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Quorum
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Vote cast against Themistocles; a quorum of 6,000 was required for ostracism under the Athenian democracy, according to Plutarch; a similar quorum was necessary in the following century for grants of citizenship[1]
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A quorum is the minimum number of members of a deliberative assembly (a body that uses parliamentary procedure, such as a legislature) necessary to conduct the business of that group. According to Robert's Rules of Order Newly Revised, the "requirement for a quorum is protection against totally unrepresentative action in the name of the body by an unduly small number of persons."[2]
The term quorum is from a Middle English wording of the commission formerly issued to justices of the peace, derived from Latin quorum, "of whom", genitive plural of qui, "who".[3] As a result, quora as plural of quorum is not a valid Latin formation.
Contents
[hide]
1 Number constituting a quorum
2 Determination of a quorum
3 Limited actions in the absence of a quorum
4 Call of the house
4.1 Examples in United States Senate
5 Quorum-busting
6 Disappearing quorum
7 By country
7.1 Australia
7.2 Austria
7.3 Canada
7.3.1 Provincial and territorial quorums
7.4 Germany
7.5 Hong Kong
7.6 India
7.7 Ireland
7.8 Turkey
7.9 United Kingdom
7.10 United Nations
7.11 United States
8 See also
9 References
10 External links
Number constituting a quorum[edit]
Each assembly determines the number of members that constitutes a quorum in its governing documents (such as in its constitution, charter, bylaws or standing orders). The quorum may also be set by law. Robert's Rules of Order Newly Revised states that the quorum set in an organization's bylaws "should approximate the largest number that can be depended on to attend any meeting except in very bad weather or other extremely unfavorable conditions."[2]
In the absence of such a provision, a quorum in an assembly whose membership can be determined is a majority of the entire membership.[2] In the meetings of a convention, unless provided otherwise, a quorum is a majority of registered delegates, even if some have departed. In a mass meeting or in an organization in which the membership cannot be accurately determined, the quorum consists of those who attend the meeting.[2]
In committees and boards, a quorum is a majority of the members of the board or committee unless provided otherwise. The board or committee cannot set its own quorum unless given such power.[4] In a committee of the whole or its variants, a quorum is the same as the assembly unless otherwise provided.
In online groups, a quorum has to be determined in a different manner since no one is actually "present". The rules establishing such groups would have to prescribe this determination.[5] An example is that a quorum in such groups could be established as "present" if enough members state that they are "present" at the designated meeting time.[6]
Determination of a quorum[edit]
The chair of the group has the responsibility to determine if a quorum is present.[7] In addition, any member can raise a point of order about an apparent absence of a quorum.[8] Because it is difficult to determine exactly when a quorum was lost, points of order relating to the absence of a quorum are "generally not permitted to affect prior action; but upon clear and convincing proof, such a point of order can be given effect retrospectively by a ruling of the presiding officer, subject to appeal."[7]
Limited actions in the absence of a quorum[edit]
When a quorum is not met, the assembly can only take limited procedural actions. These limited actions are to fix the time to which to adjourn, adjourn, recess, or take measures to obtain a quorum, such as a motion that absent members be contacted during a recess.[9]
Any other business that is conducted is not valid unless it is ratified at a later meeting where a quorum is present. However, there is no obligation to ratify such action and those responsible may be punished for their actions.[9]
Call of the house[edit]
In legislatures and other assemblies that have the legal power to compel the attendance of their members, the call of the house procedure may be used to obtain a quorum.[10] This procedure does not exist in ordinary societies, since voluntary associations have no coercive power.[10]
When a call of the house is ordered, the clerk calls the roll of members and then the names of absentees. Members who do not have an excused absence are arrested and brought in.[10] The arrested members may be charged a fee.[10]
Examples in United States Senate[edit]
In the United States Senate, the procedure was used in the early morning hours of February 25, 1988. Senator Robert C. Byrd of West Virginia, then the Senate Majority Leader, moved a call of the house after the minority Republicans walked out in an attempt to deny the Senate a quorum after Senate aides began bringing cots into the Senate cloakrooms in preparation for an all-night session over campaign finance reform for congressional elections. Byrd's motion was approved 45-3 and arrest warrants were signed for all 46 Republicans. Senate Sergeant-at-Arms Henry K. Giugni and his staff searched the Capitol's corridor and Senate office buildings for absent Senators, and after checking several empty offices, spotted Senator Steve Symms of Idaho, who fled down a hallway and escaped arrest. After a cleaning woman gave a tip that Senator Robert Packwood of Oregon was in his office, Giugni opened the door with a skeleton key. Packwood attempted to shove the door closed, but Giugni and two assistants pushed it open. Packwood was "carried feet-first into the Senate chamber by three plainclothes officers" and sustained bruised knuckles.[11]
Prior to 1988, the last time the procedure had been used was during a 1942 filibuster over civil rights legislation.[11] Southern Democrat senators had spent days filibustering legislation to end poll taxes used in the South to disenfranchise blacks and other low-income voters. Taking place just days after midterm elections had resulted in the loss of nine seats. Democratic Majority Leader Alben W. Barkley obtained an order on a Saturday session on November 14, 1942 directing Sergeant at Arms Chesley W. Jurney to round up the five Southern absentees to obtain a quorum. Jurney sent his Deputy Sergeant at Arms, J. Mark Trice, to the apartment of Democratic Senator Kenneth McKellar of Tennessee at the Mayflower Hotel. Then 73 years old and the third-most senior Senator, McKellar was later described by Republican Senator Bill Frist in his book on Tennessee senators as an "extraordinarily shrewd man of husky dimensions with a long memory and a short fuse." Trice called from the lobby, but McKellar refused to answer his phone, so the deputy sergeant at arms walked up to the apartment and convinced the senator's maid to let him in:[12]
When Trice explained that McKellar was urgently needed back at the Capitol, the 73-year-old legislator agreed to accompany him. As they approached the Senate wing, McKellar suddenly realized what was up. An aide later recalled, "His face grew redder and redder. By the time the car reached the Senate entrance, McKellar shot out and barreled through the corridors to find the source of his summons."
