Liver Cancer

What is liver cancer (hepatocellular carcinoma, HCC)?

Liver cancer (hepatocellular carcinoma) is a cancer arising from the liver. It is also known as primary liver cancer or hepatoma. The liver is made up of different cell types (for example, bile ducts, blood vessels, and fat-storing cells). However, liver cells (hepatocytes) make up 80% of the liver tissue. Thus, the majority of primary liver cancers (over 90 to 95%) arises from liver cells and is called hepatocellular cancer or carcinoma.

When patients or physicians speak of liver cancer, however, they are often referring to cancer that has spread to the liver, having originated in other organs (such as the colon, stomach, pancreas, breast, and lung). More specifically, this type of liver cancer is called metastatic liver disease (cancer) or secondary liver cancer. Thus, the term liver cancer actually can refer to either metastatic liver cancer or hepatocellular cancer. The subject of this article is hepatocellular carcinoma, which I will refer to as liver cancer.

What is the scope of the liver cancer problem?

Liver cancer is the fifth most common cancer in the world. A deadly cancer, liver cancer will kill almost all patients who have it within a year. In 1990, the World Health Organization estimated that there were about 430,000 new cases of liver cancer worldwide, and a similar number of patients died as a result of this disease. About three quarters of the cases of liver cancer are found in Southeast Asia (China, Hong Kong, Taiwan, Korea, and Japan). Liver cancer is also very common in sub-Saharan Africa (Mozambique and South Africa).

The frequency of liver cancer in Southeast Asia and sub-Saharan Africa is greater than 20 cases per 100,000 population. In contrast, the frequency of liver cancer in North America and Western Europe is much lower, less than five per 100,000 population. However, the frequency of liver cancer among native Alaskans is comparable to that seen in Southeast Asia. Moreover, recent data show that the frequency of liver cancer in the U.S. overall is rising. This increase is due primarily to chronic hepatitis C, an infection of the liver that causes liver cancer.

What are the population characteristics (epidemiology) of liver cancer?

In the U.S. the highest frequency of liver cancer occurs in immigrants from Asian countries, where liver cancer is common. The frequency of liver cancer among Caucasians is the lowest, whereas among African-Americans and Hispanics, it is intermediate. The frequency of liver cancer is high among Asians because liver cancer is closely linked to chronic hepatitis B infection. This is especially so in individuals who have been infected with chronic hepatitis B for most of their lives. If you take a world map depicting the frequency of chronic hepatitis B infection, you can easily superimpose that map on a map showing the frequency of liver cancer.

The initial presentation (symptoms) of liver cancer in patients in areas of high liver cancer frequency is quite different from that seen in low frequency areas. Patients from high frequency areas usually start developing liver cancer in their 40s, and the cancer is usually more aggressive. That is, the liver cancer presents with severe symptoms and is inoperable (too advanced for surgery) at the time of diagnosis. Also, in these areas, the frequency of liver cancer is three to four times higher in men than in women, and most of these patients are infected with chronic hepatitis B. In contrast, liver cancer in lower risk areas occurs in patients in their 50s and 60s and the predominance of men is less striking.

What are the risk factors for liver cancer?

Hepatitis B infection

The role of hepatitis B virus (HBV) infection in causing liver cancer is well established. Several lines of evidence point to this strong association. As noted earlier, the frequency of liver cancer relates to (correlates with) the frequency of chronic hepatitis B virus infection. In addition, the patients with hepatitis B virus who are at greatest risk for liver cancer are men with hepatitis B virus cirrhosis (scarring of the liver) and a family history of liver cancer. Perhaps the most convincing evidence, however, comes from a prospective (looking forward in time) study done in the 1970's in Taiwan involving male government employees over the age of 40. In this study, the investigators found that the risk of developing liver cancer was 200 times higher among employees who had chronic hepatitis B virus as compared to employees without chronic hepatitis B virus!

Studies in animals also have provided evidence that hepatitis B virus can cause liver cancer. For example, we have learned that liver cancer develops in other mammals that are naturally infected with hepatitis B virus-related viruses. Finally, by infecting transgenic mice with certain parts of the hepatitis B virus, scientists caused liver cancer to develop in mice that do not usually develop liver cancer. (Transgenic mice are mice that have been injected with new or foreign genetic material.)

How does chronic hepatitis B virus cause liver cancer? In patients with both chronic hepatitis B virus and liver cancer, the genetic material of hepatitis B virus is frequently found to be part of the genetic material of the cancer cells. It is thought, therefore, that specific regions of the hepatitis B virus genome (genetic code) enter the genetic material of the liver cells. This hepatitis B virus genetic material may then disrupt the normal genetic material in the liver cells, thereby causing the liver cells to become cancerous.

The vast majority of liver cancer that is associated with chronic hepatitis B virus occurs in individuals who have been infected most of their lives. In areas where hepatitis B virus is not always present (endemic) in the community (for example, the U.S.), liver cancer is relatively uncommon. The reason for this is that most of the people with chronic hepatitis B virus in these areas acquired the infection as adults. However, liver cancer can develop in individuals who acquired chronic hepatitis B virus in adulthood if there are other risk factors, such as chronic alcohol use or co-infection with chronic hepatitis C virus infection.

Hepatitis C infection

Hepatitis C virus (HCV) infection is also associated with the development of liver cancer. In fact, in Japan, hepatitis C virus is present in up to 75% of cases of liver cancer. As with hepatitis B virus, the majority of hepatitis C virus patients with liver cancer have associated cirrhosis (liver scarring). In several retrospective-prospective studies (looking backward and forward in time) of the natural history of hepatitis C, the average time to develop liver cancer after exposure to hepatitis C virus was about 28 years. The liver cancer occurred about eight to 10 years after the development of cirrhosis in these patients with hepatitis C. Several prospective European studies report that the annual incidence (occurrence over time) of liver cancer in cirrhotic hepatitis C virus patients ranges from 1.4 to 2.5% per year.

In hepatitis C virus patients, the risk factors for developing liver cancer include the presence of cirrhosis, older age, male gender, elevated baseline alpha-fetoprotein level (a blood tumor marker), alcohol use, and co-infection with hepatitis B virus. Some earlier studies suggested that hepatitis C virus genotype 1b (a common genotype in the U.S.) may be a risk factor, but more recent studies do not support this finding.

The way in which hepatitis C virus causes liver cancer is not well understood. Unlike hepatitis B virus, the genetic material of hepatitis C virus is not inserted directly into the genetic material of the liver cells. It is known, however, that cirrhosis from any cause is a risk factor for the development of liver cancer. It has been argued, therefore, that hepatitis C virus, which causes cirrhosis of the liver, is an indirect cause of liver cancer.

On the other hand, there are some chronic hepatitis C virus infected individuals who have liver cancer without cirrhosis. So, it has been suggested that the core (central) protein of hepatitis C virus is the culprit in the development of liver cancer. The core protein itself (a part of the hepatitis C virus) is thought to impede the natural process of cell death or interfere with the function of a normal tumor suppressor (inhibitor) gene (the p53 gene). The result of these actions is that the liver cells go on living and reproducing without the normal restraints, which is what happens in cancer.

Alcohol

Cirrhosis caused by chronic alcohol consumption is the most common association of liver cancer in the developed world. Actually, we now understand that many of these cases are also infected with chronic hepatitis C virus. The usual setting is an individual with alcoholic cirrhosis who has stopped drinking for ten years, and then develops liver cancer. It is somewhat unusual for an actively drinking alcoholic to develop liver cancer. What happens is that when the drinking is stopped, the liver cells try to heal by regenerating (reproducing). It is during this active regeneration that a cancer-producing genetic change (mutation) can occur, which explains the occurrence of liver cancer after the drinking has been stopped.

Patients who are actively drinking are more likely to die from non-cancer related complications of alcoholic liver disease (for example, liver failure). Indeed, patients with alcoholic cirrhosis who die of liver cancer are about 10 years older than patients who die of non-cancer causes. Finally, as noted above, alcohol adds to the risk of developing liver cancer in patients with chronic hepatitis C virus or hepatitis B virus infections.

Aflatoxin B1

Aflatoxin B1 is the most potent liver cancer-forming chemical known. It is a product of a mold called Aspergillus flavus, which is found in food that has been stored in a hot and humid environment. This mold is found in such foods as peanuts, rice, soybeans, corn, and wheat. Aflatoxin B1 has been implicated in the development of liver cancer in Southern China and Sub-Saharan Africa. It is thought to cause cancer by producing changes (mutations) in the p53 gene. These mutations work by interfering with the gene's important tumor suppressing (inhibiting) functions.

Drugs, medications, and chemicals

There are no medications that cause liver cancer, but female hormones (estrogens) and protein-building (anabolic) steroids are associated with the development of hepatic adenomas. These are benign liver tumors that may have the potential to become malignant (cancerous). Thus, in some individuals, hepatic adenoma can evolve into cancer.

Certain chemicals are associated with other types of cancers found in the liver. For example, thorotrast, a previously used contrast agent for imaging, caused a cancer of the blood vessels in the liver called hepatic angiosarcoma. Also, vinyl chloride, a compound used in the plastics industry, can cause hepatic angiosarcomas that appear many years after the exposure.

Hemochromatosis

Liver cancer will develop in up to 30% of patients with hereditary hemochromatosis. Patients at the greatest risk are those who develop cirrhosis with their hemochromatosis. Unfortunately, once cirrhosis is established, effective removal of excess iron (the treatment for hemochromatosis) will not reduce the risk of developing liver cancer.

Cirrhosis

Individuals with most types of cirrhosis of the liver are at an increased risk of developing liver cancer. In addition to the conditions described above (hepatitis B, hepatitis C, alcohol, and hemochromatosis), alpha 1 anti-trypsin deficiency, a hereditary condition that can cause emphysema and cirrhosis, may lead to liver cancer. Liver cancer is also strongly associated with hereditary tyrosinemia, a childhood biochemical abnormality that results in early cirrhosis.

Certain causes of cirrhosis are less frequently associated with liver cancer than are other causes. For example, liver cancer is rarely seen with the cirrhosis in Wilson's disease (abnormal copper metabolism) or primary sclerosing cholangitis (chronic scarring and narrowing of the bile ducts). It used to be thought that liver cancer is rarely found in primary biliary cirrhosis (PBC) as well. Recent studies, however, show that the frequency of liver cancer in PBC is comparable to that in other forms of cirrhosis.

