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Benign liver tumours
Benign liver tumours
These are very common lesions of the liver and are often picked up by accident on ultrasound scans done for other reasons. They represent an abnormal cluster of blood vessels, and we do not know why they occur. Often, there is more than one haemangioma. Very rarely they may show up as part of certain genetically acquired syndromes. If there is doubt about whether a lesion is definitely a haemangioma, a CT or MR scan with contrast will confirm its nature. Haemangiomas should not be biopsied unless absolutely necessary. They have little or no chance of turning malignant, and there is no need for surgery. Very occasionally, large ("giant") haemangiomas may cause symptoms or cause concern about possible rupture, and these can be surgically resected.
These are benign tumours that often occur in women, and are associated with the use of sex hormone preparations including the oral contraceptive pill. They show up on ultrasound, CT and MR scans, but can be difficult to distinguish from malignant tumours. Hence, needle biopsy (or surgical removal) may be the only way to confirm if a tumour is an adenoma or not, but even this may not be conclusive. Adenomas can sometimes regress on stopping the pill. These tumours can turn malignant and surgical removal is therefore the ideal treatment.
Focal nodular hyperplasia (FNH)
This is a benign condition where the liver tissue shows overgrowth just in one area. We do not know why this happens. It is seen commonly in middle-aged women. Ultrasound, CT and MR will show up the mass and the latter two may show some central scarring within the tumour, which is often seen in this condition. A radioisotope sulphur colloid scan can help distinguish FNH from a benign liver adenoma or a malignant tumour. If one is certain that a lesion represents FNH and not some other form of liver tumour, it can be left alone and observed.
Primary liver cancer (HCC)
Primary liver cancer (HCC)
Hepatoma or Hepatocellular carcinoma (HCC)
Section through a cirrhotic liver shows the nodular appearance of the organ and multiple bluish foci of primary liver cancer
What is HCC?
Within the liver, there are different kinds of cells. There are liver cells, or hepatocytes, and then there are cells that form bile ducts, cells that form the blood vessels, cells that work as scavengers, cells that make up the scaffolding or fibrous tissue, and so forth. Each of these cell types can give rise to cancerous growths. HCC is a cancer that arises out of the liver cells or hepatocytes. Every cancer starts off as a microscopic cluster of cells. When it is large enough to form a lump, the lump is often called a tumour. Doctors may use the terms cancer, malignancy, neoplasm, growth and tumour interchangeably, to refer to the same entity or the same process. The tumour is often multifocal i.e. there are several tumour nodules present within the liver. We do not know if this is because it starts off as one tumour that then spreads within the liver via blood vessels, or if several separate tumours start to grow at the same time. Once the tumour cells get into the blood circulation, HCC can spread to the lungs, bones and nearly any other part of the body. Tumour cells can also travel along the lymph vessels to the lymph glands (also called lymph nodes) at the base of the liver.
What causes HCC?
HCC can develop in people with perfectly healthy livers, but it is far more common in people who have cirrhosis. Cirrhosis from any cause increases the risk of developing HCC, but it is patients with Hepatitis B and C who are at the highest risk. HCC is therefore more common in parts of the world where Hepatitis B and C are prevalent, such as sub-Saharan Africa or the Far East.
What symptoms does it cause?
HCC may not cause any symptoms for quite a while, and show up only when it is in an advanced stage. It can cause jaundice (yellow discolouration of the skin and the eyes), pain in the upper abdomen, a low grade fever, weight loss and loss of appetite. Sometimes the enlarged liver or a lump can be felt in the upper right hand side of the abdomen. When it is very advanced, it can cause ascites (collection of watery fluid in the abdomen).
How is it diagnosed?
Diagnosis is usually made on the basis of an ultrasound scan, and then a CT is done to confirm that.