Barkley got his quorum...[12]
Quorum-busting[edit]
The tactic of quorum-busting—causing a quorum to be prevented from meeting—has been used in legislative bodies by minorities seeking to block the adoption of some measure they oppose. This generally only happens where the quorum is a super-majority, as quorums of a majority or less of the membership mean that the support of a majority of members is always sufficient for the quorum (as well as for passage). Rules to discourage quorum-busting have been adopted by legislative bodies, such as the call of the house, outlined above.
Quorum-busting has been used for centuries. For instance, during his time in the state legislature, Abraham Lincoln leapt out of a first story window (the doors of the Capitol had been locked to prevent legislators from fleeing) in a failed attempt to prevent a quorum from being present.[13]
A recent prominent example of quorum-busting occurred during the 2003 Texas redistricting, in which the majority Republicans in the Texas House of Representatives sought to carry out a controversial mid-decade congressional redistricting bill which would have favored Republicans by displacing five Democratic U.S. Representatives from Texas (the Texas Five) from their districts. The House Democrats, certain of defeat if a quorum were present, took a plane to the neighboring state of Oklahoma to prevent a quorum from being present (and thus the passage of the bill). The group gained the nickname "the Killer Ds."
Similarly, the minority Democrats in the Texas Legislature's upper chamber, the Texas Senate, fled to New Mexico to prevent a quorum of the Senate to prevent a redistricting bill from being considered during a special session. The Texas Eleven stayed in New Mexico for 46 days before John Whitmire returned to Texas, creating a quorum. Because there was now no point in staying in New Mexico, the remaining ten members of the Texas Eleven returned to Texas to vote in opposition to the bill.
During the 2011 Wisconsin protests, fourteen Democratic members of the Wisconsin Senate went to Illinois in order to bust the necessary 20-member quorum. Democrats in the Indiana House of Representatives did the same in order to block another union-related bill, causing the legislative clock on the bill to expire. Traveling out of their state placed these legislators beyond the jurisdiction of state troopers who could compel them to return to the chamber.[14]
Disappearing quorum[edit]
The similar tactic of disappearing quorum (refusing to vote although physically present on the floor) was used by the minority to block votes in the United States House of Representatives until 1890. That year, Speaker Thomas Brackett Reed ordered that members who were present but abstaining would count in the quorum.[15][16][17]
By country[edit]
Australia[edit]
Section 22 and section 39 of the Constitution of Australia set the quorum for sittings of the House of Representatives and Senate at one-third of the whole number of MPs and senators, respectively, but Parliament is permitted to change the quorum for each House by ordinary legislation.
In the House of Representatives, the quorum was amended down to one-fifth by the House of Representatives (Quorum) Act 1989, which means the quorum of the current House of 150 MPs is 30 MPs.[18] In the senate, the quorum was amended down to one-quarter by the Senate (Quorum) Act 1991, so 19 senators is a quorum.[19] The quorum includes the occupant of the Chair and is not reduced by the death or resignation of a member or senator.
If at the beginning of a sitting the quorum is not met, the bells are rung for five minutes and a count is then taken; if the quorum is still not met the sitting is adjourned until the next sitting day. During the sitting, any MP or senator may draw attention to the lack of quorum in which the bells are rung for four minutes, and if a quorum is still not met the sitting is adjourned.
Although quorum-busting is virtually unheard of in Australia, it is not unknown for parties to deliberately use quorum counts as a disruptive tactic and there have been some suggestions to enact rules to restrict this practice; however, this is very difficult due to the explicit mention of a quorum in the constitution. It is considered disorderly to call attention to quorum when one exists and members or senators who do so can be punished.
Austria[edit]
In the National Council of Austria at least one third of the representatives must be present, so that they may decide on a simple law (participation quorum of 33.3%). At least half of the members must participate if a constitutional law should pass the parliament (participation quorum of 50% based on the total number of members). Over and above that, constitutional laws require the consent of at least two-thirds of the members present (quorum agreement of 66.6% based on the number of voting present).
Canada[edit]
In Canada, the Constitution Act, 1867 sets quorum for sittings of the House of Commons of Canada at 20 MPs. If a member calls for quorum to be counted and a first count shows there are fewer than 20 members, bells are rung to call in the members; if after 15 minutes there are still fewer than 20 members, the session is adjourned to the next sitting day; the members present sign a roll on the table of the house, and this list is included in the Journal of the House. There is no need for quorum when the attendance of the House is requested in the Senate of Canada, for example when Royal Assent is being given to bills.[20] The quorum of the Senate is 15.[21]
Provincial and territorial quorums[edit]
Province/Territory
Quorum
Alberta 20[22]
British Columbia 10[23]
Manitoba 10[24]
New Brunswick 14[25]
Newfoundland and Labrador 15[26]
Northwest Territories majority[27]
Nova Scotia 15[28]
Nunavut majority[29]
Ontario 12[30]
Prince Edward Island 10[31]
Quebec 21[32]
Saskatchewan 15[33]
Yukon majority[34]
Germany[edit]
In the German Bundestag at least half of the members (311 out of 622) must be present so that it is empowered to make resolutions.[35] It is however common that fewer members are present, because they can still make effective decisions as long as no parliamentary group or 5% of the members of the parliament are complaining about the lack of quorum. This is in rare cases used by opposition parties to delay votes.[36]
Hong Kong[edit]
Article 75 of the Basic Law of Hong Kong stipulates that the quorum required for the meetings of the Legislative Council of Hong Kong (LegCo) as "not less than one half of its members". Between 1997 and 2012 the quorum was 30, and since 2012 it has been 35. Prior to 1997 transfer of sovereignty over Hong Kong, the quorum was set at 20.