What are the symptoms of liver cancer?

The initial symptoms (the clinical presentations) of liver cancer are variable. In countries where liver cancer is very common, the cancer generally is discovered at a very advanced stage of disease for several reasons. For one thing, areas where there is a high frequency of liver cancer are generally developing countries where access to healthcare is limited. For another, screening examinations for patients at risk for developing liver cancer are not available in these areas. In addition, patients from these regions actually have more aggressive liver cancer disease. In other words, the tumor usually reaches an advanced stage and causes symptoms more rapidly. In contrast, patients in areas of low liver cancer frequency tend to have liver cancer tumors that progress more slowly and, therefore, remain without symptoms longer.

Abdominal pain is the most common symptom of liver cancer and usually signifies a very large tumor or widespread involvement of the liver. Additionally, unexplained weight loss or unexplained fevers are warning signs of liver cancer in patients with cirrhosis. These symptoms are less common in individuals with liver cancer in the U.S. because these patients are usually diagnosed at an earlier stage. However, whenever the overall health of a patient with cirrhosis deteriorates, every effort should be made to look for liver cancer.

A very common initial presentation of liver cancer in a patient with compensated cirrhosis (no complications of liver disease) is the sudden onset of a complication. For example, the sudden appearance of ascites (abdominal fluid and swelling), jaundice (yellow color of the skin), or muscle wasting without causative (precipitating) factors (for example, alcohol consumption) suggests the possibility of liver cancer. What's more, the cancer can invade and block the portal vein (a large vein that brings blood to the liver from the intestine and spleen). When this happens, the blood will travel paths of less resistance, such as through esophageal veins. This causes increased pressure in these veins, which results in dilated (widened) veins called esophageal varices. The patient then is at risk for hemorrhage from the rupture of the varices into the gastrointestinal tract. Rarely, the cancer itself can rupture and bleed into the abdominal cavity, resulting in bloody ascites.

On physical examination, an enlarged, sometimes tender, liver is the most common finding. Liver cancers are very vascular (containing many blood vessels) tumors. Thus, increased amounts of blood feed into the hepatic artery (artery to the liver) and cause turbulent blood flow in the artery. The turbulence results in a distinct sound in the liver (hepatic bruit) that can be heard with a stethoscope in about one quarter to one half of patients with liver cancer. Any sign of advanced liver disease (for example, ascites, jaundice, or muscle wasting) means a poor prognosis. Rarely, a patient with liver cancer can become suddenly jaundiced when the tumor erodes into the bile duct. The jaundice occurs in this situation because both sloughing of the tumor into the duct and bleeding that clots in the duct can block the duct.

In advanced liver cancer, the tumor can spread locally to neighboring tissues or, through the blood vessels, to elsewhere in the body (distant metastasis). Locally, liver cancer can invade the veins that drain the liver (hepatic veins). The tumor can then block these veins, which results in congestion of the liver. The congestion occurs because the blocked veins cannot drain the blood out of the liver. (Normally, the blood in the hepatic veins leaving the liver flows through the inferior vena cava, which is the largest vein that drains into the heart.) In African patients, the tumor frequently blocks the inferior vena cava. Blockage of either the hepatic veins or the inferior vena cava results in a very swollen liver and massive formation of ascites. In some patients, as previously mentioned, the tumor can invade the portal vein and lead to the rupture of esophageal varices.

Regarding the distant metastases, liver cancer frequently spreads to the lungs, presumably by way of the blood stream. Usually, patients do not have symptoms from the lung metastases, which are diagnosed by radiologic (x-ray) studies. Rarely, in very advanced cases, liver cancer can spread to the bone or brain.

How is liver cancer diagnosed?

Blood tests

Liver cancer is not diagnosed by routine blood tests, including a standard panel of liver tests. This is why the diagnosis of liver cancer depends so much on the vigilance of the physician screening with a tumor marker (alpha-fetoprotein) in the blood and radiological imaging studies. Since most patients with liver cancer have associated liver disease (cirrhosis), their liver blood tests may not be normal to begin with. If these blood tests become abnormal or worsen due to liver cancer, this usually signifies extensive cancerous involvement of the liver. At that time, any medical or surgical treatment would be too late.

Sometimes, however, other abnormal blood tests can indicate the presence of liver cancer. Remember that each cell type in the body contains the full complement of genetic information. What differentiates one cell type from another is the particular set of genes that are turned on or off in that cell. When cells become cancerous, certain of the cell's genes that were turned off may become turned on. Thus, in liver cancer, the cancerous liver cells may take on the characteristics of other types of cells. For example, liver cancer cells sometimes can produce hormones that are ordinarily produced in other body systems. These hormones then can cause certain abnormal blood tests, such as a high red blood count (erythrocytosis), low blood sugar (hypoglycemia) and high blood calcium (hypercalcemia).

Another abnormal blood test, high serum cholesterol (hypercholesterolemia), is seen in up to 10% of patients from Africa with liver cancer. The high cholesterol occurs because the liver cancer cells are not able to turn off (inhibit) their production of cholesterol. (Normal cells are able to turn off their production of cholesterol.)

There is no reliable or accurate screening blood test for liver cancer. The most widely used biochemical blood test is alpha-fetoprotein (AFP), which is a protein normally made by the immature liver cells in the fetus. At birth, infants have relatively high levels of AFP, which fall to normal adult levels by the first year of life. Also, pregnant women carrying babies with neural tube defects may have high levels of AFP. (A neural tube defect is an abnormal fetal brain or spinal cord that is caused by folic acid deficiency during pregnancy.)

In adults, high blood levels (over 500 nanograms/milliliter) of AFP are seen in only three situations:
Liver cancer
Germ cell tumors (cancer of the testes and ovaries)
Metastatic cancer in the liver (originating in other organs)

Several assays (tests) for measuring AFP are available. Generally, normal levels of AFP are below 10 ng/ml. Moderate levels of AFP (even almost up to 500 ng/ml) can be seen in patients with chronic hepatitis. Moreover, many patients with various types of acute and chronic liver diseases without documentable liver cancer can have mild or even moderate elevations of AFP.

The sensitivity of AFP for liver cancer is about 60%. In other words, an elevated AFP blood test is seen in about 60% of liver cancer patients. That leaves 40% of patients with liver cancer who have normal AFP levels. Therefore, a normal AFP does not exclude liver cancer. Also, as noted above, an abnormal AFP does not mean that a patient has liver cancer. It is important to note, however, that patients with cirrhosis and an abnormal AFP, despite having no documentable liver cancer, still are at very high risk of developing liver cancer. Thus, any patient with cirrhosis and an elevated AFP, particularly with steadily rising blood levels, will either most likely develop liver cancer or actually already have an undiscovered liver cancer.

An AFP greater than 500 ng/ml is very suggestive of liver cancer. In fact, the blood level of AFP loosely relates to (correlates with) the size of the liver cancer. Finally, in patients with liver cancer and abnormal AFP levels, the AFP may be used as a marker of response to treatment. For example, an elevated AFP is expected to fall to normal in a patient whose liver cancer is successfully removed surgically (resected).

There are a number of other liver cancer tumor markers that currently are research tools and not generally available. These include des-gamma-carboxyprothrombin (DCP), a variant of the gamma-glutamyltransferase enzymes, and variants of other enzymes (for example, alpha-L-fucosidase), which are produced by normal liver cells. (Enzymes are proteins that speed up biochemical reactions.) Potentially, these blood tests, used in conjunction with AFP, could be very helpful in diagnosing more cases of liver cancer than with AFP alone.



Magnetic resonance imaging (MRI) can provide very clear images of the body. Its advantage over CT is that MRI can provide sectional views of the body in different planes. The technology has evolved to the point that the newer MRIs can actually reconstruct images of the biliary tree (bile ducts and gallbladder) and of the arteries and veins of the liver. (The biliary tree transports bile from the liver to the duodenum, the first part of the intestine.) MRI studies can be made even more sensitive by using intravenous contrast material (for example, gadolinium).

MRI scans are very expensive and there is tremendous variability in the quality of the images. The quality depends on the age of the machine and the ability of the patients to hold their breath for up to 15 to 20 seconds at a time. Furthermore, many patients, because of claustrophobia, cannot tolerate being in the MRI scanner. However, the current open MRI scanners generally do not provide as high quality images as the closed scanners do.

Advances in ultrasound, CT, and MRI technology have almost eliminated the need for angiography. An angiography procedure involves inserting a catheter into the femoral artery (in the groin) through the aorta, and into the hepatic artery, the artery that supplies blood to the liver. Contrast material is then injected, and X-ray pictures of the arterial blood supply to the liver are taken. An angiogram of liver cancer shows a characteristic blush that is produced by newly formed abnormal small arteries that feed the tumor (neovascularization).

What, then, is the best imaging study for diagnosing liver cancer? There is no simple answer. Many factors need to be taken into consideration. For example, is the diagnosis of liver cancer known or is the scan being done for screening? What is the expertise of doctors in the patient's area? What is the quality of the different scanners at a particular facility? Are there economic considerations? Does the patient have any other conditions that need to be considered, such as claustrophobia or kidney impairment? Does the patient have any hardware, for example, a pacemaker or metal prosthetic device? (The hardware would make doing an MRI impossible.)

If you live in Japan or Taiwan and have access to a radiologist or hepatologist with expertise in ultrasound, then it may be as good as a CT scan. Ultrasound is also the most practical (easier and cheaper) for regular screening (surveillance). In North America, a multi-phase spiral CT scan is probably the most accurate type of scan. However, for patients with impaired renal function or who have access to a state-of-the-art MRI scanner, the MRI may be the diagnostic scan of choice. Finally, keep in mind that the technology of ultrasound, CT, and MRI is ever evolving with the development of better machines and the use of special contrast materials to further characterize the tumors.

Liver biopsy or aspiration

In theory, a definitive diagnosis of liver cancer is always based on microscopic (histological) confirmation. However, some liver cancers are well differentiated, which means they are made up of nearly fully developed, mature liver cells (hepatocytes). Therefore, these cancers can look very similar to non-cancerous liver tissue under a microscope. Moreover, not all pathologists are trained to recognize the subtle differences between well-differentiated liver cancer and normal liver tissue. Also, some pathologists can mistake liver cancer for adenocarcinoma in the liver. An adenocarcinoma is a different type of cancer, and, as previously mentioned, it originates from outside of the liver. Most importantly, a metastatic adenocarcinoma would be treated differently from a primary liver cancer (liver cancer). Therefore, all of this considered, it is important that an expert liver pathologist review the tissue slides of liver tumors in questionable situations.

