Tag Archives: liver cancer

Top Five Reasons to Evaluate Nonalcoholic Fatty Liver Disease (NAFLD)

Dr. Rashid Khan adds this blog entry further reviewing important issues related to nonalcoholic fatty liver disease (NAFLD)

I few weeks ago I wrote on this topic as guest editor on Dr Joe Galati’s blog. We talked about some basic concepts surrounding Nonalcoholic Fatty Liver Disease (NAFLD). To recap, this condition involves fat accumulation in the liver of non drinkers. I mentioned the importance of prompt evaluation, necessary investigations and potential therapies. Here I once again write about this common condition, afflicting close to 100 million Americans, highlighting five reasons why NAFLD needs to be taken seriously.

  1. The most relevant reason from a liver doctor’s perspective is the potential transformation of fatty liver disease to liver cirrhosis. Fatty liver is generally benign, but the development of cirrhosis becomes a game changer.
  2. Along with the potential risk of cirrhosis, comes the added risk of developing liver cancer. Studies have shown that this risk is even present in the absence of cirrhosis, though small.
  3. Cardiovascular disease( CVD) is one of the most common medical conditions in the US and globally. NAFLD and CVD go hand in hand. Usually both exist in many patients. Fatty liver is known to be an independent predictor of CVD.
  4. Type II diabetes is another very common medical condition . Numerous studies have shown the propensity of diabetic patients to develop fatty liver . This association is bi directional, meaning some patients with fatty liver will go on to develope diabetes.
  5. Finally, I will mention chronic kidney disease( CKD), another disease afflicting millions of Americans in this day and age. While the association of NAFLD and CKD may not be as robust as with CVD and diabetes, nevertheless it all comes back to the metabolic syndrome entity, which involves dangerous plaque build up in the blood vessels throughout the body.


Here at Liver Specialists of Texas, it is our sincere hope that fatty liver disease is recognized and evaluated in its earliest stages. Our practice is specifically geared towards the management of these patients, as well as other liver diseases, and we will be more than happy to see you in our offices.

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Alcoholic Liver Disease: What You Need to Know-The Basics

Our latest video covers the basic aspects of alcohol related liver disease, and the complications of excessive alcohol intake. In general, there are three areas of concern:

1. The development of alcoholic fatty liver disease

2. The development of acute alcoholic hepatitis

3. Alcoholic cirrhosis

The major point to understanding is that all alcoholic drinks (servings) have about the same amount of alcohol in them. Thus, 1-beer, 1-glass of wine, and 1-serving of spirit (i.e. vodka, rum, gin, etc) all have approximately 10-12 grams of alcohol in them. Alcohol is alcohol, regardless of the volume, color, or taste.

The other key point to remember, is that the amount of alcohol daily is different for men and women. For women, one serving/day is the limit; two for men. Period. Above this, you run the risk of complications.

View our latest video.

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Hepatitis C, Liver Cancer, and Bad New for Patients: It’s Never Easy

Hepatitis C, Liver Cancer, and Bad New for Patients: It’s Never Easy

Liver Cancer Discussion with Dr. Joe Galati

Liver Cancer Discussion with Dr. Joe Galati

Primary liver cancer, or hepatocellular carcinoma, is a growing problem we face in the care of patients with chronic liver disease, especially hepatitis C. The number of new cases of liver cancer I see each week has grown steadily over the past 15 years. A lot of this has to do with the aging population of patients with hepatitis C. It is well known that the development of liver cancer is a function of time. The longer you liver with hepatitis C, the annual chance of developing cancer increases. The incidence of developing liver cancer is approximately 3-8% per year. Liver cancer is highest in those with cirrhosis; the risk of cancer in hepatitis C patients without cirrhosis is significantly reduced.

Over the years, we have developed a very good strategy to screen for liver cancer in those with hepatitis B and hepatitis C, as well as other causes of cirrhosis. The general strategy is to obtain an ultrasound of the liver along with a blood tumor marker, alphafetoprotein (AFP), every six months. Following these guidelines has shown to reduce death by 37%.

In practices with large numbers of patients with cirrhosis, keeping track of everyone that needs to be screened is a daunting process. Even with the use of electronic medical records, keeping up with everyone is difficult. Despite our best efforts, and alerting patients, they still need to go and have the scan performed, and get their blood work as scheduled. People are human, and they forget to get these tests done in a timely fashion. During tough financial times, patients ask me if they can extend the frequency of testing from every six months to 8-12 months. High deductibles, tuition bills, and other expenses take priority over these necessary scans. As I have said before, all I can do is encourage the patient, educate them on the importance of screening and early detection and cancer, and document it in their medical record. Unfortunately, I have seen cases where skipping required scans have resulted in the development of new, large cancers, that are not amendable to proper treatment.