The quorum for the panels, committees and subcommittees is, nevertheless, one-third or three members, whichever the greater, as according to the Rules of Procedure. The three standing committees, namely, the Finance Committee, the Public Accounts Committee and Committee on Members' Interests, is exceptional that the quorums are 9, 3 and 3 respectively.
Quorum-busting was used at least twice since 1997. In 2005, when some pro-democracy members of the council paid a silent tribute to late leader of the People's Republic of China, Zhao Ziyang, against the Rules of Procedure, the president of the council suspended the meeting. When the meeting was recalled, pro-Beijing members refused to return to the chamber, forcing the meeting to be adjourned.
On 27 January 2010, when five pro-democracy members were intending to make their resignation speeches, pro-Beijing members of the council left the chamber as a sign of protest. One of the pro-Beijing members nevertheless stayed in the chamber to call for the quorum to be counted, effectively forcing the meeting to be adjourned. The resignation was intended as a de facto referendum across all five geographical constituencies of the territory, involving the entire electorate, which would not be officially recognised anyway. Most other factions, although against the move by these five Members, stayed in the chamber.
On 2 May 2012, when the LegCo was debating a law change to bar resigning legislators to participate in by-elections in 6 months, effectively discouraging any more "de facto" referenda, some of the five pro-democracy members who resigned constantly issued quorum calls, especially when they were making their resignation speeches intended for 2 years before. In the nine-hour meeting, 23 quorum calls were issued, taking up to 3 hours. When LegCo reconvened on 3 May, it was adjourned for lack of quorum amid a boycott by the pan-democrats. The pro-government members drew a timetable to ensure a quorum, but it failed to prevent another lack of quorum.
On 18 June 2015, when the LegCo was due to vote on a resolution to amend the provisions for the election of the territory's Chief Executive, pro-Beijing members left the chamber to force a quorum roll call to make sure that a sick member could be able to rush back to the chamber. However some of the members stayed behind, citing miscommunication, and the division proceeded with two members above the required quorum of 35. While the resolution was originally predicted to be narrowly defeated due to not able to get super-majority support votes, it turned out to be a landslide defeat.[37]
Quorum-busting and attempts to thwart it are also a common feature during the annual motion debate related to the 1989 Tiananmen massacre moved by pro-democracy Members. The quorum is called to be counted from time to time by the pan-democrats, in order to force the pro-Beijing camp to keep some members in the chamber.
India[edit]
Further information: Constitution of India and Parliament of India
Article 100 of the Constitution of India stipulates that at least 10% of total number of members of the House must be present to constitute the quorum to constitute a meeting of either House of Parliament. For example, if the House has total membership of 250, at least 25 members must be present for the House to proceed with its business.[38]
If at any time during a meeting of a House there is no quorum, the Chairman has to either adjourn the House or suspend it until there is a quorum.[38]
Ireland[edit]
According to the most recent standing orders, published in 2011, the Quorum for the Irish Parliament (The Oireachtas) for both the house and senate is 20 members.
The chamber of Dail Eireann is rarely full outside question time, with often just one government representative (often an ordinary member of parliament not a minister) present to answer opposition questions.
Turkey[edit]
According to article 96 of the Turkish Constitution, unless otherwise stipulated in the Constitution, the Turkish Grand National Assembly shall convene with at least, one-third of the total number of members (184 out of 550) and shall take decisions by an absolute majority of those present; however, the quorum for decisions can, under no circumstances, be less than a quarter plus one of the total number of members.
Before the constitutional referendum of 2007, there was a quorum of two-third required in the Turkish Parliament. The opposition parties used the quorum to deadlock the presidential election of 2007, making it impossible for the parliament to choose a president. As a result, the ruling AK party proposed a referendum to lower the quorum. Nearly seventy percent of the participants supported the constitutional changes.
United Kingdom[edit]
In the Parliament of the United Kingdom, the House of Commons has a quorum of 40 MPs, including the Speaker, out of 650 members of the House. There is no need for a quorum to be present at all times. Commons debates could theoretically continue even if just one MP and the Speaker were present. However, if a division is called and fewer than 40 MPs are present, then a decision on the business being considered is postponed and the House moves on to consider the next item of business. The quorum for votes on legislation in the House of Lords is 30, but just three of the 753 peers, including the Lord Speaker, are required to be present for a debate to take place.[39]
Historically, the Quorum was a select group of the Justices of the Peace in each county in early modern Britain. In theory, they were men experienced in law, but many of the Quorum were appointed because of their status. Some legislation required the involvement of a member of the Quorum, (e.g., granting a licence to a badger). In practice, they increasingly were not qualified, as the proportion in the Quorum rose faster than proportion who were called to the bar or practising lawyers. By 1532, an average 45% of Justices of the Peace nationally were of the Quorum. In Somerset, the proportion rose from 52% in 1562 to 93% in 1636. By then, most of those not on the Quorum were new to the bench. Sometimes Justices of the Peace were removed from the Quorum as a disciplinary measure less drastic than removal from the bench.[40]
United Nations[edit]
The large deliberative bodies of the United Nations (the General Assembly and Economic and Social Council, as well as their subsidiary organs) generally require the attendance of one-third of the membership (currently 65 states in the General Assembly and 18 in ECOSOC) to conduct most business, but a majority of members (currently 97 states in the General Assembly and 28 states in ECOSOC) in order to take any substantive decisions.[41][42] The rules of the United Nations Security Council make no provisions for quorum, but nine votes are in all cases required to pass any substantive measure, effectively meaning that a meeting with fewer than nine members in attendance is pointless.[43]
United States[edit]
Article I, Section 5, Clause 1 of the United States Constitution provides that "Each House shall be the Judge of the Elections, Returns and Qualifications of its own Members, and a Majority of each shall constitute a Quorum to do Business..." Therefore, in both the House of Representatives and the Senate a quorum is a simple majority of their respective members. The only exception is that stated in the Twelfth Amendment, which provides that in cases in which no candidate for President of the United States receives a majority in the Electoral College, the election is decided by the House of Representatives, in which case "a quorum for this purpose shall consist of a member or members from two-thirds of the states," and in cases in which no candidate for Vice President of the United States has been elected, the election is decided by the Senate, in which case "a quorum for the purpose shall consist of two-thirds of the whole number of Senators."