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Other tests, such as MR, liver angiography, bone scans etc. are done only in situations where there is some diagnostic confusion. HCCs often release a substance in the blood stream, called Alpha Foeto Protein (AFP). This is known as a tumour marker. If the AFP level in the blood is raised, it very strongly suggests that the patient has a HCC. But the converse does not always apply – if the AFP levels are normal, that does not rule out a HCC. Needle biopsy can be done, but it does carry a small amount of risk, and should therefore be restricted to situations where it is absolutely necessary. Patients who are known to have cirrhosis or chronic Hepatitis B and C are often kept on regular surveillance with ultrasound scans, and many HCCs now get picked up on such scans, at an early stage.
What is the treatment?
The treatment of HCC depends on
- Tumour stage (how many nodules are present in the liver, how large are they, where exactly are they located in the liver, has the tumour spread to surrounding lymph nodes or to distant organs like the lungs or bones)
- Condition of the liver itself (is it healthy or cirrhotic, and if it is cirrhotic, how badly damaged is it)
- Age and overall fitness of the patient.
If the liver is healthy, the patient fit, and the tumour can be safely cut out, then surgical resection of the tumour can be considered. If the tumour is large and cannot be safely removed, then chemoembolisation can be considered. This involves injecting an anti-cancer drug or a radio-active substance into the artery that feeds the tumour-bearing part of the liver (the drug may be mixed in an oily fluid or in very tiny glass beads). If the tumour is small but the patient is unfit/unwilling to withstand surgery, radiofrequency ablation (RFA) can be considered. This involves placing a needle into the tumour and destroying it with energy generated at the tip of the needle.
Primary bile duct cancer (Cholangiocarcinoma)
Please see the section on Bile duct cancer
Secondary liver tumours
Secondary liver tumours
FDG PET scan picture showing a secondary tumour deposit in the liver
Why do secondary tumours develop in the liver?
A cancerous tumour in any part of the body can release cells that go floating in the bloodstream. These cells can land up in another part of the body (such as the liver), and grow there to form secondary cancers, or metastases. The liver is a common site of secondary cancer.
How are bowel cancers different from other cancers when it comes to liver secondaries?
When a breast cancer, for example, causes liver metastases, it is very likely that the cancer cells have gone floating around the entire body, and there are metastases elsewhere too, especially the lungs and the bones. But with bowel cancer, the situation is slightly different. All the blood flowing out of the bowel first goes to the liver via the portal vein. The liver acts as a filter, and is therefore the first, and often the only site of secondary deposits from bowel cancer. It is now well-recognised that surgical removal of the liver metastases from bowel cancer (or to be more precise, colon and rectum cancer) can achieve a cure in a significant proportion of patients. When it comes to other cancers, surgical resection of liver metastases may still have a role to play, but only in a very small proportion of patients.
Another group of patients who may similarly benefit from liver resection are patients with liver metastases from neuro-endocrine tumours. These are an unusual group of tumours, that arise from hormone-secreting cells in the bowel, the pancreas, or in other organs. One variety is called carcinoid. Others are named after the hormone they release e.g. insulinoma, glucagonoma, somatostatinoma or gastrinoma, because they release insulin, glucagon, somatostatin, gastrin etc. For more information on these tumours, please see the section on the pancreas.
What symptoms do liver metastases cause?
A third of liver metastases from colorectal cancer show up at the same time as the primary cancer.
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Reasons for the inconsistent results might be the dose, duration of treatment, or formulation of Garcinia extract that was used.
