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Liver Cancer Tips

Laparoscopy And Liver Cancer - Know All About It!

Dr. Praveen Sharma 86% (24 ratings)
MBBS, MD - General Medicine, DM - Gastroenterology
Gastroenterologist, Delhi
Laparoscopy And Liver Cancer - Know All About It!

Today, both doctors and patient prefer minimally invasive procedures as compared to traditional open surgery. Such procedures are also known as laparoscopic procedures or keyhole surgeries. This procedure involves making a small incision through which a long, flexible tube is passed. The end that enters the body has a powerful light and a camera through which the surgeon can view the internal organs. To facilitate movement of the tube, carbon dioxide gas may also be pumped into the abdominal cavity. In case an organ needs to be operated upon, other incisions will also be made through which surgical instruments can be used.

Liver cancer is one of the conditions that can benefit from laparoscopic procedures. Laparoscopy can be used to diagnose liver cancer and determine the stage it has reached and to treat it accordingly. In order to confirm a liver cancer diagnosis, the surgeon will look for the presence of tumors in the lymph nodes and surface of the liver. In addition, tissue samples will also be collected. These will be sent to a lab to be biopsied in order to determine whether the tumor is malignant or benign.

Once a diagnosis is confirmed, surgery to remove the tumor is the most recommended form of treatment. This may be followed by chemotherapy and radiation. Small malignant tumors on the left lateral segment of the liver or anterior segment on the right side of the liver can be safely removed with laparoscopic procedures. Laparoscopy can also be used to remove multiple tumors on the liver. However large tumors and tumors that are located close to the suprahepatic junction or portal bifurcation should not be addressed laparoscopically. Laparoscopy may also be avoided if the patient has undergone open resectional procedures earlier that may have caused dense adhesions. In such cases, open surgery is preferred. However, even these procedures may be preceded by a laparoscopic exploratory procedure that allows the surgeon to get a clearer view of the tumor.
 

As compared to open surgery, laparoscopic surgery has a number of advantages. These include:

  1. Smaller scars
  2. Faster recovery
  3. Minimal bleeding
  4. Lowered risk of infection
  5. Reduced hospitalization
  6. Lesser pain and discomfort

As with any other procedure, the skill of a surgeon plays an important role in the success of the procedure. In the case of laparoscopic procedures, this skill is critical. Hence, laparoscopic surgeries of the treatment of liver cancer are not very common.

3094 people found this helpful

Liver Transplant Surgery - Situations Where Is It Required!

Dr. Ankur Garg 89% (498 ratings)
M. Ch., FEBS, MBBS, MS - General Surgery
Liver Transplant Surgeon, Delhi
Liver Transplant Surgery - Situations Where Is It Required!

A liver transplant surgery is a procedure by the virtue of which the doctors remove the liver in that cases where it becomes non-functional or does not function appropriately. In this process, the malfunctioning liver is substituted with the healthy liver obtained from a living donor.

Liver transplant surgery has been performed in the medicine for more than 30 years and it has been observed that this surgery is successful and the patients who undergo liver transplant are able to live healthy lives.
Liver transplant is usually performed in the cases where the liver failure could not be treated by other alternative medical treatments available and cancerous conditions. There can be either acute liver failure or chronic liver failure. The Liver transplantation is more often performed in order to treat the chronic ailments.

In Adults

  1. In the cases of adults, one of the major causes of getting liver transplantation done is liver cirrhosis. Cirrhosis is a medical condition where there is a gradual deterioration of liver and severe chronic illness may lead to malfunctioning of the liver.
  2. The blood flow across the liver can be blocked due to the dominance of the scar tissue over healthy tissue.
  3. There can also be other reasons for cirrhosis which include the attack of viruses like hepatitis B and C, the alcoholic liver disease due to excess intake of alcohol, increase in the fat proportion in the liver, Autoimmune disorders of liver or you can say, hereditary diseases such as hemochromatosis and Wilson’s disease.
  4. When the alcohol intake increases rapidly, then the patients do need a liver transplant but if the person controls the intake of alcohol, then improvements can be observed significantly and the patients may even survive for a long time even without getting the transplant done. But in certain cases, even after abstaining from alcohol, the damage is untreatable and healthy liver tissue cannot be restored, in such cases, liver transplant becomes a compulsion.