Tissue can be sampled with a very thin needle. This technique is called fine needle aspiration. When a larger needle is used to obtain a core of tissue, the technique is called a biopsy. Generally, radiologists, using ultrasound or CT scans to guide the placement of the needle, perform the biopsies or fine needle aspirations. The most common risk of the aspiration or biopsy is bleeding, especially because liver cancer is a tumor that is very vascular (contains many blood vessels). Rarely, new foci (small areas) of tumor can be seeded (planted) from the tumor by the needle into the liver along the needle track.

The aspiration procedure is safer than a biopsy with less risk for bleeding. However, interpretation of the specimen obtained by aspiration is more difficult because often only a cluster of cells is available for evaluation. Thus, a fine needle aspiration requires a highly skilled pathologist. Moreover, a core of tissue obtained with a biopsy needle is more ideal for a definitive diagnosis because the architecture of the tissue is preserved. The point is that sometimes a precise diagnosis can be important clinically. For example, some studies have shown that the degree of differentiation of the tumor may predict the patient's outcome (prognosis). That is to say, the more differentiated (resembling normal liver cells) the tumor is, the better the prognosis.

All of that said, in many instances, there is probably no need for a tissue diagnosis by biopsy or aspiration. If a patient has a risk factor for liver cancer (for example, cirrhosis, chronic hepatitis B, or chronic hepatitis C) and a significantly elevated alpha-fetoprotein blood level, the doctor can be almost certain that the patient has liver cancer without doing a biopsy. The patient and physician should always ask two questions before deciding on doing a liver biopsy:
Is this tumor most likely an liver cancer?
Will the biopsy findings change the management of the patient?

If the answer to both questions is yes, then the biopsy should be done. Finally, there are two other situations related to liver cancer in which a biopsy may be considered. The first is to characterize a liver abnormality (for example, a possible tumor) seen by imaging in the absence of risk factors for liver cancer or elevated alpha-fetoprotein. The second is to determine the extent of disease when there are multiple areas of abnormalities (possibly tumors) seen by imaging in the liver.

Overall, no blanket recommendation can be given regarding the need for liver biopsy or aspiration. The decision has to be made on an individual basis, depending on the treatment options and the expertise of the medical and surgical teams.

What is the natural history of liver cancer?

The natural history of liver cancer depends on the stage of the tumor and the severity of associated liver disease (for example, cirrhosis) at the time of diagnosis. For example, a patient with a 1 cm tumor with no cirrhosis has a greater than 50% chance of surviving three years, even without treatment. In contrast, a patient with multiple tumors involving both lobes of the liver (multicentric tumors) with decompensated cirrhosis (signs of liver failure) is unlikely to survive more than six months, even with treatment.

What are the predictors of a poor outcome? Our knowledge of the prognosis is based on studying many patients with liver cancer, separating out their clinical characteristics, and relating them to the outcome. Grouped in various categories, the unfavorable clinical findings include;
Population characteristics (demographics); male gender, older age, or alcohol consumption.
Symptoms; weight loss or decreased appetite.
Signs of impaired liver function; jaundice, ascites, or encephalopathy (altered mental state).
Blood tests; elevated liver tests (bilirubin or transaminase), reduced albumin, elevated AFP, elevated blood urea nitrogen (BUN), or low serum sodium.
Staging of tumor (based on imaging or surgical findings); more than one tumor, tumor over 3 cm (almost 1¼ inches), tumor invasion of local blood vessels (portal and/or hepatic vein), tumor spread outside of the liver (to lymph nodes or other organs).

There are various systems for staging liver cancer. Some systems look at clinical findings while others rely solely on pathological (tumor) characteristics. It makes the most sense to use a system that incorporates a combination of clinical and pathological elements. In any event, it is important to stage the cancer because staging can provide guidelines not only for predicting outcome (prognosis) but also for decisions regarding treatment.

The doubling time for a cancer is the time it takes for the tumor to double in size. For liver cancer, the doubling time is quite variable, ranging from one month to eighteen months. This kind of variability tells us that every patient with liver cancer is unique. Therefore, an assessment of the natural history and the evaluation of different treatments are very difficult. Nevertheless, in patients with a solitary liver cancer that is less than 3 cm, with no treatment, we can expect that 90% of the patients will survive (live) for one year, 50% for three years, and 20% for five years. In patients with more advanced disease, we can expect that 30% will survive for one year, 8% for three years, and none for five years.

What are the treatment options for liver cancer?

The treatment options are dictated by the stage of liver cancer and the overall condition of the patient. The only proven cure for liver cancer is liver transplantation for a solitary, small (<3cm) tumor. Now, many physicians may dispute this statement. They may argue that a small tumor can be surgically removed (partial hepatic resection) without the need for a liver transplantation. Moreover, they may claim that the one and three year survival rates for resection are perhaps comparable to those for liver transplantation.

However, most patients with liver cancer also have cirrhosis of the liver and would not tolerate liver resection surgery. But, they probably could tolerate the transplantation operation, which involves removal of the patient's entire diseased liver just prior to transplanting a donor liver. Furthermore, many patients who undergo hepatic resections will develop a recurrence of liver cancer elsewhere in the liver within several years. In fact, some experts believe that once a liver develops liver cancer, there is a tendency for that liver to develop other tumors at the same time (synchronous multicentric occurrence) or at a later time (metachronous multicentric occurrence).

The results of the various medical treatments (chemotherapy, chemoembolization, ablation, and proton beam therapy) remain disappointing. Moreover, for reasons noted earlier (primarily the variability in natural history), there have been no systematic study comparisons of the different treatments. As a result, individual patients will find that the various treatment options available to them depend largely on the local expertise.

How do we know if a particular treatment worked for a particular patient? Well, hopefully, the patient will feel better. However, a clinical response to treatment is usually defined more objectively. Thus, a response is defined as a decrease in the size of the tumor on imaging studies along with a reduction of the alpha-fetoprotein in the blood, if the level was elevated prior to treatment.

Sources : www.medicinenet.com

Prostate Cancer (Overview, Anatomy, Incidence)

Overview

Adenocarcinoma of the prostate is the clinical term for a cancerous tumor on the prostate gland. As prostate cancer grows, it may spread to the interior of the gland, to tissues near the prostate, to sac-like structures attached to the prostate (seminal vesicles), and to distant parts of the body (e.g., bones, liver, lungs). Prostate cancer confined to the gland often is treated successfully.

Anatomy
The prostate gland is located in the pelvis, below the bladder, above the urethral sphincter and the penis, and in front of the rectum in men. It is made up of glandular tissue and muscle fibers that surround a portion of the urethra. The gland is covered by a membrane (called the prostate capsule) that produces prostate-specific antigen.

Incidence and Prevalence
According to the American Cancer Society (ACS), prostate cancer is the most common type of cancer in men in the United States, other than skin cancer. The ACS estimates that about 218,890 new cases will be diagnosed in 2007 and about 27,050 men will die of the disease. Prostate cancer is the second leading cause of cancer death in men, exceeded only by lung cancer.

Prostate cancer occurs in 1 out of 6 men. Reports of diagnosed cases have risen rapidly in recent years and mortality rates are declining, which may be due to increased screening.

African American men have the highest incidence of prostate cancer, and Asian and Native American men have the lowest incidence. Rates for Asian and African men increase sharply when they emigrate to the United States, suggesting an environmental connection (e.g., high-fat diet, smoking).

The risk for developing prostate cancer rises significantly with age, and 60% of newly diagnosed cases occur in men over the age of 70.


Source : www.urologychannel.com

Breast cancer

Definition

Breast cancer, the second-leading cause of cancer deaths in American women, is the disease women fear most. Experts predict 178,000 women will develop breast cancer in the United States in 2007. Breast cancer can also occur in men, but it's far less common. For 2007, the predicted number of new breast cancers in men is 2,000.

Yet there's more reason for optimism than ever before. In the last 30 years, doctors have made great strides in early diagnosis and treatment of the disease and in reducing breast cancer deaths. In 1975, a diagnosis of breast cancer usually meant radical mastectomy — removal of the entire breast along with underarm lymph nodes and muscles underneath the breast. Today, radical mastectomy is rarely performed. Instead, there are more and better treatment options, and many women are candidates for breast-sparing operations.

Symptoms

Knowing the signs and symptoms of breast cancer may help save your life. When the disease is discovered early, you have more treatment options and a better chance for a cure.

Most breast lumps aren't cancerous. Yet the most common sign of breast cancer for both men and women is a lump or thickening in the breast. Often, the lump is painless. Other potential signs of breast cancer include:

• A spontaneous clear or bloody discharge from your nipple, often associated with a breast lump
  
• Retraction or indentation of your nipple
  
• A change in the size or contours of your breast
  
• Any flattening or indentation of the skin over your breast
  
• Redness or pitting of the skin over your breast, like the skin of an orange
  

A number of conditions other than breast cancer can cause your breasts to change in size or feel. Breast tissue changes naturally during pregnancy and your menstrual cycle. Other possible causes of noncancerous (benign) breast changes include fibrocystic changes, cysts, fibroadenomas, infection or injury.

If you find a lump or other change in your breast — even if a recent mammogram was normal — see your doctor for evaluation. If you haven't yet gone through menopause, you may want to wait through one menstrual cycle before seeing your doctor. If the change hasn't gone away after a month, have it evaluated promptly.

Causes
 

In breast cancer, some of the cells in your breast begin growing abnormally. These cells divide more rapidly than healthy cells do and may spread (metastasize) through your breast, to your lymph nodes or to other parts of your body. The most common type of breast cancer begins in the milk-producing ducts, but cancer may also begin in the lobules or in other breast tissue.

In most cases, it isn't clear what causes normal breast cells to become cancerous. Doctors do know that only 5 percent to 10 percent of breast cancers are inherited. Families that do have genetic defects in one of two genes, breast cancer gene 1 (BRCA1) or breast cancer gene 2 (BRCA2), have a much greater risk of developing both breast and ovarian cancer. Other inherited mutations — including the ataxia-telangiectasia mutation gene, the cell-cycle checkpoint kinase 2 (CHEK-2) gene and the p53 tumor suppressor gene — also make it more likely that you'll develop breast cancer. If one of these genes is present in your family, you have a 50 percent chance of having the gene.