Any patient who has been diagnosed with colorectal cancer, should have their liver scanned, and the surgeon removing the cancer should inspect the liver during the operation. The rest may show up months or years after the primary has been diagnosed and treated. These tumours may not cause any symptoms for quite a while, and show up only when in an advanced stage. They can cause jaundice (yellow discolouration of the skin and the eyes), pain in the upper abdomen, weight loss and loss of appetite. Sometimes the enlarged liver or a lump can be felt in the upper right hand side of the abdomen. How are liver metastases diagnosed? Diagnosis is usually made on the basis of an ultrasound scan, and then a CT or an MR is done to confirm that. Patients who have already undergone surgery for colorectal cancer are often kept on regular surveillance with ultrasound scans, and many liver metastases now get picked up on such scans, at an early stage. A whole body scan called FDG PET is useful in determining if there are other secondaries elsewhere in the body. A radioisotope-labelled substance called Fluoro-deoxy-glucose is injected into the bloodstream, and gets taken up cancer deposits wherever they are. These then show up on a whole-body scan (but only if they are close to 1 cm in size). Colorectal cancers often release a substance in the blood stream, called Carcinoembryonic antigen (CEA). This is known as a tumour marker. If the CEA level in the blood is raised, it very strongly suggests that the patient has colorectal cancer. But the converse does not always apply – if the CEA levels are normal, that does not rule out cancer. Needle biopsy of liver metastases can be done, but it does carry a small amount of risk, and should therefore be restricted to situations where it is absolutely necessary.
What is the treatment?
The treatment of colorectal liver metastases depends on:
- Tumour stage (how many nodules are present in the liver, how large are they, where exactly are they located in the liver, has the tumour spread to surrounding lymph nodes or to distant organs like the lungs or bones
- Condition of the liver itself (is it healthy or cirrhotic, and if it is cirrhotic, how badly damaged is it)
- Age and overall fitness of the patient.
If the patient is fit to undergo surgery and has an otherwise healthy liver, and the tumours can be safely cut out, then surgical resection should be considered. In surgical units that carry out such operations routinely, over 95% of patients who undergo a liver resection will recover from the surgery and go home. If the tumours cannot be safely removed, because they are either too large, too many, or located close to major blood vessels then several other treatment options can be considered.
- RFA: For tumours up to 4 cm in diameter, radiofrequency ablation (RFA) can be considered. This involves placing a needle into the tumour and destroying it with energy generated at the tip of the needle. The procedure is reasonably safe, but there is not enough evidence yet to show that this is as effective as surgical resection in the longer term
- Chemotherapy: For a long time, the mainstay of chemotherapy for colon cancer was a drug called 5-FU, with modest results. Over the past decade, several new and highly effective drugs have become available, such as Oxaliplatin and Irinotecan. More recently, drugs such as Cetuximab and Bevacizumab have been introduced. Patients with unresectable liver tumours may be given chemotherapy with the specific intent of downsizing the tumours and then carrying out surgical resection.
- Portal vein embolisation: Sometimes, the tumours are located in such a manner within the liver that a large part of the liver needs to be removed (for example the entire right lobe and part of the left lobe). But the amount of liver that will then be left behind may be too small and the patient will run a very high risk of developing liver failure. In such situations, it is possible to block off the portal vein inflow of blood into the parts of the liver that are going to be removed.
Reported side effects for garcinia cambogia are mild.
They then start to shrink (atrophy) while the rest of the liver (the part that is going to be left behind) starts to grow. In a period of 2 to 6 weeks, substantial growth may be seen, and a surgical resection may become possible. The procedure itself involves a puncture of the liver to inject glue-like material into the relevant branch of the portal vein. Alternatively the branch of the portal vein may be tied off during a surgical operation.
- SIRT or selective intra-arterial radiation therapy involves injection of tiny glass beads or microspheres containing a radioactive substance, directly into the artery that feeds the liver. This selectively targets the tumour deposits in the liver. While it is deemed safe, its efficacy has not been shown to be any better than standard chemotherapy, and it is not funded by the NHS.
- Liver transplantation should NOT be considered in patients with metastatic colorectal cancer. It has been tried, with abysmal results. The patients inevitably develop recurrent cancer and do not survive long. However, in patients with metastatic neuroendocrine cancer, a small proportion of patients with disease confined to the liver alone may benefit from transplantation.