Routine screening with AFP and ultrasound (or in certain cases MRI or CT scan), small liver cancers are detected. In the setting of cirrhosis, surgical resection is never routinely recommended, due to the high risk of precipitating progressive liver failure and death. Instead, local therapy applied to the tumor is preferred. The two most common therapies we use are radio-frequency ablation (RFA), and transarterial-chemoembolization (TACE). Collectively, these are referred to as loco-regional therapies. A review is available here. In both of these therapies, along with the local delivery of radiation, in the form of yttrium-90, focused treatment can be delivered right to the tumor, instead of a systemic method, which is given by mouth or vein, exposing the entire body to these medicines.

In addition to loco-regional therapy, liver transplantation is at the heart of therapy for hepatocellular carcinoma in patients with cirrhosis. To be considered for transplant, the size and location of the tumor needs to be within specific guidelines.

The Milan criteria state that a patient is selected for transplantation when he or she has:

  • one lesion smaller than 5 cm.
  • up to 3 lesions smaller than 3 cm.
  • no extrahepatic manifestations
  • no vascular invasion

With all of this said, we have:

a. Identified those patients with an increased risk of liver cancer (hepatitis C, hepatitis B, alcoholic cirrhosis, all other forms of cirrhosis).

b. Established a screening strategy (ultrasound and AFP every six months).

c. Understand the biology of these tumors, the doubling time and rate of growth.

d. Developed protocols for treatment (loco-regional therapies, sorafenib, liver transplant).

Unfortunately, this always doesn’t work out as planned.

Today, I had the unfortunate job of talking with a long-time patient of mine, and explaining to him that literally out of nowhere, a liver cancer developed, exceeding criteria for transplant, and that there appeared to be invasion of the tumor into his portal vein. This further complicated the options for him. He had always been compliant, getting scans and blood work in a timely fashion. His last MRI was a little less than 6 months ago. On review, no less that five times, with multiple sets of expert eyes, there was no indication that there was a tumor brewing at the last scan, that may have been missed. He had the best of technology scanning his liver.

The lessons here are important. Despite all parties doing their job in a diligent manner, bad things happen to good people. As a physician, I am reminded daily that I have little control in what happens to my patients. All of the science and technology cannot save everyone. The news I shared was devastating to him and his wife. He walked into my office this afternoon thinking that a transplant was needed, but left with the news that most good options had been lost. Keeping emotions at bay, I forged ahead to develop a credible plan “B”. In situations like this, physicians and all healthcare providers need to display empathy, rather than sympathy for our patients. I purposely did not discuss with them “survival”, or “how much time he had left”. Over the many years of listening to patients, the one thing that upsets patients more than anything else is a physician telling them, with authority, what their expected survival will be. In cases of clear-cut terminal illness, I will be more specific. These are cases where an amateur could see that a person was moments from death. Once you define length of survival in these early discussions mortality, more negative comes from it than good.

We did take the time to lay out a plan, one I believe can leave them with a sense that there will be options to try. At each turn, we can readjust our expectations. I do not feel I candy-coated the discussion.

After 25 plus years of delivering bad news to patients, it is never easy, and it pains me and my staff each and every time. We all take the time to get to know our patients, and their families. We become friends, and share laughs when we meet. Days like today suck for all of us.

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Second Opinion in Hepatitis: Videoconferencing Between Houston and the World

Each week, I receive dozens of e-mails from followers of our social media sites (Twitter, YouTube, FaceBook, Your Health First, and Liver Specialists of Texas) seeking assistance regarding some form of liver disease they are suffering from, or one of their relatives. I usually respond back with some direction they should head in, or ask if they are available to travel to Houston for a face-to-face evaluation.

As technology improves, the availability of videoconferencing has never been easier. Working with Houston based software developers, there is now the opportunity to participate in a second opinion program with experts in liver disease in our practice. Because there is such variability in everyone’s home or work connectivity to the internet, we plan on supplying you with the needed technology to connect.

The savings of not having to travel to Houston, hotel and food charges, lost wages, and time, makes this an economically sensible alternative.

Second opinions in all aspects of liver disease will be available, including abnormal liver tests, fatty liver disease, hepatitis C, hepatitis B, cirrhosis, liver cancer, alcohol related liver disease, liver transplant, hemochromatosis, and autoimmune disease of the liver. The cost for this service will be based on a minimum of a 30 minute consultation, allowing for additional time at 15 minute increments. Medical records, x-ray reports and films, biopsies, and past consultations will be reviewed.