Yet most genetic mutations related to breast cancer aren't inherited. These acquired mutations may result from radiation exposure — women treated with chest radiation therapy for lymphoma in childhood or during adolescence when breasts are developing have a significantly higher incidence of breast cancer than do women not exposed to radiation. Mutations may also develop as a result of exposure to cancer-causing chemicals, such as the polycyclic aromatic hydrocarbons found in tobacco and charred red meats.

Researchers are now trying to discover whether a relationship exists between a person's genetic makeup and environmental factors that may increase the risk of breast cancer. Breast cancer eventually may prove to have a number of causes.

Risk factors

A risk factor is anything that makes it more likely you'll get a particular disease. Some risk factors, such as your age, sex and family history, can't be changed, whereas others, including weight, smoking and a poor diet, are under your control.

But having one or even several risk factors doesn't necessarily mean you'll develop cancer — most women with breast cancer have no known risk factors other than simply being women. In fact, being female is the single greatest risk factor for breast cancer. Although men can develop the disease, it's far more common in women.

Other factors that may make you more susceptible to breast cancer include:
Age. Your chances of developing breast cancer increase with age. Close to 80 percent of breast cancers occur in women older than age 50. In your 30s, you have a one in 233 chance of developing breast cancer. By age 85, your chance is one in eight.
A personal history of breast cancer. If you've had breast cancer in one breast, you have an increased risk of developing cancer in the other breast.
Family history. If you have a mother, sister or daughter with breast or ovarian cancer or both, or a male relative with breast cancer, you have a greater chance of also developing breast cancer. In general, the more relatives you have who were diagnosed with breast cancer before reaching menopause, the higher your own risk. If you have one first-degree relative — a mother, sister or daughter — who was diagnosed with the disease before age 50, your risk is doubled. If you have two or more relatives, your risk increases even more. Just because you have a family history of breast cancer doesn't mean it's hereditary, though. Most people with a family history of breast cancer (familial breast cancer risk) haven't inherited a defective gene, such as BRCA1 or BRCA2. Rather, cancer becomes so common in women who live into their 80s and beyond that random, noninherited breast tumors may appear in more than one member of a single family.
Genetic predisposition. Between 5 percent and 10 percent of breast cancers are inherited. Defects in one of several genes, especially BRCA1 or BRCA2, put you at greater risk of developing breast, ovarian and colon cancers. Usually these genes help prevent cancer by making proteins that keep cells from growing abnormally. But if they have a mutation, the genes aren't as effective at protecting you from cancer.
Radiation exposure. If you received radiation treatments to your chest as a child or young adult, you're more likely to develop breast cancer later in life. Your risk is greatest if you received radiation as an adolescent during breast development.
Excess weight. The relationship between excess weight and breast cancer is complex. In general, weighing more than is healthy increases your risk, particularly if you gained the weight as an adolescent. But risk is even greater if you put the weight on after menopause. Your risk also is greater if you have more body fat in the upper part of your body.
Early onset of menstrual cycles. If you got your period at a young age, especially before age 12, you may have a greater likelihood of developing breast cancer. Experts attribute this risk to the early exposure of the breast tissue to estrogen.
Late menopause. If you enter menopause after age 55, you're more likely to develop breast cancer. Experts attribute this to the prolonged exposure of the breast tissue to estrogen.
First pregnancy at older age. If your first full-term pregnancy occurs after age 30, or you never become pregnant, you have a greater chance of developing breast cancer. Although it's not entirely clear why, an early first pregnancy may protect breast tissue from developing genetic mutations that result from estrogen exposure.
Race. White women are more likely to develop breast cancer than black, Hispanic or Asian women are, but black women are more likely to die of the disease because their cancers are found at a more advanced stage. Although some studies show that black women may have more aggressive tumors, it's also likely that the disparity is at least partially due to socioeconomic factors. Women of all races with incomes below the poverty level are more often diagnosed with late-stage breast cancer and more likely to die of the disease than are women with higher incomes. Low-income women often don't receive the routine medical care that would allow breast cancer to be discovered earlier.
Hormone therapy. Treating menopausal symptoms with the hormone combination of estrogen and progesterone for four or more years increases your risk of breast cancer. In addition, therapy with estrogen and progesterone can make malignant tumors harder to detect on mammograms, leading to cancers that are diagnosed at more advanced stages and that are harder to treat. Using estrogen alone hasn't been shown to increase breast cancer risk in postmenopausal women.
Birth control pills. Use of birth control pills is associated with an increased risk of breast cancer in premenopausal women. The risk seems to be greater for women who use birth control pills for four or more years before their first full-term pregnancy, but since delayed first pregnancy is also a risk factor, part of the risk could be attributed to that. Overall, risk of breast cancer for users of birth control pills is small and appears to be confined to the short term. Risk levels return to normal within five to 10 years after discontinuing use. Using birth control pills also doesn't appear to further increase breast cancer risk in women with a family history of breast cancer or with a personal history of benign breast disease. Because this is an area of ongoing study, talk with your doctor about the latest information on the pill and breast cancer.
Smoking. Evidence is mixed on the relationship between smoking and breast cancer risk. Some studies show no link between cigarette smoking and exposure to secondhand smoke and breast cancer. Others suggest that smoking increases breast cancer risk. Exposure to secondhand smoke and breast cancer risk remains an area of active research. Despite the controversy surrounding this issue, there are clear health benefits — other than minimizing breast cancer risk — to quitting smoking and limiting your exposure to secondhand smoke.
Excessive use of alcohol. According to the American Cancer Society, women who drink more than one alcoholic beverage a day have about a 20 percent greater risk of breast cancer than do women who don't drink. To reduce your breast cancer risk, limit alcohol to no more than one drink daily.
Precancerous breast changes (atypical hyperplasia, lobular carcinoma in situ). These changes are discovered only after you have a breast biopsy, most commonly done for another reason. If these changes are present, your risk of breast cancer is higher than it is for women who don't have one of these so-called "markers." If you have carcinoma in situ, discuss treatment and monitoring options with your doctor.

Mammographic breast density. Breasts described as "dense" have a high ratio of connective and glandular tissue to fat. On X-ray images, dense breast tissue looks solid and white, so it can mask tumors and make mammograms difficult to interpret. Increasingly, though, breast density is also being recognized as a breast cancer risk factor in itself. The mechanism behind this increased risk is unknown.

Your age and menopausal status affect your breast density. Younger women tend to have denser breasts. Hormones also have an effect — higher hormone levels generally mean denser breasts. Still, the actual increase in risk due to mammographic density is very small. If you're at high risk of breast cancer and your mammograms are difficult to interpret because of breast density, your doctor may recommend additional screening tests.

When to seek medical advice

Although most breast changes aren't cancerous, it's important to have them evaluated promptly. See your doctor if you discover a lump or any of the other warning signs of breast cancer, especially if the changes persist after one menstrual cycle or they change the appearance of your breast. If you've been treated for breast cancer, report any new signs or symptoms immediately. Possible warning signs include a new lump in your breast or a bone ache or pain that doesn't go away after three weeks. In addition, talk to your doctor about developing a breast-screening program, which may vary, depending on your family history and other significant risk factors

Tests and diagnosis

Screening — looking for evidence of disease before signs or symptoms appear — is the key to finding breast cancer in its early, treatable stages. Depending on your age and risk factors, screening may include breast self-examination, examination by your nurse or doctor (clinical breast exam), mammograms (mammography) or other tests.

Breast self-examination. Breast self-examination is an option beginning at age 20. By becoming proficient at breast self-examination and familiar with the usual appearance and feel of your breasts, you may be able to detect early signs of cancer. Learn how your breasts typically look and feel and watch for changes. If you detect a change, promptly bring it to your doctor's attention. Have your doctor review your examination technique if you'd like input or you have questions.



Clinical breast exam. Unless you have a family history of cancer or other factors that place you at high risk, the American Cancer Society recommends having clinical breast exams once every three years until age 40. After that, the American Cancer Society recommends having a yearly clinical exam.


During this exam, your doctor examines your breasts for lumps or other changes. He or she may be able to feel lumps you miss when you examine your own breasts and will also check for enlarged lymph nodes in your armpit (axilla).

Mammogram
A mammogram, which uses a series of X-ray images of your breast tissue, is currently the best imaging technique for detecting tumors before you or your doctor can feel them. For that reason, the American Cancer Society has long recommended screening mammography for all women over 40.

Two types of mammograms include:

• Screening mammograms. Screening mammograms are performed on a regular basis — about once a year — to check your breast tissue for any changes since your last mammogram.
  
• Diagnostic mammograms. Your doctor may recommend a diagnostic mammogram to evaluate a breast change detected by you or your doctor. During a diagnostic mammogram, the radiologist performing the exam can take additional views to evaluate the area of concern more closely.
  
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Yet mammograms aren't perfect. A certain percentage of breast cancers — sometimes even lumps you can feel — don't show up on X-rays (false-negative result). The rate is higher for women in their 40s. That's because women of this age and younger tend to have denser breasts, making it more difficult to distinguish abnormal from normal tissue.

At other times, mammograms may indicate a problem when none exists (false-positive result). This can lead to unnecessary biopsies, to fear and anxiety, and to increased health care costs. The skill and experience of the radiologist reading the mammogram also have a significant effect on the accuracy of the test results. In spite of these drawbacks, however, most experts agree mammography is the most reliable screening test for most women.

During a mammogram, your breasts are compressed between plastic plates while a radiology technician takes the X-rays. The whole procedure should take less than 30 minutes. You may find mammography somewhat uncomfortable. If you have too much discomfort, inform the technician. If you have tender breasts, schedule your mammogram for a time after your menstrual period. Avoiding caffeine for two days before the test may help reduce breast tenderness.

Also available at some mammography centers is a soft, single-use, foam pad that can be placed on the surface of the compression plates of the mammography machine, making the test less uncomfortable. The pad doesn't interfere with the image quality of the mammogram.

If possible, try to schedule your mammogram around the same time as your annual clinical exam. That way the radiologist can specifically look at any changes your doctor may discover.

Most important, don't let a lack of health insurance keep you from having regular mammograms. Many state health departments and Planned Parenthood clinics offer low-cost or free screenings.

