Hepatoma, [s8]very common

Hepatoma is the world's most common malignant tumour, mostly because it is so common in China and Africa, where it it is even more common than secondary tumours of the liver. In Africa, there is a 90% chance that a liver with a hepatoma is also cirrhotic, due to the strong association of hepatoma with hepatitis B infection, and with the aflatoxin produced by the aspergillus fungus growing in damp stored food.

A hepatoma nearly always arises simultaneously as multiple nodules in many parts of the liver. Sometimes, a huge mass deforms one lobe. The other primary liver tumour, carcinoma of the bile-ducts, is as uncommon in the developing world as it is elsewhere.

The patient has an 8:1 chance of being male, and is usually between 30 and 50. He complains of pain, anorexia, weight loss, or a mass; jaundice is late. His pain is usually constant, and sharp or burning, and is in his upper abdomen, usually on the right. It is commonly made worse by food, which causes an inappropriate feeling of fullness after only a small meal. Typically, his pain is made much worse by alcohol; so much so that it may have driven him to stop drinking.

Usually, he presents late with a large, or even a huge, firm, irregular, tender liver. Quite a small tumour may confine him to bed, or he may be remain active with a large one. He may be emaciated and cachectic, or he may present at a stage when weight loss is not yet severe. He may have ascites and a large spleen. Look for collateral veins running vertically over his anterior costal margin, or parallel to his spinous processes. Listen over the tumour for a bruit; this can be intermittent, so listen on several occasions. Spider naevi cannot be seen in a dark skin, and although liver palms can be, they are seldom seen in Africa.

If there is any room for doubt, do all you can to confirm the diagnosis. Several diseases present as swellings of the upper abdomen. Try to distinguish those you can treat, such as liver abscesses, hydatid cysts, and tuberculosis (rare), from those you can only palliate. If you have any hope of sending specimens for histology, learn to biopsy the liver. This can be dangerous, so do it carefully.

NEEDLE, liver biopsy, Menghini, 1.6 mm, normal Menghini point, with adjustable stop, one only (SHR).

NEEDLE, liver biopsy, Vim[nd]Silverman, adult size, 23 mm[mu]88.5 mm, with Franklin modification, one only (SHR). This has hollowed-out biopsy jaws, a sleeve which fits over them, and an obturator to discharge the specimen. The inner jaws grasp a core of tissue, after which you slide the sleeve over them to trap it. Surgeons vary in the needle they prefer. A Menghini needle is in a patient's liver for a shorter time, so it is safer. Its disadvantage is that it is less likely to withdraw a satisfactory specimen if he is cirrhotic. This is important because cirrhosis is common in areas where hepatoma is common.

Fig. 32-14 BIOPSY NEEDLES. A, the Menghini needle. This consists of: A stout needle with a sharpened end (1). An adjustable guard (2). An obturator to clear the needle (3). (4) A short sharp trocar to pierce the skin (4). A ''blocking pin' or ''nail' (5), which slips loosely inside the needle and prevents the biopsy fragment from falling back, and breaking up in the syringe.

B, a Vim[nd]Silverman needle. This has a sheath (6), an obturator (7), and hollowed-out biopsy jaws (8), with special ends (9).

HEPATOMA SPECIAL TESTS. A patient's bilirubin rises late, and is often not raised when he presents. If it is [mt]40 [gm]mol/l (2 mg/dl), his life expectancy is weeks only. His bilirubin and alkaline phosphatase are raised parallel with one another. His transaminases are normal, unless he also has chronic active hepatitis. If he has ascites, aspirate a sample of the fluid and examine it. Blood-stained fluid supports the diagnosis of malignancy, not necessarily of the liver. Anaemia is seldom a marked feature.

X-RAYS. A chest X-ray usually shows that the right lobe of his diaphragm is raised. 50% of patients have secondaries in their lungs post mortem, but a chest X-ray seldom shows them during life.

DIFFERENTIAL DIAGNOSIS. Try to exclude treatable diseases. Some of these are inflammatory, and so produce fever, but this does occur in primary hepatoma (8%), so it is not a reliable guide.

Suggesting secondary carcinoma of the liver[md]a hard nodular liver, evidence for a primary tumour. In carcinoma of the stomach there may be a separate mass, dyspeptic symptoms, or symptoms of pyloric obstruction.

Suggesting carcinoma of the bile-ducts[md]deep jaundice, no bruit, and a liver which is less big and irregular than with hepatoma.

Suggesting carcinoma of the head of the pancreas[md]deepening jaundice, little or no pain, the absence of bile pigment in his stools, a gall-bladder which is usually palpable, no bruit.

Suggesting amoebic abscess[md]fever, a smooth, diffusely enlarged, tender liver with no obvious lumps, no jaundice; tenderness, especially intercostal tenderness.

Suggesting gallstones[md]severe colicky pain, biliary dyspepsia, little or no weight loss.

Suggesting hydatid disease, with cholangitis[md]contact with dogs, a tense, almost painless, long-standing (years), smooth, rubbery mass, commonly in the right upper quadrant; little weight loss, general condition good.

Suggesting a subphrenic abscess with downward displacement of the liver[md]fever and an acute or subacute illness, cough and chest signs on the right side, shoulder tip pain on the right side, fever.