- If the patient is very unwell, or the tumour is very large or has spread beyond the liver, then control of symptoms should be the main focus of care. Chemotherapy with a palliative intent can be considered. External beam radiation may help in the treatment of painful bone secondaries. Any new treatments offered to such patients should be within the context of a proper clinical trial.
CT scan showing the liver (lilac outline) and a secondary tumour within it (the dark area)
Find a Vitamin or Supplement
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See All Names Brindal Berry, Brindle Berry, Cambogia binucao, Cambogia gemmi-guta, Garcinia affinis, Garcinia Cambogi, Garcinia cambogia, Garcinia gummi-guta, Garcinia sulcata, Gorikapuli, Kankusta, Kudam puli, Malabar Tamarind, Mangostana cambogia, Tamarinier de Malabar, Vrikshamla.
GARCINIA Overview Information
Garcinia is a small to medium-sized tree that grows in India and Southeast Asia. The fruit rind contains the chemical hydroxycitric acid (HCA) and is used to make medicine. Don't confuse Garcinia with Garcinia hanburyi (gamboge resin).
How does it work?
Garcinia contains the chemical hydroxycitric acid (HCA). Developing research suggests that HCA might prevent fat storage, control appetite, and increase exercise endurance; however, whether these effects occur in humans is unclear.
GARCINIA Uses & Effectiveness
Insufficient Evidence for:
- Exercise performance. Taking a chemical compound found in Garcinia called hydroxycitric acid (HCA) might increase how long untrained women are able to exercise. However, it does not seem benefit men in the same way.
- Weight loss. Research on the effect of Garcinia on weight loss is inconsistent. Some research shows that taking Garcinia extract that contains 50% hydroxycitric acid (HCA) for 8-12 weeks doesn't decrease fat breakdown or energy expenditure in overweight people. However, other research suggests that it might improve weight loss when taken for 12 weeks. Taking a specific Garcinia product containing 60% HCA (Super CitriMax InterHealth Nutriceuticals) by mouth in three doses daily 30 to 60 minutes before meals for 8 weeks, together with a healthy diet, seems to improve weight loss more than just diet alone. But other research shows that adding this specific Garcinia product to cereal bars or tomato juice and consuming them before lunch and dinner for 2 weeks does not improve weight loss. Reasons for the inconsistent results might be the dose, duration of treatment, or formulation of Garcinia extract that was used.
- Joint pain.
- Treating worms and parasites.
- Emptying the bowel.
- Severe diarrhea (dysentery).
- Other conditions.
GARCINIA Side Effects & Safety
Garcinia is POSSIBLY SAFE for most people when taken by mouth for 12 weeks or less.
Criticisms Of This Study One of the main criticisms of this study comes from Harry Preuss, a researcher at Georgetown University who claims that the JAMA study “used whatever the dose was at the time, and they never mentioned the type of citrate they used.” In other words, they may have been using the wrong HCA.
Long-term safety is unknown. Garcinia can cause nausea, digestive tract discomfort, and headache.
Special Precautions & Warnings:
We currently have no information for GARCINIA Interactions
The appropriate dose of garcinia depends on several factors such as the user's age, health, and several other conditions. At this time, there is not enough scientific information to determine an appropriate range of doses for garcinia. Keep in mind that natural products are not always necessarily safe and dosages can be important. Be sure to follow relevant directions on product labels and consult your pharmacist or physician or other healthcare professional before using.
Bunchorntavakul, C. and Reddy, K. R. Review article: herbal and dietary supplement hepatotoxicity. Aliment.Pharmacol.Ther 2013;37(1):3-17. View abstract.
Jena, B. S., Jayaprakasha, G. K., Singh, R. P., and Sakariah, K. K. Chemistry and biochemistry of (-)-hydroxycitric acid from Garcinia. J Agric.Food Chem. 1-2-2002;50(1):10-22. View abstract.