In children

  1. In the case of children, biliary atresia is the most prominent reason for the liver transplant surgery. It is a very rare condition wherein the bile duct that connect the liver and the small intestine is either blocked or absent in newborn babies. Hence, the function of bile ducts, i.e. removal of bile juice from the liver gets hampered and obstructed bile leads to cirrhosis. The digestion of the food could not be carried out properly.
  2. There can be several other reasons for liver transplantation such as the cancer in the liver or benign tumors that can be present in the liver. When a patient suffers from liver cirrhosis, the chances of acquiring the primary cancer increase by multiple times. The likelihood increases furthermore in those patients who have liver disorders along with hepatitis B. Mostly, after liver transplant surgery, patients are able to live their life normally, but if the cancer starts spreading to other body parts from the liver, then liver transplantation is not the solution.
1874 people found this helpful

Bile Duct Cancer - Signs And Symptoms Associated With It!

Dr. Anuj Gupta 92% (709 ratings)
Post Graduate Certficate in Ksharsutra & Ano-Rectal Diseases, BAMS, IMA Ayush , Vaidratnam kerala
General Physician, Gurgaon
Bile Duct Cancer - Signs And Symptoms Associated With It!

Cholangiocarcinoma (Bile duct cancer), like any other cancer, leaves a person physically, mentally and emotionally drained. It has been mostly found to affect people above 60 years of age. The signs and symptoms associated are so common that very few people consult a physician. A delayed diagnosis implies delayed treatment. This goes on to aggravate and complicate the situation further. One needs to be a little alert. Any symptoms, no matter how common, should not be taken lightly. Look for the early signs and symptoms and bile duct cancer can be fully cured.
Signs and symptoms associated with Cholangiocarcinoma
Bile duct cancer can be Extrahepatic (occurs in the duct outside the liver) or Intrahepatic (cancer develops within the smaller ducts inside the liver). It must be noted that Intrahepatic Bile duct cancer and Liver cancer are different.
-      Bile duct cancer results in blocking the bile duct. This blockage severely effects the secretion of bilirubin and bile from the liver. Thus, the secretions (bile and bilirubin) which are supposed to flow into the intestine move back into the bloodstream. An elevated level of bilirubin in the blood gives rise to a condition, known as Jaundice (a condition resulting in yellowing of the eyes and the skin). The problem lies in the fact that many other factors can equally contribute to Jaundice. Consulting a physician at the earliest is the best resort.
-      A sudden or drastic weight loss and loss of appetite is an alarming sign of Cholangiocarcinoma.
-      Excessive itching can be an indication of something as big as bile duct cancer. Itching can be an outcome of the increased bilirubin (blood) reaching the skin.
-      At an advanced stage of Cholangiocarcinoma, a patient may experience severe abdominal pain.
-      At times, the tumour in the bile duct might exert immense pressure on the nearby organs. This can give rise to an enlarged abdominal mass. Bloated feeling is also very common amongst the patients.
-      An unusual change in the colour of the stool and urine should not be neglected. The elevated bilirubin level from the intestine is usually eliminated out of the system through the urine.  Thus the stool appears lighter and the urine a shade darker.
-      A cholangiocarcinoma patient can, at times feel nauseated. Fever is also a common but an extremely important indication.

Bile duct cancer or cholangiocarcinoma can lead to many other complications. 

2972 people found this helpful

Liver Cancer - Its Symptoms And Diagnosis!

Dr. Swarup Kumar Ghosh 88% (82 ratings)
MD - Bio-Chemistry, MF Homeo (London), DHMS (Diploma in Homeopathic Medicine and Surgery), BHMS
Homeopath, Kolkata
Liver Cancer - Its Symptoms And Diagnosis!