Other tests

• Computer-aided detection (CAD). In traditional mammography, your X-rays are reviewed by a radiologist, whose skill and experience play a large part in determining the accuracy of the test results. In CAD, a computer scans your mammogram after a radiologist has reviewed it. CAD identifies highly suspicious areas on the mammogram, allowing the radiologist to focus on specific spots, but many of these areas may later prove to be normal. Still, using mammography and CAD together may increase the cancer detection rate.
  
• Digital mammography. In this procedure, an electronic process is used to collect and display X-ray images on a computer screen. This allows your radiologist to alter contrast and darkness, making it easier to identify subtle differences in tissue. In addition, digital images can be transmitted electronically, so women who live in remote areas can have their mammograms read by an expert who is based elsewhere. Digital mammography has been found to be most helpful in evaluating dense breast tissue in women in their 40s.
  
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• Magnetic resonance imaging (MRI). This technique uses a magnet and radio waves to take pictures of the interior of your breast. Although not used for routine screening, MRI can reveal tumors that are too small to detect through physical exams or are difficult to see on conventional mammograms. MRI doesn't take the place of mammograms, but rather is performed as an additional (adjunct) study of the breast.
  
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• MRI isn't recommended for routine screening on women at average risk because it has a high rate of false-positive results, leading to unnecessary anxiety and biopsies. It's also expensive, not readily available and requires interpretation by an experienced radiologist. However, the American Cancer Society now recommends annual screening MRI for women with a lifetime breast cancer risk of 20 percent or higher, women who received chest radiation between ages 10 and 30, and women with a strong family history of breast and ovarian cancers.
  
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• Recent recommendations propose that women with newly diagnosed breast cancer in one breast have a one-time MRI done. MRI can detect breast tumors in the opposite (contralateral) breast missed by mammograms. The test can also detect additional lesions in the affected breast. However, whether finding early tumors in this situation improves treatment outcomes — and deaths from breast cancer — is still unknown.
  
• Breast ultrasound (ultrasonography). Your doctor may use this technique to evaluate an abnormality seen on a mammogram or found during a clinical exam. Ultrasound uses sound waves to produce images of structures deep within the body. Because it doesn't use X-rays, ultrasound is a safe diagnostic tool that can help determine whether an area of concern is a cyst or solid tissue. But breast ultrasound isn't used for routine screening because it has a high rate of false-positive results — finding problems where none exist.
  

Experimental procedures

• Ductal lavage. In this procedure, your doctor inserts a tiny, flexible tube (catheter) into the lining of a duct in your breast — the site where most cancers originate — and withdraws a sample of cells. The cells are then examined for precancerous changes that might eventually lead to disease. These changes may show up long before tumors can be detected on a mammogram. But because ductal lavage is a new and invasive procedure, many unknowns remain, including the rate of false-negative results, the exact location in the breast of abnormal cells and whether those cells will necessarily lead to cancer. Clinical trials are being conducted to help find the answers to these questions. In the meantime, ductal lavage isn't recommended as a screening tool.
  
• Molecular breast imaging (MBI). This experimental technique tracks the movement of a radioactive isotope injected into the bloodstream and taken up by breast tissue, particularly tumors. In preliminary studies, MBI found small tumors that both mammography and ultrasound missed. It's not yet clear how any abnormal findings from MBI could be biopsied, but this is an area of study. Besides requiring some radiation, this imaging method also involves slight compression of the breast. This imaging technique is being studied in women with dense breast tissue and women at high risk of breast cancer. Depending on study results, MBI would most likely become an adjunct to — but not a replacement for — mammography.
  

Diagnostic procedures
Unlike screening tests, diagnostic procedures help to further characterize breast abnormalities found by some other means, such as by feeling a breast lump or seeing a spot on a mammogram or MRI. These tests help your doctor determine the need for a biopsy and also may be used to help guide a biopsy.

Ultrasound
Ultrasound uses sound waves to create an image of your breast on a computer screen. By analyzing this image, your doctor may be able to tell whether a lump is a cyst or a solid mass. Cysts, which are sacs of fluid, usually aren't cancerous, although your doctor may recommend draining the cyst. If the cyst appears very typical and disappears completely with removal of the fluid, then observation is the only follow-up necessary. If the cyst appears complex, doesn't disappear completely when the fluid is drained or contains bloody fluid, a biopsy is necessary to determine whether cancer is present.

Biopsy
A biopsy — a small sample of tissue removed for analysis in the laboratory — is the only test that can tell if cancer is present. Biopsies can provide important information about an unusual breast change and help determine whether surgery is needed and if so, the type of surgery required. Types of biopsies include:

• Fine-needle aspiration biopsy. Your doctor uses a thin, hollow needle to withdraw tissue from the lump. He or she then sends the tissue to a lab for microscopic analysis. The procedure takes about 30 minutes and is similar to drawing blood. A similar procedure — fine-needle aspiration — is typically performed to remove the fluid from a painful cyst, but it can also help distinguish a cyst from a solid mass.
  
• Core needle biopsy. A radiologist or surgeon uses a hollow needle to remove tissue samples from a breast lump. As many as 15 samples, each about the size of a grain of rice, may be taken then sent to a pathologist to be analyzed for malignant cells. The advantage of a core needle biopsy is that it removes more tissue for analysis. Sometimes your radiologist or surgeon may use ultrasound to help guide the placement of the needle.
  
• Stereotactic biopsy. This technique is used to sample and evaluate an area of concern, such as microcalcification, that can be seen on a mammogram but that cannot be felt or seen on an ultrasound. During the procedure, a radiologist takes a core needle biopsy, using your mammogram as a guide. Stereotactic biopsy usually takes about an hour and is performed using local anesthesia.
  
• Wire localization. Your doctor may recommend this technique when a worrisome lump is seen on a mammogram but can't be felt or evaluated with a stereotactic biopsy. Using your mammogram as a guide, a thin wire is placed in your breast and the tip guided to the lump. Wire localization is usually performed right before a surgical biopsy and is a way to guide the surgeon to the area to be removed and tested.
  
• Surgical biopsy. This remains one of the most accurate methods for determining whether a breast change is cancerous. During this procedure, your surgeon removes all or part of a breast lump. In general, a small lump will be completely removed (excisional biopsy). If the lump is large, only a sample will be taken (incisional biopsy). The biopsy is generally performed on an outpatient basis in a clinic or hospital.
  

Estrogen and progesterone receptor tests
Malignant cells removed in a biopsy can be tested for the presence of hormone receptors. If the cancer cells have receptors for estrogen or progesterone or both, your doctor may recommend treatment with a drug such as tamoxifen, which prevents estrogen from binding to these sites.

Staging tests
Staging tests determine the size and location of your cancer and whether it has spread. They also help with treatment planning. Cancer is staged using the numbers 0 through IV.

Stage 0 cancers are also called noninvasive, or in situ (in one place), cancers. Although they don't have the ability to invade normal breast tissue or spread to other parts of your body, it's important to have them removed because they eventually can become invasive cancers.

Stage I to IV cancers are invasive tumors that have the ability to invade normal breast tissue or spread to other areas. A stage I cancer is small and well localized and has a high cure rate. But the higher the stage number, the lower the chances of cure. By stage IV, the cancer has spread beyond your breast to other organs, such as your bones, lungs or liver. Although it's not possible to cure cancer at this stage, it may still respond well to various treatments, which could effectively shrink and control the cancer for an extended period of time.

Genetic tests
If you have a strong family history of breast cancer or other cancers, blood tests may help identify defective BRCA or other genes that are being passed through the family. These tests are often inconclusive and should only be done in select cases after a thorough evaluation with a genetic counselor. Unless you are at high risk of hereditary breast or ovarian cancers, genetic testing usually isn't recommended.

In general, testing is beneficial only if the results will help you make a decision about how you might best reduce your breast or other cancer risk. Options range from lifestyle changes and closer screening and therapy with medications such as tamoxifen to extreme measures such as preventive (prophylactic) bilateral mastectomy and removal of your ovaries (oophorectomy).


Treatments and drugs

A diagnosis of breast cancer is one of the most difficult experiences you can face. In addition to coping with a potentially life-threatening illness, you must make complex decisions about treatment.

Talk with your health care team to learn as much as you can about your treatment options. Consider a second opinion from a breast specialist in a breast center or clinic. Talking to other women who have faced the same decision also may help.

Treatments exist for every type and stage of breast cancer. Most women will have surgery and an additional (adjuvant) therapy such as radiation, chemotherapy or hormone therapy. Experimental treatments are also available at cancer treatment centers.

Surgery
Today, radical mastectomy is rarely performed. Instead, the majority of women are candidates for simple mastectomy or lumpectomy. If you decide on mastectomy, you may opt for breast reconstruction.

Breast cancer operations include the following:

• Lumpectomy. This operation saves as much of your breast as possible by removing only the lump plus a surrounding area of normal tissue. Many women can have lumpectomy — often followed by radiation therapy — instead of mastectomy, and in most cases survival rates for both operations are similar. But lumpectomy may not be an option if a tumor is very large, deep within your breast, or if you have already had radiation therapy, have two or more widely separated areas of cancer in the same breast, have a connective tissue disease that makes you sensitive to radiation, or if you have inflammatory breast cancer. If you have a large tumor but still want to consider the possibility of lumpectomy, chemotherapy before surgery may be an option to shrink the tumor and make you eligible for the procedure.
  
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• In general, lumpectomy is almost always followed by radiation therapy to destroy any remaining cancer cells. But when very small, noninvasive cancers are involved, some studies question the role and benefits of radiation therapy — especially for older women. These studies haven't shown that lumpectomy plus radiation prolongs a woman's life any better than does lumpectomy alone.
  
• Partial or segmental mastectomy. Another breast-sparing operation, partial mastectomy involves removing the tumor as well as some of the breast tissue around the tumor and the lining of the chest muscles that lie beneath it. In almost all cases, you'll have a course of radiation therapy following your operation, similar to if you had a lumpectomy.
  
• Simple mastectomy. During a simple mastectomy, your surgeon removes all your breast tissue — the lobules, ducts, fatty tissue and skin, including the nipple and areola. Depending on the results of the operation and follow-up tests, you may also need further treatment with radiation to the chest wall, chemotherapy or hormone therapy.
  
• Modified radical mastectomy. In this procedure, a surgeon removes your entire breast, including the overlying skin, and some underarm lymph nodes (axillary lymph node dissection), but leaves your chest muscles intact. This makes breast reconstruction less complicated.
  

