compensation from those responsible for your situation.

MESOTHELIOMA DIAGNOSIS - MESOTHELIOMA INFORMATION

The early detection of mesothelioma is critical to the patient outlook and in determining applicable treatment options. However, mesothelioma is often difficult to diagnose for a variety of reasons. Because mesothelioma is a rare disease, many doctors are not familiar with it. In addition, the non-specific nature of patient symptoms can be indicators of other medical conditions. The extended length of time between asbestos exposure and a patient's symptomatic responses, often between 15-50 years, further hinders immediate detection of mesothelioma. Despite these difficulties there are many procedures available for the accurate diagnosis of mesothelioma.

Initial Evaluation
The initial patient evaluation(s) are critical in identifying patients at risk for developing mesothelioma. To establish risk factors and the presence of symptoms, your physician will complete a medical history that includes questions to help determine the timeframe and environment in which you may have been exposed to asbestos. Communication between the patient and doctor is important so that the earliest possible detection of mesothelioma can be made. Make certain that you have shared all relevant information regarding previous work history and possible asbestos exposure with your physician.

In addition to constructing a medical profile and detailed medical history, a complete physical examination will be performed. During a physical exam your doctor may look for the following:

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Breath Sounds: listening to the chest cavity as the patient inhales/exhales there may be an absence of breath sounds, or these sounds may be muted. The absence of, or muted nature of, these breath sounds may be an indication of fluid in the chest cavity, or of pleural effusions.

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A doctor may listen to the chest cavity while having the patient make vowel sounds - comparing the sound resonance in the right and left chest cavities. Muted, or dull, sounds between the cavities could be an indicator of a buildup of fluid.

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By percussing, or tapping, on the chest area a doctor may notice a dull, solid thumping sound, rather than a hollow resonance. This may also indicate the presence of fluid, or a mass, in the chest cavity.

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A physical examination will also check for enlarged lymph nodes.

There are often very few signs during an initial physical exam that would identify the presence of mesothelioma. On the basis of patient symptoms, medical history, the presence of specific risk factors (work environment, asbestos exposure), and a complete physical examination, the doctor can use one or more of the methods described below to determine if the disease is present.

Diagnostic Tests
Doctors use a variety of diagnostic procedures to determine if a patient has mesothelioma. Comparing results from imaging scans, tissue biopsies, pulmonary function tests, and other diagnostic techniques, the presence of mesothelioma can be identified.

* Imaging Techniques
There are many available technologies that allow doctors to view, or image, organs and tissue that might show the presence of fluid or tumors.

A chest x–ray may show an unusual thickening of the pleura, lowering of the lung fissures (spaces between the lobes of the lungs), an accumulation of fluid in the lungs (pleural effusion), and/or an irregular mass in the chest cavity.

A CT (computed tomography) scan uses x-ray and computers to give more sophisticated and detailed pictures of the insides of our body than conventional x-rays. A rotating x-ray beam is used to take a series of pictures of the body from different angles. A computer combines the series of pictures to produce a detailed cross-sectional image of a specific part of the body. The CT scan allows a radiologist to see distinct aspects of the lungs and pleura.

Magnetic Resonance Imaging (MRI) uses a strong magnetic field and radiowaves to scan the body. There is no radiation involved. This imaging method produces a series of cross-sectional pictures. MRI scans are useful for viewing 'soft tissues' in the body and can show the extent of mesothelioma. New MRI techniques where surface imaging techniques are combined with quick breath-holding sequences and gadolinium contrast medium give images, which detect tumor growth in the pleura and thoracic wall better than the previous methods. MRI images tend to be quite clear and are superior to routine x–ray images.

Positron Emission Tomography (PET) scans use a camera that produces powerful images of the body’s biological functions. Because cancers and other disease processes metabolize sugars at a higher rate than normal tissues or organs, the PET scan uses tracers to indicate where there is abnormal metabolic activity and can pinpoint the regions of active disease. PET scans can also identify extremely small cancerous cells, indicate benign or malignant cells, and help determine whether treatment therapies are working.

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Pathological Tests
Mesothelioma is diagnosed by pathological examination. Tissue is removed, put under the microscope, and a pathologist makes a definitive diagnosis, and issues a pathology report.

A tissue sample of a pleural or pericardial tumor can be obtained using a relatively new technique called thoracoscopy. A thoracoscope (telescope-like instrument connected to a video camera) is inserted through a small incision into the chest. The doctor can see the tumor through the thoracoscope and can use special forceps to take a tissue biopsy.

A laparoscopy can be used to see and obtain a biopsy of a peritoneal tumor. In this procedure, a flexible tube is attached to a video camera that is inserted into the abdominal cavity via small incisions. Fluid can also be collected during thoracoscopy or laparoscopy.

A bronchoscopy may be performed if pleural mesothelioma is suspected. In this process, the doctor inserts a flexible lighted tube down the trachea, and into the bronchi to check for masses in the airway. At that time, small samples of abnormal-appearing tissue may also be removed for testing.

Lymph nodes are collections of immune system cells that help the body fight infection. By examining the lymph nodes, the doctor can determine if the cancer has spread. During a mediastinoscopy, a patient has a lighted tube inserted under the sternum (chest bone) at the neck level and then moved down into the chest. The surgeon can see the lymph nodes and take tissue samples to check for cancer. This procedure can also help the physician determine if you have lung cancer or mesothelioma.

* Pulmonary Function Tests (PFT’s)
PFTs encompass a wide variety of tests that evaluate the entire respiratory system. The tests are useful in the assessment and diagnosis of pulmonary disease and aid in determining a course of treatment. PFTs can be a simple peak flow measurement, or complex body plethysmography and ventilation/perfusion scans which are performed in hospitals and clinics. PFTs can also be useful in monitoring patient response to treatment.

Although Mesothelioma can often be difficult to initially detect, the above medical procedures and diagnostic tests can lead to a clear diagnosis. Early medical diagnosis is one of the primary variables affecting long-term prognosis. Click here to learn more about available treatment options.

Staging is a method of evaluating the progress of cancer in a patient. It looks at the mesothelioma and the extent to which it has developed and its possible spread to other parts of the body. Click here to learn more about the staging of mesothelioma.