Why and when to do liver cancer test?
The liver is a pyramid-shaped organ in our body that lies just below the right lung. It is the largest organ inside the human body. This vital organ is divided into right and left lobes and performs a number of functions. It makes bile necessary to digest fat, makes various proteins used by the body for a number of other purposes, breaks down toxic materials in the blood that are later removed by the body as waste, helps in blood clotting and stores certain nutrients absorbed from the intestine. Thus liver is primary to the healthy functioning of the human body. Liver cancer test in India when cancerous cells form in the liver, it is known as liver cancer. Primary liver cancer is cancer that starts in the liver tissue; whereas cancer that starts in some other site and spreads to the liver is classified as the secondary liver cancer. Varied methods & techniques are available to treat liver cancer.

Diagnosis: After examining your health and learning about family history, your doctor may tell you to go for one or more of the following tests for diagnosing liver cancer:

  • Liver biopsy: Liver biopsy is done in order to remove a tissue sample from the suspected site in the liver. This tissue sample is analyzed under the microscope to confirm the presence of cancerous cells. Biopsy of liver laparoscopic biopsy, needle biopsy, and surgical biopsy are the different types of biopsies done.
  • Blood tests: You may need to perform some blood tests like liver function tests (LFTs). Besides these, if a suspicion of liver cancer arises, doctors check the level of alphafetoprotein (AFP) in the blood. The level of AFP is usually found higher in people with primary level cancer; although there are cases of people with liver cancer having normal levels of AFP. Again the ratio of des-gamma-carboxy prothrombin is also checked.
  • Ultrasound: Imaging tests are done to find suspicious sites that may be cancerous and also to know whether cancer has spread. Ultrasound uses sound waves to create an image on a video screen. This test can show tumors in the liver and these tumors are later tested for cancer if required.
  • Computed tomography (scan): During a ct scan for diagnosing liver tumors, cross-sectional images of the abdomen are taken. Information regarding the shape, size, and location of the tumors in the liver or nearby blood vessels can be known which help the doctors plan certain treatments. Sometimes some contrast material may be used that aims to outline the intestine in order to avoid confusion regarding tumors. You may be given oral contrast or intravenous (iv) contrast.
  • Magnetic resonance imaging (MRI): The difference between ct scan and MRI is that the latter uses radio waves and strong magnets instead of x-rays used by the former. Through waves and magnetic rays, certain images of the inside of the liver are taken. Your doctor can provide you contrast material if needed.
  • Angiography: During an angiography, a contrast dye is injected into the bloodstream to know about the arteries supplying blood to a liver. This test is used for both surgical and non-surgical purposes.

Symptoms:
Liver cancer does not have any symptoms, of its own. However, the tumor causes some symptoms and these symptoms appear in the later stages of cancer. Sometimes these symptoms may show up in the early stages also. The common symptoms are mentioned below:

  • Loss of appetite
  • Vomiting
  • Abdominal pain
  • Unexplained weight loss
  • Fever, yellowing of the skin and eyes (due to jaundice)
  • Itching
  • Feeling full while eating
  • Wasting (cachexia)
  • Increased swelling of the belly and feet
  • Feeling of a mass under the ribs on the right side

Symptoms of liver cancer sometimes some tumors in the liver build hormones that influence other organs. These hormones may cause certain signs like low blood sugar levels, high cholesterols levels, enlarged breasts, high counts of red blood cells and high levels of calcium in the blood. If you have any of the symptoms at any stage of your life, you must consult your doctor right away to avoid unnecessary complications.

Stages:
The stages of liver cancer tell the doctor how far cancer has spread. Once the stage is determined, individualized treatment plans can be designed. There are different staging systems for this cancer, but all doctors across the globe do not follow the same system. The American joint committee on cancer (ajcc) is the commonly accepted method for staging liver cancer. According to this system, the stages can be evaluated on the basis of three main factors like:

  • Tumor (t): It stands for the size and number of the original tumor.
  • Lymph node (n): It describes if there is any cancer present in the nearby lymph nodes.
  • Metastasis (m): It indicates whether cancer has spread to other parts of the body like lungs, bones etc.

Besides these, the letter x and a number (0-4) are also assigned to these factors. For instance, t1, t2, t3 and so on; a higher number refers to increasing severity. And the letter x indicates that no information could be gathered. Liver-cancer-stages-medifee

Usually, the size and number of the tumor (s) and whether cancer has spread to blood vessels or lymph nodes are the important criteria for staging liver cancer. Here a brief description of the 4 stages of liver cancer is described:

Stage 1: In stage 1, there is only one tumor and there is no growth of cancerous cells in the blood vessels, any other organs of the body or lymph nodes.