The Senate has the additional ordinary requirement in Rule VI of its Standing Rules that "A quorum shall consist of a majority of the Senators duly chosen and sworn."
See also[edit]
Quorum call
Minyan - the quorum of 10 Jews (traditionally, ten male adults, above the age of 13) necessary for Jewish communal prayer to be conducted
Quorum sensing in bacteria
References[edit]
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^ Jump up to: a b c d Robert, Henry M.; et al. (2011). Robert's Rules of Order Newly Revised (11th ed.). Philadelphia, PA: Da Capo Press. p. 21. ISBN 978-0-306-82020-5.
Jump up ^ "Quorum," Merriam-Webster's Online Dictionary, 11th Edition.
Jump up ^ Robert 2011, p. 347
Jump up ^ Robert 2011, p. 99
Jump up ^ Stackpole, John D. (July 2001). "Electronic Meetings: Rules for Electronic (e-mail) Meetings or The E-liberative Assembly" (PDF). aipparl.org. American Institute of Parliamentarians. Retrieved 2016-01-23.
^ Jump up to: a b Robert 2011, p. 349
Jump up ^ "Frequently Asked Questions about RONR (Question 3)". The Official Robert's Rules of Order Web Site. The Robert's Rules Association. Retrieved 2015-12-13.
^ Jump up to: a b Robert 2011, p. 348
^ Jump up to: a b c d Robert 2011, pp. 350–351
^ Jump up to: a b Lauter, David. "Senate Police Seize Packwood for Quorum Call." Los Angeles Times February 25, 1988.
^ Jump up to: a b "November 14, 1942: Arrests Compel Senate Quorum." United States Senate History.
Jump up ^ Donald, David Herbert (1995). Lincoln. Random House. p. 77.
Jump up ^ Burton, Thomas M. (February 24, 2011). "Indiana GOP Drops Union Bill, but Democrats Stay Out of State". Wall Street Journal.
Jump up ^ Oleszek, Walter J. (December 1998). "A Pre-Twentieth Century Look at the House Committee on Rules, The Reed Rules". archives.democrats.rules.house.gov. The U.S. House of Representatives Committee on Rules. Retrieved 2016-01-27.
Jump up ^ "The History and Lessons of Congressional Crises". The New York Times. ISSN 0362-4331. Retrieved 2017-03-27.
Jump up ^ "House quorum rule changed, Jan. 29, 1890". POLITICO. Retrieved 2017-03-27.
Jump up ^ "Guide to Procedures". Aph.gov.au. 2005-03-18. Archived from the original on December 21, 2008. Retrieved 2010-06-20.
Jump up ^ "Chapter 8, Odgers' Australian Senate Practice Eleventh Edition". Aph.gov.au. Archived from the original on August 15, 2008. Retrieved 2010-06-20.
Jump up ^ "Marleau, Robert, and Camille Montpetit, eds. ''House of Commons Procedure and Practice.'' 2000 ed. Accessed 13 June 2008". Parl.gc.ca. Retrieved 2010-06-20.
Jump up ^ The Constitution Act, 1867, 30 & 31 Vict, c 3, s 35 <http://canlii.ca/t/ldsw#sec35> retrieved on 2013-10-21
Jump up ^ https://www.assembly.ab.ca/pro/standing/standing_orders.pdf
Jump up ^ Constitution Act
Jump up ^ Manitoba Laws
Jump up ^ http://www.gnb.ca/legis/publications/rules-reglement.pdf
Jump up ^ [1] Archived October 21, 2013, at the Wayback Machine.
Jump up ^ Northwest Territories Act
Jump up ^ Rules and Forms of Procedure
Jump up ^ "Rules of the Legislative Assembly of Nunavut" (PDF). Legislative Assembly of Nunavut. May 2013. Retrieved 16 May 2015.
Jump up ^ Standing Orders - Legislative Assembly of Ontario
Jump up ^ http://www.gov.pe.ca/photos/original/legassembly_rul.pdf
Jump up ^ Quorum - National Assembly of Québec
Jump up ^ Legislative Assembly of Saskatchewan - Glossary
Jump up ^ Yukon Act
Jump up ^ "§ 45 Geschäftsordnung des Deutschen Bundestages". Bundestag.de. Retrieved 2010-06-20.
Jump up ^ "Bundestag bricht überraschend Sitzung ab". Spiegel Online. 2012-06-15. Retrieved 2012-06-15.
Jump up ^ One Sick Lawmaker Makes Vote on Hong Kong Democracy a Landslide - Bloomberg Business
^ Jump up to: a b "Rajya sabha handbook". Archived from the original on 27 Sep 2012. Retrieved 3 May 2013.
Jump up ^ "Quorum" (October 23, 2008). BBC.
Jump up ^ Gleason, J.H. The Justice of the Peace in England 1558-1640, Oxford, 1969
Jump up ^ United Nations General Assembly. "UN General Assembly Rules of Procedure". United Nations. Retrieved 23 April 2012.
Jump up ^ United Nations Economic and Social Council. "UN Economic and Social Council Rules of Procedure" (PDF). United Nations. Retrieved 23 April 2012.
