Liver or Lung Dysfunction in Advanced Cancer

The liver and the lungs are two of the most common places cancer spreads to. NCI names the liver, the lungs and bone as the three most common sites of metastasis. Liver dysfunction means the liver has slowed down. It can no longer clear waste, make clotting proteins and process drugs at its normal rate. Lung dysfunction means the lungs can no longer move enough oxygen into the blood. It can also mean the effort of breathing has become too great.

They matter for the same practical reason. Both change what your body can do with the medicines you are taking. Both also produce warning signs that are easy to mistake for "just being tired".

Call emergency services (911 in the US, 999 or 112 in the UK) if:

• New confusion, drowsiness that is hard to shake off, or behavior that is out of character.
• The hands flap when arms are held out straight with the wrists bent back. This sign is called asterixis.
• Vomiting blood. MedlinePlus says to contact your provider or go to the emergency room if this happens. You need to be examined right away. MedlinePlus says black or tarry stools mean contacting your provider right away too. Call straight away if you also feel dizzy or lightheaded.
• Breathlessness at rest, or being unable to finish a sentence in one breath.
• An oxygen reading on a finger probe of 88 percent or lower. MedlinePlus says to seek immediate medical attention at that level.
• Blue or grey lips, gums or fingernails.
• Sudden breathlessness with sharp chest pain that is worse on breathing in. This matters most if a calf is also swollen and tender. That combination suggests a clot in the lung.
• Coughing up blood.
• Temperature of 38.0 °C / 100.4 °F or higher. The CDC uses 100.4 °F. The NCI uses 100.5 °F. Use the lower number.

Call your team the same day if:

• A finger probe reads 92 percent or lower at rest. That is MedlinePlus's threshold for contacting your provider.
• Breathlessness has clearly worsened over a few days, or you now need to sleep propped up.
• Yellowing of the eyes or skin is deepening. Or urine is darker, or stools have turned pale. MedlinePlus says to contact your provider if you notice a change in the colour of your urine and stools. Do the same if you develop jaundice.
• The belly is swelling or tightening. StatPearls tells people with hepatic encephalopathy to seek medical attention straight away for increased abdominal swelling. The same goes for worsening jaundice, fever, or a mental state that is getting worse.
• No bowel movement in two or three days. NCI's Eating Hints booklet says to tell your doctor or nurse at that point. Vomiting that stops you keeping tablets down is another reason to call. If you are on lactulose, the target is two to three soft stools a day. Falling short of that is worth reporting.
• Sleep and waking have flipped: awake at night, asleep all day.

StatPearls lists several triggers for hepatic encephalopathy. They include constipation, infections, dehydration, bleeding in the gut and electrolyte imbalances. Medicines are on the list too. StatPearls names benzodiazepines, opioids and anti-inflammatory drugs. Most of those triggers are fixable. That is why the call is worth making early.

An NIH StatPearls review explains the plumbing. The portal vein collects the venous drainage from the pancreas, the spleen and almost all of the gut. It delivers all of that to the liver first. So the liver both processes what you digest and catches cancer cells from the abdomen. The same review puts the liver at nearly 25 percent of all cases of cancer metastasis. It also says nearly 20 to 25 percent of people diagnosed with colorectal cancer will develop liver metastases.

When enough liver is replaced or the ducts are squeezed, several things go at once:

• Bilirubin builds up, giving yellow eyes and skin, dark urine, pale stools and itching.
• Albumin falls, so fluid leaks into the abdomen as ascites, and into the ankles.
• Clotting proteins fall, so bruising, nosebleeds and gum bleeding become easy.
• Toxins reach the brain, producing hepatic encephalopathy.

Encephalopathy is graded. StatPearls sets out the West Haven grades. Grade 1 is a trivial lack of awareness, euphoria or anxiety, and a shortened attention span. Grade 2 is lethargy or apathy, with minimal disorientation to time or place. It also includes subtle personality changes or inappropriate behavior. Grade 3 is somnolence to semi-stupor, with confusion and gross disorientation, but the person still responds to voice. Grade 4 is coma. Families usually notice grade 1 long before a clinic does. So say what you see.

Lactulose is the main treatment. StatPearls says the dose is adjusted to achieve at least 2 to 3 soft stools a day. It says about 70 to 80 percent of people with hepatic encephalopathy improve on it. Too few stools and the confusion returns. Too many and dehydration itself brings it back. The antibiotic rifaximin is often added.

A failing liver clears drugs slowly, so ordinary doses build up. Sedatives and strong painkillers hit harder and last longer. StatPearls names benzodiazepines, opioids and nonsteroidal anti-inflammatory drugs among the medicines that can set off hepatic encephalopathy. It adds that sedatives such as benzodiazepines can make it worse and hold up recovery.

Take your full medicine list to the next appointment. Include anything bought over the counter, such as acetaminophen, herbal products and sleeping tablets. Then ask which doses should change now.

Breathlessness in advanced cancer rarely has one cause. NCI lists many possible causes. One is a tumor narrowing an airway. Others are fluid around the lung or heart, a clot in the lung vessels, and weakened breathing muscles. Treatment can cause it too. NCI names lung scarring after radiotherapy, heart muscle weakened by chemotherapy, and inflammation of the lung from immunotherapy. Older problems count as well, such as chronic lung disease, heart failure and anemia.

One common cause is a malignant pleural effusion. That is fluid collecting between the lung and the chest wall. StatPearls says breathlessness is the most common presenting complaint of a pleural effusion. It is seen in more than 50 percent of cases. StatPearls also notes that at least 200 mL of fluid must be present before a standard front-to-back chest X-ray will show it. As little as 50 mL may be visible on a side view. That is part of why ultrasound is used to find and mark the fluid.

Draining it works fast, but the fluid comes back. StatPearls reports that recurrence approaches 98 percent within 30 days after a single thoracentesis. So teams offer a longer-term answer. One is a tunnelled pleural catheter that you drain at home. Another is talc pleurodesis, which sticks the two layers together. StatPearls notes that volumes over 1.5 liters are linked to re-expansion pulmonary edema. That means fluid flooding the lung as it re-inflates. Some expert groups consider 1.2 to 1.8 liters safe to remove in a single session.

Breathlessness and low oxygen are different problems. Plenty of people feel starved of air with a normal reading. NCI says opioids such as morphine may help with distress and fatigue. It says they may also help the feeling that you cannot get enough air. NCI lists non-drug treatments too. These include breathing with the lips pursed and using a fan to blow cold air across the cheek. NCI also lists meditation, relaxation training, biofeedback, and talk therapy for anxiety. These help more than people expect.

Ask two questions at every review. Which tests would actually change what we do next? And what is available to make this easier now, whatever the scan shows? Palliative care teams can be involved at the same time as active treatment. You do not have to wait until treatment stops.

• National Cancer Institute — Advanced Cancer
• National Cancer Institute — Metastatic Cancer: When Cancer Spreads
• National Cancer Institute — Cardiopulmonary Syndromes (PDQ) Patient Version
• NIH StatPearls (NCBI Bookshelf) — Liver Metastasis
• NIH StatPearls (NCBI Bookshelf) — Hepatic Encephalopathy
• NIH StatPearls (NCBI Bookshelf) — Malignant Pleural Effusion
• MedlinePlus — Pulse Oximetry
• MedlinePlus — Bile duct obstruction
• MedlinePlus — Vomiting blood
• MedlinePlus — Black or tarry stools
• National Cancer Institute — Eating Hints (patient booklet)
• CDC — Watch Out for Fever (Preventing Infections in Cancer Patients)