Kriketos, A. D., Thompson, H. R., Greene, H., and Hill, J. O. (-)-Hydroxycitric acid does not affect energy expenditure and substrate oxidation in adult males in a post-absorptive state. Int J Obes.Relat Metab Disord. 1999;23(8):867-873. View abstract.
Actis GC, Bugianesi E, Ottobrelli A, Rizzetto M. Fatal liver failure following food supplements during chronic treatment with montelukast. Dig Liver Dis. 2007 Oct;39(10):953-5. View abstract.
Allen SF, Godley RW, Evron JM, et al. Acute necrotizing eosinophilic myocarditis in a patient taking Garcinia cambogia extract successfully treated with high-dose corticosteroids. Can J Cardiol 2014;30(12):1732 e13-1732 e15. View abstract.
Badmaev V, Majeed M, Conte AA. Garcinia cambogia for weight loss. JAMA 1999;282:233-4; discussion 235. View abstract.
Chuah LO, Yeap SK, Ho WY, et al. In vitro and In vivo toxicity of Garcinia or hydroxycitric acid: a review. Evid Based Compl Alt Med 2012;2012:197920. View abstract.
Corey R, Werner KT, Singer A, Moss A, Smith M, Noelting J, Rakela J. Acute liver failure associated with Garcinia cambogia use. Ann Hepatol. 2016 Jan-Feb;15(1):123-6. View abstract.
Dara L, Hewett J, Lim JK. Hydroxycut hepatotoxicity: a case series and review of liver toxicity from herbal weight loss supplements. World J Gastroenterol. 2008 Dec 7;14(45):6999-7004. View abstract.
Firenzuoli F, Gori L. Garcinia cambogia for weight loss. JAMA 1999;282:234; discussion 235. View abstract.
García-Cortés M, Robles-Díaz M, Ortega-Alonso A, Medina-Caliz I, Andrade RJ. Hepatotoxicity by Dietary Supplements: A Tabular Listing and Clinical Characteristics. Int J Mol Sci. 2016 Apr 9;17(4):537. View abstract.
Hasegawa N. Garcinia extract inhibits lipid droplet accumulation without affecting adipose conversion in 3T3-L1 cells. Phytother Res 2001;15:172-3. View abstract.
Heymsfield SB, Allison DB, Vasselli JR, et al. Garcinia cambogia (hydroxycitric acid) as a potential antiobesity agent: a randomized controlled trial. JAMA 1998;280:1596-600. View abstract.
Ishihara K, Oyaizu S, Onuki K, Lim K, et al. Chronic (-)-hydroxycitrate administration spares carbohydrate utilization and promotes lipid oxidation during exercise in mice. J Nutr 2000;130:2990-5. View abstract.
Kovacs EM, Westerterp-Plantenga MS, Saris WH. The effects of 2-week ingestion of (--)-hydroxycitrate and (--)-hydroxycitrate combined with medium-chain triglycerides on satiety, fat oxidation, energy expenditure and body weight. Int J Obes Relat Metab Disord 2001;25:1087-94. View abstract.
Lim K, Ryu S, Nho HS, et al. (-)-Hydroxycitric acid ingestion increases fat utilization during exercise in untrained women. J Nutr Sci Vitaminol (Tokyo) 2003;49:163-167. View abstract.
Lopez AM, Kornegay J, Hendrickson RG. Serotonin Toxicity Associated with Garcinia cambogia Over-the-counter Supplement. J Med Toxicol. 2014 Apr 4. [Epub ahead of print]. View abstract.
Mansi IA, Huang J.
In another study, which was published in the International Journal of Obesity and Related Metabolic Disorders in 2002, a study called “The Affect of Hydroxycitrate on Energy Intake and Satiety in Overweight Individuals,” showed that a group of 12 subjects who took 900mg of HCA over the course of 12 weeks consumed less calories, experienced less snacking, and had an overall reduced body weight.
Rhabdomyolysis in response to weight-loss herbal medicine. Am J Med Sci 2004;327:356-357. View abstract.