Jump up ^ United Nations Security Council (1983). "UN Security Council Provisional Rules of Procedure". United Nations. Archived from the original on May 2, 2012. Retrieved 23 April 2012.
External links[edit]
Look up quorum in Wiktionary, the free dictionary.
"Quorum". Encyclopædia Britannica. 22 (11th ed.). 1911.
"Voting and Quorum Procedures" (PDF). U.S. Senate.
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Liver cancer
From Wikipedia, the free encyclopedia
Jump to navigation Jump to search
Liver cancer
Synonyms
Hepatic cancer, primary hepatic malignancy, primary liver cancer
CT scan of a liver with cholangiocarcinoma
Specialty
Oncology
Symptoms
Lump or pain in the right side below the rib cage, swelling of the abdomen, yellowish skin, easy bruising, weight loss, weakness[1]
Usual onset
55 to 65 years old[2]
Causes
Cirrhosis due to hepatitis B, hepatitis C, or alcohol, aflatoxin, non-alcoholic fatty liver disease, liver flukes[3][4]
Diagnostic method
Blood tests, medical imaging, tissue biopsy[1]
Prevention
Immunization against hepatitis B, treating those infected with hepatitis B or C[3]
Treatment
Surgery, targeted therapy, radiation therapy[1]
Prognosis
Five-year survival rates ~ 18% (US)[2]
Frequency
618,700 (point in time in 2015)[5]
Deaths
810,500 (2015)[6]
Liver cancer, also known as hepatic cancer and primary hepatic cancer, is cancer that starts in the liver.[1] Cancer which has spread from elsewhere to the liver, known as liver metastasis, is more common than that which starts in the liver.[3] Symptoms of liver cancer may include a lump or pain in the right side below the rib cage, swelling of the abdomen, yellowish skin, easy bruising, weight loss, and weakness.[1]
The leading cause of liver cancer is cirrhosis due to hepatitis B, hepatitis C, or alcohol.[4] Other causes include aflatoxin, non-alcoholic fatty liver disease, and liver flukes.[3] The most common types are hepatocellular carcinoma (HCC), which makes up 80% of cases, and cholangiocarcinoma.[3] Less common types include mucinous cystic neoplasm and intraductal papillary biliary neoplasm.[3] The diagnosis may be supported by blood tests and medical imaging with confirmation by tissue biopsy.[1]
Preventive efforts include immunization against hepatitis B and treating those infected with hepatitis B or C.[3] Screening is recommended in those with chronic liver disease.[3] Treatment options may include surgery, targeted therapy, and radiation therapy.[1] In certain cases ablation therapy, embolization therapy, or liver transplantation may be used.[1] Small lumps in the liver may be closely followed.[1]
Primary liver cancer is globally the sixth most frequent cancer (6%) and the second leading cause of death from cancer (9%).[3][7] In 2012 it occurred in 782,000 people and in 2015 resulted in 810,500 deaths.[7][6] In 2015, 263,000 deaths from liver cancer were due to hepatitis B, 167,000 to hepatitis C, and 245,000 to alcohol.[6] Higher rates of liver cancer occur where hepatitis B and C are common, including Asia and sub-Saharan Africa.[3] Males are more often affected with HCC than females.[3] Diagnosis is most frequent among those 55 to 65 years old.[2] Five-year survival rates are 18% in the United States.[2] The word "hepatic" is from the Greek hêpar, meaning "liver."[8]
Contents
[hide]
1 Classification
2 Signs and symptoms
3 Causes
3.1 Viral infection
3.2 Cirrhosis
3.3 Aflatoxin
3.4 Other causes in adults
3.5 Children
4 Diagnosis
5 Prevention
6 Treatment
6.1 Hepatocellular carcinoma
6.2 Cholangiocarcinoma
6.3 Hepatoblastoma
7 Epidemiology
7.1 UK
7.2 India
8 Research
9 See also
10 References
11 External links
Classification[edit]
The most frequent liver cancer, accounting for approximately 75% of all primary liver cancers, is hepatocellular carcinoma (HCC) (also named hepatoma, which is a misnomer because adenomas are usually benign). HCC is a cancer formed by liver cells, known as hepatocytes, that become malignant. Another type of cancer formed by liver cells is hepatoblastoma, which is specifically formed by immature liver cells.[9] It is a rare malignant tumor that primarily develops in children, and accounts for approximately 1% of all cancers in children and 79% of all primary liver cancers under the age of 15. Most hepatoblastomas form in the right lobe.[10]
Liver cancer can also form from other structures within the liver such as the bile duct, blood vessels and immune cells. Cancer of the bile duct (cholangiocarcinoma and cholangiocellular cystadenocarcinoma) account for approximately 6% of primary liver cancers.[9] There is also a variant type of HCC that consists of both HCC and cholangiocarcinoma.[11] Tumors of the blood vessels (angiosarcoma and hemangioendothelioma, embryonal sarcoma and fibrosarcoma are produced from a type of connective tissue known as mesenchyme. Cancers produced from muscle in the liver are leiomyosarcoma and rhabdomyosarcoma. Other less common liver cancers include carcinosarcomas, teratomas, yolk sac tumours, carcinoid tumours and lymphomas.[9] Lymphomas usually have diffuse infiltration to liver, but It may also form a liver mass in rare occasions.
Many cancers found in the liver are not true liver cancers, but are cancers from other sites in the body that have spread to the liver (known as metastases). Frequently, the site of origin is the gastrointestinal tract, since the liver is close to many of these metabolically active, blood-rich organs near to blood vessels and lymph nodes (such as pancreatic cancer, stomach cancer, colon cancer and carcinoid tumors mainly of the appendix), but also from breast cancer, ovarian cancer, lung cancer, renal cancer, prostate cancer.