Stage 2: In this stage, there is a single tumor and it has started growing into the blood vessels. Again there may also be more than one tumor which is less than 5cm and have not grown into the blood vessels. In either of the case, cancer may be described to be in stage 2.

Stage 3: In this stage, 3 things can happen. Stage 3a refers to more than a single tumor and at least one of them is larger than 5 cm. But the cancerous cells have not grown in the lymph nodes or any other part of the body. Stage 3b refers to cancer that has grown either into the portal vein or hepatic vein. Again, there is no growth of cancerous cells in any part of the body or lymph nodes. Stage 3c describes the stage where cancer has spread into organs of the body that are close to the liver, like pancreas but not to lymph nodes or any distant organs.

Stage 4: Stage 4a refers to the phase where there can be more than one tumor of any size in the liver. Also, the cancerous cells may have spread to other organs around the liver and also blood vessels. Cancer has spread to lymph nodes but not to other body parts. Stage 4b is the phase when cancer has spread to another part of the body. The tumor is any size and may be more than one. It may have spread to the blood vessels and other organs around the liver. There may or may not be any presence of cancerous cells into the lymph nodes.

Doctors may follow any of the two staging criteria mentioned above or even go for some other staging processes. 

1 person found this helpful

Can Liver Cancer Be Found Early?

MCh - Surgical Gastroenterology/G.I. Surgery, MBBS, MS - General Surgery
General Surgeon, Noida
Can Liver Cancer Be Found Early?

Screening is used to look for cancer before you have any symptoms or signs.If you know you have  risk factors for liver cancer such as cirrhosis most commonly caused by alcohol abuse, other causes are Obesity, NAFLD, and diabetes, viral hepatitis (types B and C), too much iron in the liver from a disease called hemochromatosis, and some other rare types of chronic liver disease,then it is extremely important to talk with your doctor about whether you should be regularly screened for liver cancer.Finding a cancer before any symptoms have developed will increase the chance of successful treatment, Screening options include testing the blood for a substance called alpha-fetoprotein (AFP), which may be produced by cancer cells, or having imaging tests like an ultrasound.

 

1 person found this helpful

Who Is Not The Right Candidate For Liver Transplant Surgery?

Dr. Rajiv Lochan 85% (10 ratings)
MBBS, MS - General Surgery, FRCS (edinburgh), MD - R & D, FRCS Intercollegiate
Liver Transplant Surgeon, Bangalore
Who Is Not The Right Candidate For Liver Transplant Surgery?

The liver has a significant role to play in metabolism and digestion. The failure of a liver can lead to significant health issues. There are some causes for liver failure, which cannot be treated with medications. In these people, a transplant, which is replacing the diseased or injured liver with another liver, is the only definitive treatment option.

Some conditions which can require a liver transplant are:

Types of transplant:

  • Living donor transplant: In some patients, partial liver can be removed from a close family member and transplanted into the affected individual. The liver is known for its regeneration ability, and over time, will grow in the recipient.
  • Cadaveric transplant: Immediately after death, a liver can be removed and transplanted.

While the concept of a transplant sounds quite convincing and appealing for those with a severe liver disease, it is also important to note that not all would qualify for a liver transplant. The conditions which would disqualify a recipient are discussed below:

  • Significant heart disease: Those with severe coronary artery disease, valvular disease, cardiomyopathy, aortic stenosis, and cardiomyopathy are not candidates for a liver transplant.
  • Severe lung disease: Those with poor lung perfusion do not qualify for a liver transplant.
  • Advanced age: Greater the age, lesser the survival rates. So, people aged more than 70 are usually not considered for a transplant.
  • Obesity: A person with a BMI of more than 35 is often not a good candidate for a transplant. The overall health should be managed in these people.
  • Malnutrition: On the other extreme, severely malnourished individuals are also not considered for a transplant.
  • HIV infection: A person who is HIV-infected does not qualify for a liver transplant.
  • Substance abuse: Anyone who is actively abusing alcohol and/or substances is definitely removed from the list for a transplant.
  • Metastasis: If a patient is looking for a liver transplant due to hepatic cancer, it is essential that the cancer is contained. If it has spread to various parts, then containing it would be difficult, and a transplant may not succeed.
  • Multisystem organ failure: Other than heart and lungs, even people with poor renal function are not ideal candidates for a liver transplant.