Marquez F, Babio N, Bullo M, Salas-Salvado J. Evaluation of the safety and efficacy of hydroxycitric acid or Garcinia cambogia extracts in humans. Crit Rev Food Sci Nutr 2012;52:585-94. View abstract.
Mattes RD, Bormann L. Effects of (-)-hydroxycitric acid on appetitive variables. Physiol Behav 2000;71:87-94. View abstract.
Melendez-Rosado J, Snipelisky D, Matcha G, Stancampiano F. Acute hepatitis induced by pure Garcinia cambogia. J Clin Gastroenterol. 2015 May-Jun;49(5):449-50. View abstract.
Preuss HG, Bagchi D, Bagchi M, et al. Effects of a natural extract of (-)-hydroxycitric acid (HCA-SX) and a combination of HCA-SX plus niacin-bound chromium and Gymnema sylvestre extract on weight loss. Diabetes Obes Metab 2004;6:171-180. View abstract.
Rashid NN, Grant J. Hydroxycut hepatotoxicity. Med J Aust. 2010 Feb 1;192(3):173-4. View abstract.
Schaller JL. Garcinia cambogia for weight loss. JAMA 1999;282:234; discussion 235. View abstract.
Sharma T, Wong L, Tsai N, Wong RD. Hydroxycut(®) (herbal weight loss supplement) induced hepatotoxicity: a case report and review of literature. Hawaii Med J. 2010 Aug;69(8):188-90. View abstract.
Soni MG, Burdock GA, Preuss HG, et al. Safety assessment of (-)-hydroxycitric acid and Super CitriMax, a novel calcium/potassium salt. Food Chem Toxicol 2004;42:1513-29. View abstract.
Stevens T, Qadri A, Zein NN. Two patients with acute liver injury associated with use of the herbal weight-loss supplement hydroxycut. Ann Intern Med 2005;142:477-8. View abstract.
Vasques CA, Schneider R, Klein-Júnior LC, et al. Hypolipemic effect of Garcinia Cambogia in obese women. Phytother Res 2014;28(6):887-91. View abstract.
Westerterp-Plantenga MS, Kovacs EMR. The effect of (-)-hydroxycitrate on energy intake and satiety in overweight humans. Int J Obesity 2002;26:870-2. View abstract.
WHAT IS CERVICAL SPONDYLOSIS & neck Pain ?
What is Cervical Spine ?
The cervical spine is made up of small circular bones (vertebrae) stacked on top of each other. Between each vertebrae is an intervertebral disc which acts like a shock absorber and allows flexibility of the spine. Muscles and ligaments run between, and are attached to, the vertebrae. Nerves from the spinal cord pass between the vertebrae going to the shoulder, neck, arm, and upper chest.
Reach your right arm over your head so that your palm is on topВ of your skull, your fingers resting just above the left ear. Allow the weight of your arm, along with light fingertip pressure, to gently bend the head toward your right shoulderВ (fig.1). Do not strain. Check to make sure your shoulders are still relaxed. You should be looking forward. Hold the pose for 30 seconds. Move your fingers toward the back left corner of your skull, this time allowing your head to bend forward and to the right, about 45 degrees in front of your shoulderВ (fig.2).
Hold for 30 seconds. Now place your fingers at the back of your skull and gently pull your head straight forward, toward your chestВ (fig.3). Hold for 30 seconds. Switch hands and repeat the stretches in reverse order: Pull forward, then 45 degrees in front of your left shoulder, and finally directly over your left shoulder. Do not push your head backward. Do an isometric push against your hand to strengthen the neck. Hold your left palm against the left side of your head(fig.4). Push your left hand against your head while also pushing your head toward your left hand at about half strength. Hold for 30 seconds. Repeat with your right hand on the right side of the head. Do the same exercise, using either hand, with the back of the headВ (fig.5)В and the foreheadВ (fig.6).