Signs and symptoms[edit]
Because liver cancer is an umbrella term for many types of cancer, the signs and symptoms depend on what type of cancer is present. Cholangiocarcinoma is associated with sweating, jaundice, abdominal pain, weight loss and liver enlargement.[12] Hepatocellular carcinoma is associated with abdominal mass, abdominal pain, emesis, anemia, back pain, jaundice, itching, weight loss and fever.[13]
Causes[edit]
Viral infection[edit]
This electron micrograph shows hepatitis B virus "Dane particles", or virions.
Viral infection with either hepatitis C virus (HCV) or Hepatitis B virus (HBV) is the chief cause of liver cancer in the world today, accounting for 80% of hepatocellular carcinoma (HCC).[14][15][16] The viruses cause HCC because massive inflammation, fibrosis and eventual cirrhosis occurs within the liver. HCC usually arises after cirrhosis, with an annual incidence of 1.7% in cirrhotic HCV-infected individuals.[17] Around 5-10% of individuals that become infected with HBV become chronic carriers, and around 30% of these acquire chronic liver disease, which can lead to HCC.[14] HBV infection is also linked to cholangiocarcinoma.[18] The role of viruses other than HCV or HBV in liver cancer is much less clear, although there is some evidence that co-infection of HBV and hepatitis D virus may increase the risk of HCC.[19]
Many genetic and epigenetic changes are formed in liver cells during HCV and HBV infection, which is a major factor in the production of the liver tumors. The viruses induce malignant changes in cells by altering gene methylation, affecting gene expression and promoting or repressing cellular signal transduction pathways. By doing this the viruses can prevent cells from undergoing a programmed form of cell death (apoptosis) and promote viral replication and persistence.[14][17]
HBV and HCV also induce malignant changes by causing DNA damage and genomic instability. This is by creating reactive oxygen species, express proteins that interfere with DNA repair enzymes, and HCV causes activation of a mutator enzyme.[20][21]
Cirrhosis[edit]
High magnification micrograph of a liver with cirrhosis. Trichrome stain. The most common cause of cirrhosis in the Western world is alcohol abuse - the cause of cirrhosis in this case.
In addition to virus-related cirrhosis described above, other causes of cirrhosis can lead to HCC. Alcohol intake correlates with risk of HCC, and the risk is far greater in individuals with an alcohol-induced cirrhotic liver. There are a few disorders that are known to cause cirrhosis and lead to cancer, including hereditary hemochromatosis and primary biliary cirrhosis.[22]
Aflatoxin[edit]
Aflatoxin exposure can lead to the development of HCC. The aflatoxins are a group of chemicals produced by the fungi Aspergillus flavus (the name comes from A. flavus toxin) and A. parasiticus. Food contamination by the fungi leads to ingestion of the chemicals, which are very toxic to the liver. Common foodstuffs contaminated with the toxins are cereals, peanuts and other vegetables. Contamination of food is common in Africa, South-East Asia and China. Concurrent HBV infection and aflatoxin exposure increases the risk of liver cancer to over three times that seen in HBV infected individuals without aflatoxin exposure. The mechanism by which aflatoxins cause cancer is through genetic mutation of a gene required for the prevention of cancer: p53.[23][24]
Other causes in adults[edit]
High grade dysplastic nodules are precancerous lesions of the liver. Within 2 years, there is a risk of cancer arising from these nodules of 30-40%.[25]
Obesity has emerged as an important risk factor as it can lead to steatohepatitis.[16][24]
Diabetes increases the risk of HCC.[24]
Smoking increases the risk of HCC compared to non-smokers and previous smokers.[24]
There is around 5-10% lifetime risk of cholangiocarcinoma in people with primary sclerosing cholangitis.[26]
Liver fluke infection increases the risk of cholangiocarcinoma, and is the reason Thailand has particularly high rates of this cancer.[27]
Children[edit]
Increased risk of liver cancer in children can be caused by Beckwith-Wiedemann Syndrome (associated with hepatoblastoma),[28][29] familial adenomatous polyposis (associated with hepatoblastoma),[29] low birth weight (associated with hepatoblastoma),[10] Progressive familial intrahepatic cholestasis (associated with HCC)[30] and Trisomy 18 (associated with hepatoblastoma).[29]
Diagnosis[edit]
Further information: Hepatocellular carcinoma § Diagnosis
Many imaging modalities are used to aid in the diagnosis of primary liver cancer. For HCC these include sonography (ultrasound), computed tomography (CT) and magnetic resonance imaging (MRI). When imaging the liver with ultrasound, a mass greater than 2 cm has more than 95% chance of being HCC. The majority of cholangiocarcimas occur in the hilar region of the liver, and often present as bile duct obstruction. If the cause of obstruction is suspected to be malignant, endoscopic retrograde cholangiopancreatography (ERCP), ultrasound, CT, MRI and magnetic resonance cholangiopancreatography (MRCP) are used.[31]
Tumor markers, chemicals sometimes found in the blood of people with cancer, can be helpful in diagnosing and monitoring the course of liver cancers. High levels of alpha-fetoprotein (AFP) in the blood can be found in many cases of HCC and intrahepatic cholangiocarcinoma. Cholangiocarcinoma can be detected with these commonly used tumor markers: carbohydrate antigen 19-9 (CA 19-9), carcinoembryonic antigen (CEA) and cancer antigen 125 (CA125). These tumour markers are found in primary liver cancers, as well as in other cancers and certain other disorders.[32][33]
Prevention[edit]
Prevention of cancers can be separated into primary, secondary, and tertiary prevention. Primary prevention preemptively reduces exposure to a risk factor for liver cancer. One of the most successful primary liver cancer preventions is vaccination against hepatitis B. Vaccination against the hepatitis C virus is currently unavailable. Other forms of primary prevention are aimed at limiting transmission of these viruses by promoting safe injection practices, screening blood donation products, and screening high-risk asymptomatic individuals. Aflatoxin exposure can be avoided by post-harvest intervention to discourage mold, which has been effective in west Africa. Reducing alcohol abuse, obesity, and diabetes would also reduce rates of liver cancer. Diet control in hemochromatosis could decrease the risk of iron overload, decreasing the risk of cancer.[34]
Secondary prevention includes both cure of the agent involved in the formation of cancer (carcinogenesis) and the prevention of carcinogenesis if this is not possible. Cure of virus-infected individuals is not possible, but treatment with antiviral drugs such as interferon can decrease the risk of liver cancer. Chlorophyllin may have potential in reducing the effects of aflatoxin.[34]