Sentinel lymph node biopsy
Because breast cancer first spreads to the lymph nodes under the arm, all women with invasive cancer need to have these nodes examined. Rather than remove as many lymph nodes as possible, surgeons now focus on finding the sentinel nodes — the first nodes to receive the drainage from breast tumors and therefore the first place cancer cells will travel. If a sentinel node is removed, examined and found to be normal, the chance of finding cancer in any of the remaining nodes is small and no other nodes need to be removed. This spares many women the need for a more extensive operation and greatly decreases the risk of complications.

Axillary lymph node dissection
If the sentinel lymph node does show the presence of cancer, then your surgeon removes additional lymph nodes in your armpit (axilla). The removal of these lymph nodes does increase the risk of serious arm swelling (lymphedema), but newer surgical techniques make this complication much less likely. Knowing if cancer has spread to the lymph nodes is important in determining the best course of treatment, including whether you'll need chemotherapy or radiation therapy.

Reconstructive surgery
If you want to have breast reconstruction done, discuss this with your surgeon before you have any surgery done. Not all women are candidates for reconstruction. A plastic surgeon can describe the various procedures, show you photos of women who have had different types of reconstruction, and discuss which type of reconstruction might be best in your case. Your options include reconstruction with a synthetic breast implant or reconstruction using your own tissue. These operations can be performed at the time of your mastectomy or at a later date.

• Reconstruction with implants. This technique uses artificial material — silicone gel or saline, in an implantable, leak-proof shell — to replace surgically removed breast tissue. If you don't have enough muscle and skin to cover an implant, your doctor may use a tissue expander, which is an empty implant shell that inflates as fluid is injected. It's placed under your skin and muscle, and your doctor gradually fills it with fluid — usually over a period of several months. When your muscle and skin have stretched enough, the expander is removed and replaced with a permanent implant.
  
• Reconstruction with a tissue flap. Known as a transverse rectus abdominal muscle (TRAM) flap, this surgery reconstructs your breast using tissue, including fat and muscle, from your abdomen, although surgeons sometimes may use tissue from your back or buttocks instead. Because the procedure is fairly complicated, recovery may take six to eight weeks. Complications include the risk of infection and tissue death. If you have a low percentage of body fat, this type of reconstruction may not be an option for you.
  
• Deep inferior epigastric perforator (DIEP) reconstruction. In this procedure, fat tissue from your abdomen is used to create a natural-looking breast. But because your abdominal muscles are left intact, you're less likely to experience complications than you are with traditional TRAM flap breast reconstruction. You may also have less pain, and your healing time may be reduced.
  
• Reconstruction of your nipple and areola. After initial surgery with either tissue transfer or an implant, you may have further surgery to make a nipple and areola. Using tissue from elsewhere in your body, your surgeon first creates a small mound to resemble a nipple. He or she may then tattoo the skin around the nipple to create an areola. Your surgeon may also take a skin graft from elsewhere on your body, place it around the reconstructed nipple to slightly raise the skin and then tattoo the skin graft.
  

Radiation therapy
Radiation therapy uses high-energy X-rays to kill cancer cells and shrink tumors. It's administered by a radiation oncologist at a radiation center. In general, radiation is the standard of care following a lumpectomy for both invasive and noninvasive breast cancers. Oncologists are also likely to recommend radiation following a mastectomy for a large tumor, for inflammatory breast cancer, for cancer that has invaded the chest wall or for cancer that has spread to more than four lymph nodes in your armpit.

If you won't be receiving chemotherapy, radiation is usually started three to four weeks after surgery. If your doctors recommend chemotherapy, it's usually administered before you undergo radiation therapy. You'll typically receive radiation treatment five days a week for five to six consecutive weeks. The treatments are painless and are similar to getting an X-ray. Each takes about 30 minutes. The effects are cumulative, however, and you may become tired toward the end of the series. Your breast may be pink, puffy and somewhat tender, as if it had been sunburned.

In a small percentage of women, more serious problems may occur, including arm swelling, damage to the lungs, heart or nerves, or a change in the appearance and consistency of breast tissue. Radiation therapy also makes it somewhat more likely that you'll develop another tumor. For these reasons, it's important to learn about the risks and benefits of radiation therapy when deciding between lumpectomy and mastectomy. You may also want to talk to a radiation oncologist about clinical trials investigating shorter courses of radiation or focal application of radiation.

Chemotherapy
Chemotherapy uses drugs to destroy cancer cells. The size of the tumor, characteristics of the cancer cells, and extent of spread of the cancer help determine your need for chemotherapy. If your cancer has a high chance of returning or spreading to another part of your body, your doctor may recommend chemotherapy after surgery to decrease the chance that the cancer will recur. This is known as adjuvant chemotherapy. If your cancer has already spread to other parts of your body, chemotherapy may be recommended to try to control the cancer and decrease any symptoms the cancer is causing.

Treatment often involves receiving two or more drugs in different combinations. These may be administered intravenously, in pill form or both. You may have between four and eight treatments spread over three to six months.

Because chemotherapy affects healthy cells as well as cancerous ones, side effects are common. Your digestive tract, hair and bone marrow — all composed of fast-growing cells — tend to take the brunt of this toxicity, leading to hair loss, nausea, vomiting and fatigue. Not everyone has all of these side effects, however, and methods to control chemotherapy side effects have improved greatly in the past few decades. Notably, more effective drugs are now available to help prevent or reduce nausea and vomiting.

Depending on the chemotherapy drugs your doctor recommends, other side effects may occur, including possible damage to the heart, nerves, kidneys and other organs. Chemotherapy may also temporarily affect your white blood cells — cells that fight off infection.

Another recently described side effect is "chemobrain," the common term for memory and concentration problems that happen to some people during and after chemotherapy. Chemobrain is associated with difficulties involving specific thought processes, including word finding, memory and multitasking.

Premature menopause and infertility also are potential side effects of chemotherapy. The older you are when you begin treatment, the greater the likelihood that your reproductive cycle will be affected. In rare cases, certain chemotherapy medications may lead to cancer of the white blood cells (acute myeloid leukemia) — often years after treatment ends.

Hormone therapy
Hormone therapy — perhaps more properly termed hormone blocking therapy — is often used to treat women whose cancers are sensitive to hormones — estrogen and progesterone receptor positive cancers. Similar to chemotherapy, this form of therapy can be used to decrease the chance of your cancer returning. If the cancer has already spread, hormone therapy may shrink and control it.

Two classes of medications are used in hormone therapy: selective estrogen receptor modulators (SERMs) and aromatase inhibitors.

• Selective estrogen receptor modulators (SERMs). SERMs act by blocking any estrogen present in the body from attaching to the estrogen receptor on the cancer cells, slowing the growth of tumors and killing tumor cells. SERMs can be used in both pre- and postmenopausal women. The most common SERM prescribed for hormone therapy is tamoxifen (Nolvadex). Tamoxifen is used as a treatment for women with hormone-sensitive metastatic breast cancer, as an adjuvant therapy for women with early-stage estrogen receptor positive breast cancer, and as a preventive agent in some high-risk women. You take tamoxifen daily, in pill form, for up to five years. It may reduce the risk of recurrence of breast cancer and is less toxic than most anti-cancer drugs. But tamoxifen isn't trouble-free. Women taking tamoxifen may experience menopausal symptoms such as night sweats, hot flashes, and vaginal itching, discharge or dryness. More serious side effects, including blood clots and endometrial cancer, occur infrequently. Older women, especially those with other medical conditions, may be at greater risk of more serious side effects than are younger women.
  
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• Aromatase inhibitors. This class of drugs, which includes anastrozole (Arimidex), letrozole (Femara) and exemestane (Aromasin), blocks the conversion of a hormonal substance (androstenedione) into estrogen. This effectively stops estrogen production in cells other than the ovaries. Fat cells, the adrenal gland and other normal cells all make small amounts of estrogen. These drugs are only effective in postmenopausal women. In several randomized, controlled trials, women receiving aromatase inhibitors have fared slightly better than have those receiving tamoxifen. Women treated with aromatase inhibitors also had a lower incidence of blood clots and endometrial cancer. To date, the primary drawback of aromatase inhibitors is an increased risk of osteoporosis. The main question about aromatase inhibitors seems to be whether women should take tamoxifen first and then switch to an aromatase inhibitor or simply take an aromatase inhibitor from the start.
  

Biological therapy
As scientists learn more about the differences between normal cells and cancer cells, treatments aimed at these differences — called biological therapy — are being developed. Three biological therapies are now available for breast cancer. They include:

• Trastuzumab (Herceptin). This FDA-approved biological therapy uses monoclonal antibody technology to attack a protein — called HER2-neu — that's overproduced in about one out of every three breast cancers. By attacking this protein, Herceptin kills cancer cells on its own and in conjunction with chemotherapy or hormone therapy. Herceptin can be used as an adjuvant therapy or to treat advanced disease.
  
• Bevacizumab (Avastin). Now approved for treating metastatic breast cancer, Avastin also uses monoclonal antibody technology to target new blood vessels and stop them from growing. Cancer cells need to grow new blood vessels in order to survive. This therapy halts that process and kills the cancer cells.
  
• Lapatinib (Tykerb). Like Herceptin, Tykerb zeros in on and blocks the effects of the HER2 protein. But while Herceptin blocks HER2's action from the outside of the cell, Tykerb is a smaller molecule that works on the inside of the cell. Tykerb works for some women for whom Herceptin is no longer effective. This drug is only approved for use in conjunction with chemotherapy and in women with advanced, metastatic breast cancers.
  

Clinical trials
Clinical trials are used to test new and promising agents in the treatment of cancer. Clinical trials represent the cutting edge of technology, but they're often unproven treatments that may or may not be superior to currently available therapies. Talk with your doctor about clinical trials to see if one is right for you.

Clinical trials involve more than just new medications. For example, breast surgeons and radiologists are developing nonsurgical methods of destroying cancerous breast tissue. One of these techniques, radiofrequency ablation, uses ultrasound to locate the tumor. Then a metal probe about the size of a toothpick is inserted into the tumor. Inside the tumor, the probe creates heat that destroys cancer cells. Although early tests of radiofrequency ablation have been promising, not all women would be candidates for the procedure if it eventually were approved for widespread use.

Prevention

Nothing guarantees that you won't develop breast cancer. But there are some things you may be able to do to reduce your risk of the disease.