Feedback on this program is important to us. Please let us know what you think.

For additional information, contact Dee at (713) 634-5103.

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World Hepatitis Day: Missed Opportunities for Awareness?

Yesterday was World Hepatitis Day. This is a day where we can give special attention to the world wide problem of viral hepatitis, the people that it affects, and celebrate the new therapies and technology that are available.

Reviewing numerous websites and online publications, they all state the desire to alert the world, as well as those of us in the United States, to the perils of viral hepatitis. A press release from the American Liver Foundation stated the following:

Hopefully, July 28 will be a day when more Americans become familiar with how to prevent, get tested and treated for hepatitis.

Unfortunately, the best of sincere intentions has made barely a ripple in the global understanding of viral hepatitis. No major television news outlet in the United States, nor such papers such as the New York Times, mentioned World Hepatitis Day.

Considering there are 1.4 million cases of hepatitis A every year, 240 million people living with chronic hepatitis B, 150 million people chronically infected with hepatitis C, this remains a global health concern. Untreated hepatitis B and C leads to progressive liver failure, the eventual development of liver cancer, and the need for liver transplantation. Effective antiviral therapies are available, and the key is early diagnosis and intervention.

The hepatitis community needs to take a more aggressive strategic stance, along the lines of HIV and breast cancer awareness. I salute these two diseases, and their respective organizations, in that they have done a superior job in creating public awareness and a call to action.

I dream for the day that the publics understanding and awareness of viral hepatitis is at the level of HIV and breast cancer awareness. My goal day after day is to touch as many people as possible, spreading the word on viral hepatitis, both locally and on a worldwide basis.

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Boxer Joe Frazier Dies of Liver Cancer

Boxer Joe Frazier Dies of Liver Cancer

Liver Cancer

It was announced that boxer Joe Frazier died of liver cancer. The 67 year old boxer was reported to have a “short” bout with liver cancer that ended his life quickly.

As of this morning, there is no mention as to they type of cancer that he suffered from. Liver cancer, also called hepatocellular carcinoma, or hepatoma, is cancer that originates in the liver, opposed to metastatic liver cancer that starts elsewhere, and then spreads to the liver. Colon and breast cancer are two cancers that commonly spread to the liver.

Primary liver cancer in the majority of cases is related to underlying chronic liver disease, caused by chronic viral hepatitis B and hepatitis C. Alcoholic liver disease is also a strong risk factor for developing hepatocellular carcinoma.

Treatment for liver cancer depends on the stage of the disease. In patients without cirrhosis and small tumors, surgical resection is a possible consideration. In those with advanced liver disease and cirrhosis, local therapy with chemotherapy, also known as transarterial chemoembolization (TACE), is usually the first line of therapy. Radiofrequency ablation (RFA) is an alternative option to locally treat the tumor. Liver transplantation, where the entire liver is removed, will be considered in those with signs of advanced liver disease or cirrhosis.

Recently, there has been FDA approval of Nexavar (sorafenib) for the treatment of liver cancer.

Nexavar® (sorafenib) tablets, is approved in more than 100 countries for the treatment for patients with hepatocellular carcinoma (HCC), the most common form of liver cancer, and for patients with advanced renal cell carcinoma (RCC), or kidney cancer.

The American Cancer Society’s most recent estimates for primary liver cancer and intrahepatic bile duct cancer in the United States are for 2010:

About 24,120 new cases (17,430 in men and 6,690 in women) will be diagnosed
About 18,910 people (12,720 men and 6,190 women) will die of these cancers
The percentage of Americans developing liver cancer has been rising slowly for several decades.

If you have any form of chronic liver disease, chronic alcoholism, chronic hepatitis B, hepatitis C, or cirrhosis, you need to be regularly screened for liver cancer. A blood test called alpha fetoprotein should be done at six month intervals, which tests for the presence of liver cancer, and imaging of the liver with either ultrasound, CT scan, or MRI should also be done at six month intervals. The development of a small tumor, should one develop, allows for the greatest chance that early treatment can be initiated and survival can be at its highest level.

I am currently at the annual meeting of the Association for the Study of Liver Diseases in San Francisco, and there is an enormous amount of research being presented on expanding therapies for liver cancer. Why Joe Frazier presented so late with his disease is a question we may never know for sure. While aggressive forms of liver cancer do exist, and in the best of situations there is little to do as a result of its rapid advancement. The more common story I see every day is one of lack of awareness, lack of screening, and a very late presentation.

Awareness of the presence of liver disease and appropriate screening saves lives.

Your feedback is welcomed.

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