Tertiary prevention includes treatments to prevent the recurrence of liver cancer. These include the use of chemotherapy drugs and antiviral drugs.[34]
Treatment[edit]
Hepatocellular carcinoma[edit]
This section needs to be updated. Please update this article to reflect recent events or newly available information. (June 2017)
Left lobe liver tumor in a 50-year-old male, operated in King Saud Medical Complex, Riyadh, Saudi Arabia
Partial surgical resection is the optimal treatment for hepatocellular carcinoma (HCC) when patients have sufficient hepatic function reserve. Increased risk of complications such as liver failure can occur with resection of cirrhotic (i.e. less-than-optimally functional) livers. 5-year survival rates after resection have massively improved over the last few decades and can now exceed 50%. However, recurrence rates after resection can exceed 70%, whether due to spread of the initial tumor or formation of new tumors .[35] Liver transplantation can also be considered in cases of HCC where this form of treatment can be tolerated and the tumor fits specific criteria (such as the Milan criteria). In general, patients who are being considered for liver transplantation have multiple hepatic lesions, severe underlying liver dysfunction, or both. Less than 30-40% of individuals with HCC are eligible for surgery and transplant because the cancer is often detected at a late stage. Also, HCC can progress during the waiting time for liver transplants, which can prevent transplant due to the strict criteria.
Percutaneous ablation is the only non-surgical treatment that can offer cure. There are many forms of percutaneous ablation, which consist of either injecting chemicals into the liver (ethanol or acetic acid) or producing extremes of temperature using radio frequency ablation, microwaves, lasers or cryotherapy. Of these, radio frequency ablation has one of the best reputations in HCC, but the limitations include inability to treat tumors close to other organs and blood vessels due to heat generation and the heat sink effect, respectively.[36][37] In addition, long-term of outcomes of percutaneous ablation procedures for HCC have not been well studied. In general, surgery is the preferred treatment modality when possible.
Systemic chemotherapeutics are not routinely used in HCC, although local chemotherapy may be used in a procedure known as transarterial chemoembolization. In this procedure, cytotoxic drugs such as doxorubicin or cisplatin with lipiodol are administered and the arteries supplying the liver are blocked by gelatin sponge or other particles. Because most systemic drugs have no efficacy in the treatment of HCC, research into the molecular pathways involved in the production of liver cancer produced sorafenib, a targeted therapy drug that prevents cell proliferation and blood cell growth. Sorafenib obtained FDA approval for the treatment of advanced hepatocellular carcinoma in November 2007.[38] This drug provides a survival benefit for advanced HCC.[37]
Radiotherapy is not often used in HCC because the liver is not tolerant to radiation. Although with modern technology it is possible to provide well-targeted radiation to the tumor, minimizing the dose to the rest of the liver. Dual treatments of radiotherapy plus chemoembolization, local chemotherapy, systemic chemotherapy or targeted therapy drugs may show benefit over radiotherapy alone.[39]
A surgeon performing photodynamic therapy
Cholangiocarcinoma[edit]
Resection is an option in cholangiocarcinoma, but fewer than 30% of cases of cholangiocarcinoma are resectable at diagnosis. After surgery, recurrence rates are up to 60%.[40][41] Liver transplant may be used where partial resection is not an option, and adjuvant chemoradiation may benefit some cases.[26]
60% of cholangiocarcinomas form in the perihilar region and photodynamic therapy can be used to improve quality of life and survival time in these unresectable cases. Photodynamic therapy is a novel treatment that utilitizes light activated molecules to treat the tumor. The compounds are activated in the tumor region by laser light, which causes the release of toxic reactive oxygen species, killing tumor cells.[40][42]
Systemic chemotherapies such as gemcitabine and cisplatin are sometimes used in inoperable cases of cholangiocarcinoma.[26]
Radio frequency ablation, transarterial chemoembolization and internal radiotherapy (brachytherapy) all show promise in the treatment of cholangiocarcinoma.[41]
Radiotherapy may be used in the adjuvant setting or for palliative treatment of cholangiocarcinoma.[43]
Hepatoblastoma[edit]
Removing the tumor by either surgical resection or liver transplant can be used in the treatment of hepatoblastoma. In some cases surgery can offer a cure. Chemotherapy may be used before and after surgery and transplant.[44]
Chemotherapy, including cisplatin, vincristine, cyclophosphamide, and doxorubicin are used for the systemic treatment of hepatoblastoma. Out of these drugs, cisplatin seems to be the most effective.[45]
Epidemiology[edit]
Deaths from liver cancer per million persons in 2012
6-18
19-24
25-32
33-40
41-50
51-65
66-72
73-90
91-122
123-479
Globally, as of 2010[update], liver cancer resulted in 754,000 deaths, up from 460,000 in 1990, making it the third leading cause of cancer death after lung and stomach.[46] In 2012, it represented 7% of cancer diagnoses in men, the 5th most diagnosed cancer that year.[47] Of these deaths 340,000 were secondary to hepatitis B, 196,000 were secondary to hepatitis C, and 150,000 were secondary to alcohol.[46] HCC, the most common form of liver cancer, shows a striking geographical distribution. China has 50% of HCC cases globally, and more than 80% of total cases occur in sub-Saharan Africa or in East-Asia due to hepatitis B virus.[27][48] Cholangiocarcinoma also has a significant geographical distribution, with Thailand showing the highest rates worldwide due to the presence of liver fluke.[27][49]
UK[edit]
Liver cancer is the eighteenth most common cancer in the UK (around 4,300 people were diagnosed with liver cancer in the UK in 2011), and it is the twelfth most common cause of cancer death (around 4,500 people died of the disease in 2012).[50]
India[edit]
The number of new cases of hepatocellular carcinoma per year in India in males is about 4.1 and for females 1.2 per 100,000. It typically occurs between 40 and 70 years of age.[51]
Research[edit]
Hepcortespenlisimut-L is an oral immunotherapy that is going through a phase 3 clinical trial for HCC.[52]
See also[edit]
Timeline of liver cancer
References[edit]
^ Jump up to: a b c d e f g h i "Adult Primary Liver Cancer Treatment (PDQ®)–Patient Version". NCI. 6 July 2016. Archived from the original on 2 October 2016. Retrieved 29 September 2016.