Chemoprevention
Chemoprevention is the use of certain medications to decrease breast cancer risk. Two drugs used for breast cancer prevention in high-risk women come from the class of drugs known as selective estrogen receptor modulators (SERMs):

• Tamoxifen (Nolvadex). Tamoxifen is approved for use as a preventive agent in women age 35 and older who have an elevated risk of developing breast cancer within the next five years. Data from several clinical prevention trials found that tamoxifen use in women at higher than average risk results in a relative risk reduction of about one-third for noninvasive breast cancer and about one-half for invasive breast cancer.
  
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• Raloxifene (Evista). Raloxifene is approved for prevention of invasive breast cancer in postmenopausal women at high risk of the disease, as well as in women with postmenopausal osteoporosis. In the second group, the drug is approved for both breast cancer prevention and osteoporosis treatment. Large clinical trials have also suggested that raloxifene is as effective as tamoxifen in preventing estrogen receptor positive breast cancer in high-risk postmenopausal women who don't have a personal history of breast cancer.  The Gail model computerized risk assessment is a simple and helpful tool to estimate a woman's risk of developing invasive breast cancer. A five-year Gail model score higher than 1.66 percent is considered high risk. This tool is available online at the National Cancer Institute.
  

Preventive surgery
Although it's a radical step, preventive surgery also reduces breast cancer risk in high-risk women. Options include:

• Prophylactic mastectomy. This preventive surgery involves removing one or both of your breasts to prevent or reduce your risk of breast cancer. You might consider this option if you're at high risk of breast cancer, you've already had cancer in one breast, you have a family history of breast cancer, you received positive results from genetic testing, or your doctors have identified early signs of cancer in your breast.
  
• Prophylactic oophorectomy. This preventive option involves surgically removing your ovaries. Although the procedure is usually performed to reduce ovarian cancer risk, having an oophorectomy before you reach menopause also reduces your risk of breast cancer.
  

Lifestyle factors
Some lifestyle strategies may help reduce breast cancer risk:

• Ask your doctor about aspirin. Taking an aspirin just once a week may help protect against breast cancer, but be sure to talk to your doctor before you start. When used for long periods of time, aspirin can cause stomach irritation, bleeding and ulcers. More serious aspirin side effects include bleeding in the intestinal and urinary tracts and hemorrhagic stroke. In general, you're not a candidate for aspirin therapy if you have a history of ulcers, liver or kidney disease, bleeding disorders, or gastrointestinal bleeding.
  
• Limit alcohol. Drinking alcohol is strongly linked to breast cancer. The type of alcohol consumed — wine, beer or mixed drinks — seems to make no difference. To help protect against breast cancer, limit the amount of alcohol you drink to less than one drink a day or avoid alcohol completely.
  
• Maintain a healthy weight. There's a clear link between obesity — weighing more than is appropriate for your age and height — and breast cancer. The association is stronger if you gain the weight later in life, particularly after menopause.
  
• Avoid long-term hormone therapy. The link between postmenopausal hormone therapy and breast cancer has been a subject of debate for years, partly because research results have been mixed. Estrogen exposure clearly contributes to breast cancer risk, but for most women, the size of the contribution over a lifetime is small — particularly in the absence of other risk factors, such as family history of the disease. If you're approaching menopause and having frequent symptoms, it's probably safe to take hormones for as long as four to five years. Any longer does increase your breast cancer risk, without conferring any clear benefits. The same is true of hormone therapy after age 60.
  
• Stay physically active. No matter what your age, aim for at least 30 minutes of exercise on most days. Try to include weight-bearing exercises such as walking, jogging or dancing. These have the added benefit of keeping your bones strong.
  
• Eat foods high in fiber. Try to increase the amount of fiber you eat to between 20 and 30 grams daily — about twice that in an average American diet. Among its many health benefits, fiber may help reduce the amount of circulating estrogen in your body. Foods high in fiber include fresh fruits and vegetables and whole grains.
  
• Emphasize olive oil. Oleic acid, the main component of olive oil, appears both to suppress the action of the most important oncogene in breast cancer and to increase the effectiveness of the drug Herceptin.
  
• Avoid exposure to pesticides. The molecular structure of some pesticides closely resembles that of estrogen. This means they may attach to receptor sites in your body. Although studies have not found a definite link between most pesticides and breast cancer, it is known that women with elevated levels of pesticides in their breast tissue have a greater breast cancer risk.
  

New directions in research
Scientists are investigating a number of potential preventive therapies for breast cancer, including:

• Retinoids. Natural or synthetic forms of vitamin A (retinoids) may have the ability to destroy or inhibit the growth of cancer cells. Unlike other experimental therapies, retinoids may be effective in premenopausal women and in those whose tumors aren't estrogen positive. Research is ongoing.
• Flaxseed. Flaxseed is high in lignan, a naturally occurring compound that lowers circulating estrogens in your body. Flaxseed appears to decrease estrogen production — acting much like tamoxifen does — which may inhibit the growth of breast cancer tumors. Lignans are also antioxidants with weak estrogen-like characteristics. These characteristics may be the mechanism by which flaxseed works to decrease hot flashes. Further research should clarify the connection.
  

Sources: www.mayoclinic.com

Ovarian Cancer

Ovarian cancer is a disease that affects ovarian tissue in the female reproductive system. The ovaries are responsible for producing eggs (ova) and are also a production site for the hormones estrogen and progesterone.
Causes and Risk Factors of Ovarian Cancer
Unfortunately, we cannot pinpoint exactly what causes ovarian cancer, but researchers have identified several known risk factors for it. We know that ovarian cancer most often is diagnosed in women who:

• are post-menopausal.
  
• are Caucasian.
  
• have a family history of colon, breast, or ovarian cancer.
  
• were previously diagnosed with breast cancer.
  
• suffer from obesity.
  
• used Clomid (a fertility drug) for longer than one year
  
• use(d) estrogen replacement therapy
  
• who have not given birth.
  
• have a a known inherited mutation of BRCA 1 or 2 gene conformed through genetic testing
  
• Ovarian Cancer Symptom

Ovarian cancer is often referred as the "silent killer" because there are no early warning signs, or symptoms aren't noticeable until the advanced stages, when it is less treatable. Early ovarian cancer symptoms are often vague and are commonly chalked up to be related to other, less serious conditions. Early ovarian cancer symptoms may include:

• changes in bowel habits like constipation or diarrhea
  
• pelvic pain or pressure
  
• frequent urge to urinate
  

Symptoms of ovarian cancer that usually do not appear until the disease has progressed include:

• abdominal bloating
  
• pain during sexual intercourse
  
• persistent fatigue
  
• abdominal weight gain
  
• sudden unexplained weight gain or weight loss
  

Persistent symptoms that continue for several weeks need to be reported to your doctor. You should not wait to see if symptoms get better or go away on their own. Seeing your doctor early may lead to an earlier diagnosis

Diagnosis of Ovarian Cancer
If your doctor discovers an ovarian mass during an exam or suspects an abnormality related to the ovary, a pelvic exam, ultrasound, and CA-125 test (a blood test that screens for a protein that is often elevated in the bloodstreams of women with ovarian cancer) are the first steps in making a diagnosis.

An ultrasound can reveal characteristics about masses that may help doctors determine if they are benign cysts or potentially cancerous. During the ultrasound, characteristics about the mass are noted, like appearance, fluid content, solidity, whether it has spread, and if the other ovary also contains a mass. Based on these characteristics, the radiologist assigns a score of the ultrasound that contributes to the risk of malignancy index (RMI).

The RMI is a scoring systems that determines the risk of a mass being cancerous. The ultrasound score is combined with a score that evaluates menopause status and the results of the CA-125 tumor marker test. The sum of these numbers reveal how high of a risk that the mass is cancerous. Keep in mind that the RMI only determines the risk of it being cancer, it is not a diagnosis. It may not be used for all types of cancer in helping to make a diagnosis.

A biopsy is necessary to confirm the presence of cancer and involves removing small tissue samples to be evaluated later under a microscope. An ovarian biopsy can be done surgically through a procedure called a laparotomy. During a laparotomy, the surgeon makes an incision into the abdomen and looks for signs of cancer in the abdominal cavity. This includes taking a biopsy or possibly removing an ovary for further evaluation by a pathologist. If cancer is obvious, the surgeon may try to remove as much of it as possible. This is called debulking, and is a common method of treating ovarian cancer.

A less invasive surgery, laparoscopic surgery, may also be an option for some women instead of a laparotomy. Laparoscopic surgery involves the surgeon making a small incision into the abdomen. A laparoscope (a fiber optic rod equipped with a light and camera) is inserted through the incision and transmits live video feed to a monitor.

If cancer is confirmed from the biopsy, the stage and grade of ovarian cancer is then determined. For women with suspected advanced stages of ovarian cancer, then additional tests, like imaging tests are required to stage the disease.
Treatment of Ovarian Cancer
Treatment options weigh heavily on the stage and grade of ovarian cancer. There are three treatment methods for ovarian cancer: surgery, chemotherapy, and radiation therapy. Surgery combined with chemotherapy is the most common treatment course. Radiation therapy may be used in some cases, but it is rare.

Surgery. Debulking, also called cytoreduction surgery, is the primary type of ovarian cancer treatment. The goal of the surgery is to remove as much of the tumor as possible, which in turn, will help increase the effectiveness of chemotherapy.

Chemotherapy. Chemotherapy to treat ovarian cancer helps eliminate cancer cells that remain after surgery. The drugs are delivered either intravenously or directly into the abdominal cavity (intraperitoneal). Chemotherapy may be given before or after surgery. It can also be given alone in palliative care cases. How often and how long a person receives chemotherapy is based on their stage of ovarian cancer and other health factors.

Radiation Therapy. Radiation therapy is rarely used to treat ovarian cancer. It may be used to reduce symptoms caused by the cancer.

Like most type of cancer, there are no guaranteed methods of prevention. Several factors reduce our risk:
Oral Contraceptive Use: Several studies show that several years of using birth control pills may decrease a woman's risk of ovarian cancer.
Childbirth: Giving birth to at least one child may cut the risk of ovarian cancer by 80%. It is not recommended to have children just for the sake of risk reduction though.
Tubal Ligation or Hysterectomy: Tubal ligation or a hysterectomy may reduce your risk of ovarian cancer, but these surgeries are never done solely for the purpose of ovarian cancer prevention. They are simply an added benefit of treating another condition.
Some women who are considered to be at higher risk of ovarian cancer choose more drastic methods of prevention. A prophylactic oophorectomy (surgical removal of the ovaries) to prevent ovarian cancer is one method of prevention that may be available to women who are high risk. This option is normally an option for women who have a mutated BRCA 1 or 2 gene, confirmed through genetic testing.