Suggesting tuberculosis of the liver (rare) [md]a hard irregular liver, often with no fever, no jaundice, pain is not marked. When there is no jaundice, you cannot distinguish hepatoma and secondary carcinoma from tuberculosis, except by needle biopsy, which is one reason why it is so useful.

PROGNOSIS. Few patients survive more than 6 months.

MANAGEMENT. Chemotherapy does not cure, nor palliate usefully. There is little you or anyone else can do for him, so there is no point in referring him, with the rare exception of a single tumour confined to his left lobe.

NEEDLE BIOPSY [s7]OF THE LIVER INDICATIONS. An enlarged liver when the diagnosis is unknown.

CONTRAINDICATIONS. (1) Deep jaundice, severe anaemia, or any bleeding tendency, as shown by petechiae, ecchymoses, or haemorrhages. (2) Hydatid disease, where needle biopsy may lead to fatal anaphylaxis or dissemination. (3) Inability to transfuse him if necessary.

CAUTION ! (1) Measure his bleeding time (normal [lt]3 minutes) and clotting time (normal [lt]8 minutes) before taking a biopsy. (2) Give him water-soluble vitamin K[,1] 10 mg intramuscularly on 3 successive days.

ANAESTHESIA. Use local anaesthesia in an adult (A 5.4); a child may need a general anaesthetic. He is likely to be ''ill', and some anaesthetic agents are hepatotoxic.

PRACTICE. Before you use either needle for the first time, try it out by doing the biopsy on a banana, and if possible practise on a cadaver.

CAUTION ! To avoid tearing his liver, he must hold his breath when you are pushing the needle in, pushing it in further, or pulling it out. There are also times when you will want him to breathe deeply to check the position of the needle.

MENGHINI NEEDLE. Before you start, make quite sure that he understands what is being done. If you are using local anaesthesia, get him to practise holding his breath. This is important, because you must do the punture itself and anaesthetise his skin beforehand, while he holds his breath at the end of expiration.

Lay him on his back near to the right side of the bed, and place a firm pillow against his left side in the hollow of the bed. Place his right arm behind his head, and turn his face to the left.

Choose a point in his mid or anterior axillary line in his 8th, 9th, or 10th intercostal spaces, or over the palpable mass that you want to biopsy. Clean his skin with iodine, and anaesthetize the chosen site with local anaesthetic solution.

Pierce the anaesthetized area with a scalpel (or with the special trocar). While he holds his breath, use a long (8 cm) fine-bore needle to infiltrate 5 ml of anaesthetic solution into his skin and parietal peritoneum.

Fit the Menghini needle to a well-fitting 10 ml syringe, set the guard at about 4 cm, and draw up 3 ml of sterile saline.

Pass the needle point through the anaesthetized track down to, but not through the intercostal space. Inject 2 ml of saline to clear the needle point of any skin fragments. There is some difference of opinion as to the plane in which this is best done. Menghini himself advised that saline be discharged and the needle cleared in the subcutaneous tissues. Others prefer to go through the intercostal muscle just short of the liver before clearing the needle.

CAUTION ! Now, ask him to hold his breath in expiration.

Start to aspirate, and while continuing to aspirate, rapidly push the needle into his liver perpendicular to his skin, then, immediately pull it out again. Apply pressure to the site of the biopsy.

Continue aspirating until you have placed the needle point under some saline in a glass dish. Discharge the saline remaining in the syringe. The biospy specimen will appear. Rescue it and transfer it to formol saline. Clear the needle with the obturator.

VIM[nd]SILVERMAN NEEDLE. Proceed to the step ''Pierce the anaesthetized area with a scalpel[...]'' above. Then, having pierced the anaesthetized area with a scalpel, fit the inner obturator into the sheath. With firm, but well-controlled pressure, push the needle through his abdominal wall while he holds his breath. You will feel his peritoneum ''give' as you go through it. Don't push the needle in too far at this stage. Ask him to take a deep breath. If the needle moves with respiration, its tip is already in his liver; if not, ask him to hold his breath again, and gently push it 3 cm further in, or until it moves.

CAUTION ! Don't manipulate the needle while he is breathing, or you may tear his liver.

Ask him to hold his breath, then remove the inner obturator and replace it with the biopsy jaws. Steady the needle with your left hand, and push the jaws with your right hand into the needle as far as they will go.

Ask him to hold his breath again. Hold the biopsy jaws firmly with your right hand, and slide the outer jaws 3 cm further into his liver. This will wedge the jaws and the tissue firmly in the outer sheath. Rotate the needle once or twice, to break off any tissue which is attached at the tip, and then quickly withdraw it. Ask him to breathe again. You can do everything in a few seconds. He need not hold his breath for long.

Slide the sheath over the biopsy jaws and open them. Use a fine needle to remove the core of tissue from the jaws into formol saline.

If you have not succeeded, try again in a different place. If you fail after several attempts, there is probably no solid tissue that can be biopsied. If the needle goes in without any resistance, attach a 20 ml syringe to it and aspirate[md]you may withdraw the ''anchovy sauce' of an amoebic abscess (31.12).

POSTOPERATIVELY, (both methods), lay him flat for 24 hours. Monitor his pulse and blood pressure during this time, just in case he bleeds into his peritoneal cavity. A hepatoma is very vascular, and occasionally bleeds when you biopsy it.

Fig. 32-15 MENGHINI LIVER BIOPSY. From ''Medical Care in Developing Countries' 1965, by the editor.