^ Jump up to: a b c d "SEER Stat Fact Sheets: Liver and Intrahepatic Bile Duct Cancer". NCI. Archived from the original on 2017-07-28. Retrieved 2016. Check date values in: |accessdate= (help)
^ Jump up to: a b c d e f g h i j k World Cancer Report 2014. World Health Organization. 2014. pp. Chapter 5.6. ISBN 9283204298.
^ Jump up to: a b GBD 2013 Mortality and Causes of Death, Collaborators (17 December 2014). "Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013". Lancet. 385: 117–71. doi:10.1016/S0140-6736(14)61682-2. PMC 4340604  . PMID 25530442.
Jump up ^ GBD 2015 Disease and Injury Incidence and Prevalence, Collaborators. (8 October 2016). "Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015". Lancet. 388 (10053): 1545–1602. doi:10.1016/S0140-6736(16)31678-6. PMC 5055577  . PMID 27733282.
^ Jump up to: a b c GBD 2015 Mortality and Causes of Death, Collaborators. (8 October 2016). "Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015". Lancet. 388 (10053): 1459–1544. doi:10.1016/s0140-6736(16)31012-1. PMC 5388903  . PMID 27733281.
^ Jump up to: a b World Cancer Report 2014. World Health Organization. 2014. pp. Chapter 1.1. ISBN 9283204298.
Jump up ^ "Hepato- Etymology". dictionary.com. Archived from the original on 10 October 2015. Retrieved 24 October 2015.
^ Jump up to: a b c Ahmed, Ahmed, I; Lobo D.N.; Lobo, Dileep N. (January 2009). "Malignant tumours of the liver". Surgery (Oxford). 27 (1): 30–37. doi:10.1016/j.mpsur.2008.12.005.
^ Jump up to: a b Emre, S; McKenna, GJ (December 2004). "Liver tumors in children". Pediatric transplantation. 8 (6): 632–8. doi:10.1111/j.1399-3046.2004.00268.x. PMID 15598339.
Jump up ^ Khan SA, Davidson BR, Goldin RD, Heaton N, Karani J, Pereira SP, Rosenberg WM, Tait P, Taylor-Robinson SD, Thillainayagam AV, Thomas HC, Wasan H (2012). "Guidelines for the diagnosis and treatment of cholangiocarcinoma: an update". Gut. 61 (12): 1657–69. doi:10.1136/gutjnl-2011-301748. PMID 22895392.
Jump up ^ Cholangiocarcinoma at eMedicine
Jump up ^ "Liver tumors in Children". Boston Children's Hospital. Archived from the original on 2011-06-04.
^ Jump up to: a b c Arzumanyan, A; Reis, HM; Feitelson, MA (February 2013). "Pathogenic mechanisms in HBV- and HCV-associated hepatocellular carcinoma". Nature Reviews. Cancer. 13 (2): 123–35. doi:10.1038/nrc3449. PMID 23344543.
Jump up ^ Rosen, HR (Jun 23, 2011). "Clinical practice. Chronic hepatitis C infection". The New England Journal of Medicine. 364 (25): 2429–38. doi:10.1056/NEJMcp1006613. PMID 21696309.
^ Jump up to: a b "General Information About Adult Primary Liver Cancer". National Cancer Institute. Archived from the original on 2 January 2013. Retrieved 13 January 2013.
^ Jump up to: a b Jeong, SW; Jang, JY; Chung, RT (December 2012). "Hepatitis C virus and hepatocarcinogenesis". Clinical and molecular hepatology. 18 (4): 347–56. doi:10.3350/cmh.2012.18.4.347. PMC 3540370  . PMID 23323249.
Jump up ^ Ralphs, S; Khan, SA (May 2013). "The role of the hepatitis viruses in cholangiocarcinoma". Journal of viral hepatitis. 20 (5): 297–305. doi:10.1111/jvh.12093. PMID 23565610.
Jump up ^ Kew, MC (March 2013). "Hepatitis viruses (other than hepatitis B and C viruses) as causes of hepatocellular carcinoma: an update". Journal of viral hepatitis. 20 (3): 149–57. doi:10.1111/jvh.12043. PMID 23383653.
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External links[edit]
Classification
D
ICD-10: C22
ICD-9-CM: 155
OMIM: 114550
MeSH: D008113
DiseasesDB: 7547
External resources
MedlinePlus: 000280
eMedicine: article/197319
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Liver Cancer at Johns Hopkins University
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Digestive system neoplasia (C15–C26/D12–D13, 150–159/211)
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