While surgical prevention may drastically cut a woman's risk, a similar type of cancer called primary peritoneal cancer (cancer of the lining of the abdominal cavity), may develop. This type of cancer is rare, but in women with a known mutated BRCA gene, the risk is heightened.

Sources : www.cancer.about.com

CANCER

If someone asked you to define cancer, could you do it? We all have heard the word "cancer" many times, however very few people understand the disease and how it develops.

What is Cancer?
Cancer is a complex group of over 100 different types of cancer. Cancer can affect just about every organ in the human body.

How Does Cancer Develop?
The organs in our body are made up of cells. Cells divide and multiply as the body needs them. When these cells continue multiplying when the body doesn't need them, the result is a mass or growth, also called a tumor.

These growths are consider either benign or malignant. Benign is considered non-cancerous and malignant is cancerous.

Benign tumors rarely are life threatening and do not spread to other parts of the body. They can often be removed.

How Does Cancer Spread to Other Parts of the Body?
The cells within malignant tumors have the ability to invade neighboring tissues and organs, thus spreading the disease. It is also possible for cancerous cells to break free from the tumor and enter the blood stream, and spreading the disease to other organs. This process of spreading is called metastasis.

When cancer has metastasized and has affected other areas of the body, the disease is still referred to the organ of origination. For instance, if cervical cancer spreads to the lungs, it is still called cervical cancer, not lung cancer.

Although most cancers develop this way, diseases like leukemia do not. They affect the blood and the organs that form blood and then invade nearby tissues.

All cancers are different, and require different treatment. What may be effective for prostate cancer, probably will not be for bladder cancer. Diagnosing cancer will vary as well, depending on the organ affected.

Fast Facts About Cancer
One in three people will develop cancer.
One in four people will die of cancer.
In 2005, about 1.4 million new cases of cancer were diagnosed.
More than 1500 Americans died each day of cancer this year.
Over 1,000,000 cases of skin cancer will be diagnosed this year.
Cancer is the leading cause of death among Americans under the age of 85.

Sources : www.cancer.about.com

Sistem Reproduksi Yang Berperan Dalam Pemenuhan Kebutuhan

By : Hendra Arif
1. Anatomi Dan Fisiologi Seksual
i. Organ Seks Wanita
Genitalia wanita terdiri atas organ seks internal eksternal. Organ seks eksternal, secara kolektif disebut vulva, yang mencakup mons veneris, labia mayora, labia minora, klitoris, dan ostium vaginalis atau introitus. Vagina, uterus, tubulus falopi, dan ovari tersusun ke dalam organ seks internal. (Potter, Patricia A , 2005)
a. Organ Seks Eksternal
Mons Veneris. Mons veneris (mons pubis) adalah lapisan jaringan lemak yang menutupi tulang pubis dan dilapisi oleh rambut pubis setelah pubertas.
Labia. Kedua labia mayora lipatan kulit berlemak yang memanjang dari mons veneris yang membentuk batasan terluar dari vulva. Labia mayora menutup dan karenanya melindungi vagina dan ostrium uretra. Labia mayora mempunyai reseptor sensoris yang sensitif terhadap sentuhan, tekanan nyeri, dan suhu. Kedua labia minora, yang tepat di dalam labia mayora, adalah lipatan kulit tipis berpigmen yang memanjang ke atas untuk membentuk kepala litoral. Lipatan sebelah dalam ini mempunyai banyak pembuluh darah, labia minora dapat menunjukkan perubahan warna yang signifikan selama rangsangan seksual dan kadang disebut sebagai kulit seks.
Klitoris. Klitoris terdiri sebagian besar atas jaringan erektil, mempunyai banyak ujung saraf, dan sangat sensitive terhadap sentuhan, tekanan , dan suhu. Klitoris adalah organ yang paling sensitive terhadap stimulasi dan mempunyai peran sentral dalam rangsangan seksual dan peningkatan perasaan ketegangan seksual (Boston Women’s Health Book Colective, 1992).
Vestibula. Vestibula adalah area vulva di sebelah dalam labia minora. Baik ostium uranium (meatus) dan ostium vaginalis (intritus) terletak di dalam vestibula. Meatus urinarius terletak di garis tengah dalam vestibula antara klitoris dan ostium vaginalis. Ostium vaginalis atau introitus terletak di antara uretra dan anus. Himen adalah lipatan jaringan membranosa yang sebagian menutup introitus
a. Organ Seks Internal
Vagina. Vagina adalah organ muscular, berdinding tipis yang terangkat ke arah atas pada sudut 45 derajat mengarah ke bagian belakang. Dinding vagina terdiri atas tiga lapis jaringan:
1. Lapisan serosa luar yang tipis, yang merupakan bagian dari membrane yang melapis kavitas tubuh dan menutupi organ.
2. Lapisan tengah otot polos, involunter yang dilanjutkan dengan otot dari uterus.
3. Lapisan terdalam adalah membran mukosa yang disebut mukosa.
Vagina berfungsi sebagai saluran untuk darah menstruasi, melahirkan anak, dan kenikmatan. Lapisan otot bersifat sangat mudah di regangakan sehingga memungkinkan hubungan senggama dan pelahiran anak. Selama rangsangan seksual, terjadi vasokongesti. Sebagai akibat lapisan mukosa berkeringat dan memberikan lumasan vaginal.
Kelenjar Bartholin terletak pada kedua sisi ostium vaginalis. Kelenjar ini dulu diduga menjadi sumber lubrikasi selama rangsangan seksual. Peran ini sekarang dipertanyakan karena lubrikasi yang dihasilkan minimal (Denny & Quadgno, 1992).
Uterus. Uterus adalah organ muscular berdinding tebal yang terletak diantara kandung kemih dan rectum. Uterus mempunyai panjang sekitar 7,6 cm dan tampak sapeti buah pir terbalik. Tuba fallopii memasuki uterus pada kedua sisi uterus dekat bagian atas. Bagian atas yang lebar dari uterus dikenal sebagai badan. Bagian dasar disebut serviks, memanjang ke dalam vagina. Serviks eksternal (vaginalis) disebut ektoserviks, dan kanalis servikalis internal disebut sebagai endoservik. Uterus terbentuk dari lapisan jaringan penyambung eksternal yang disebut perimetrium, lapisan tengah adalah lapisan otot polos yang disebut miometrium, dan membran mukosa bagian dalam disebut endometrium. Serat otot dari lapisan miometrium membesar selama kehamilan untuk memungkinkan pertumbuhan janin.. Kontraksi otot uterus juga terjadi selama orgamus. Setiap bulan endometrium menebal dalam persiapan untuk kemungkinan implantasi ovum yang telah dibuahi.
Tuba fallopian. Kedua tuba fallopian mulai pada bagian atas uterus dan berakhir dengan fimbriae panjang seperti jari dekat ovarium. Tuba fallopii berfungsi sebagai saluran untuk lewatnya telur dan sperma sehingga dapat terjadi fertilisasi. Fertilisasi biasanya terjadi dalam bagian atas dari salah satu tuba fallopi.
Ovarium. Terdapat dua buah ovarium yang berukuran sebesar kacang hijau, satu pada masing-masing sisi uterus. Kedua ovarium ini menyekresi hormon wanita, termasuk estrogen, progesterone, dan sejumlah kecil androgen, secara langsung ke dalam aliran darah. Kedua ovarium ini juga memproduksi telur yang dilepaskan dan ditransportasikan melalui tuba fallopi. Proses produksi telur berawal dari janin wanita dan berakir sebelum lahir. Setiap wanita dilahirkan dengan kelengkapan otot ova. Telur ini terus mengalami atresia (degenerasi dan resorpsi) sehingga hanya sekitar 400.000 yang masih tertinggal saat pebertas. Satu tel;ur mengalami maturasi setiap bulan. Siklusnya berlanjut sampai fungsi ovarium menurun saat menopause.
ii. Organ Seks Laki – laki ( Irianto, Kus , 2004 )
Testis. Merupakan kelenjar gonad pria , dikenal sebagai buah pelir atau buah zakar terdapat sepasang yang terdapat dalam suatu kantong pelindung yang disebut skrotum. Di dalamnya terdapat kumpulan sel – sel sperma.
Epididimis. Saluran ini berjalan berkelok- kelok membentuk suatu gumpalan memanjang menempel di belakang testis. Sel- sel sperma yang masak akan ditampung dalam saluran tersebut. Fungsi epididimis tempat penyimpanan dan pematangan spermatozoa.
Vas deferens. Saluran vas deferens keluar dari epididimis berjalan lurus meninggalkan testis untuk menuju rongga panggul. Di dalam Rongga panggul kedua vas deferens kanan kiri saling mendekat ke belakang kandung kemih kemudian menembus kelenjar prostat untuk bermuara dalam uretra , selanjutnya sel- sel mani dapat mengalir melalui uretra dalam penis.
Penis. Penis (zakar) berjumlah satu buah.Bagian depan adalah kepala zakar dan pada ujung depanya terdapat lubang untuk mengeluarakan urine. Penis berfungsi memasukkan sperma kea lat kelamin wanita.
Kelenjar Tambahan,(vesika seminalis, kelenjar kelenjar bulbouretral, kelenjar prostate).
Air mani. Adalah campuran dari cairan hasil sekresi kelenjar tambahan dengan spermatozoa yang dikeluarkan oleh duktus deferens.
Jumlah sperma kira- kira 60-100 juta per cc semen.
Air mani yang normal memiliki beberapa kriteria , antara lain
1. Berupa cairan sedikit kental warna putih kadang-kadang kekuningan
2. Volume 3-5 cc
3. > 60% sperma bergerak aktif
4. Jumlah aperma 50-100 juta per cc jika dibawah 20 juta per cc menunjukkan infertilitas
5. Jumlah sperma normal harus lebih besar dari 70%
Sumber :
1. Irianto, Kus. (2004). Struktur Dan Fungsi Tubuh Manusia Untuk Paramedis . Bandung : Rama Widya
2. Potter & Perry. (2005). Buku Ajar Fundamental Keperawatan. Jakarta: EGC.