A detailed liver recipient evaluation assessing the severity of liver disease, chances of survival, and overall health are done before a person is listed for liver transplant. This evaluation ensures a better success rate with the transplant.

Begin Liver Tumors - Ayurvedic Remedies That Can Help Controlling it!

Dr. Srinivasa Debata 92% (382 ratings)
Bachelor of Ayurveda, Medicine and Surgery (BAMS), BTCM, DTCM
Ayurveda, Bargarh
Begin Liver Tumors - Ayurvedic Remedies That Can Help Controlling it!

Liver tumors are abnormal growth of tissues or cells on or inside the liver. Benign (harmless) liver tumors are those that are non-cancerous in nature and do not spread to other organs of the body. The three most common types of benign liver tumors are hemangiomas, hepatocellular adenomas, and focal nodular hyperplasias. Hemangiomas are the most common of all benign liver tumors and they are masses of abnormal blood vessels. The focal nodular hyperplasias are less common and are generally found in women in their 20s and 30s.

The hepatocellular adenomas are the least common and affects women who are of childbearing age. Some of the signs and symptoms of benign liver tumor include weight loss, fatigue, loss of appetite, and swelling of the stomach. These tumors are not cancerous and may not cause pain in a majority of the cases. Therefore, its detection is normally not easy and it can be diagnosed only through ultrasound, CT test, or MRI scan. When the tumor becomes cancerous, surgery is the only option but before that, it can be cured with medicines. Allopathic medicines are harsh in nature but Ayurveda remedies are gentle and assure permanent relief.

Here are some Ayurvedic remedies that are beneficial for benign liver tumors.

  1. Haldi (Turmeric): Haldi has strong liver protection properties and it also helps with the regeneration of liver cells. It has anti-liver cancer agents called curcumin that fights against tumors and keeps them from turning cancerous.
  2. Green Tea: Hailed as the storehouse of antioxidants, green tea carries polyphenol compounds such as ellagic acid and epigallocatechin-3-gallate (EGCG), which have tumor-fighting properties. They reduce the size of benign tumors and also keep the formation of new tumors in check. It kills the cells responsible for causing cancer.
  3. Milk Thistle (Silybum marianum): Milk thistle contains a flavonoid called silymarin that safeguards the liver from toxins. It has antioxidant and anti-inflammatory properties that boost immunity and reduce swelling of the liver. It fights DNA damage and also reverses the growth of benign tumors. Even the tumors that have turned cancerous can be treated with milk thistle.
  4. Mangosteen (Garcinia mangostana): It is very effective in reducing the risk of cancer. Possessing antibacterial, antioxidant, and antifungal properties, it fights against a variety of infections and also strengthens the immune system. It carries a compound called xanthones that has cancer-killing properties. It leads to an action called apoptosis that causes the death of benign as well as cancerous cells.
  5. Giloy: Carrying strong anti-cancer properties, giloy causes antioxidant activity in the body that reverses the damage done by the abnormal growth of cells. It possesses chemical compounds that also prevent cancer.
  6. Ashwagandha (Withania somnifera): A strong anti-cancer herb, ashwagandha slows down the formation of the abnormally growing tumor cells. It also kills the cancer cells and if someone has had a chemotherapy for cancer, then it protects the normal cells from the damage done by chemotherapy. It also prevents the formation of treatment-resistant cells in the body, thereby, making chemotherapy a success.

Benign liver tumors can be treated if they are detected on time and therefore if the diagnosis confirms tumor, one should take the recourse to remedy. 

In case you have a concern or query you can always consult an expert & get answers to your questions!

4437 people found this helpful

What Are The Signs And Symptoms Of Bile Duct Cancer?

Dr. Pitamber Sadhwani 88% (31 ratings)
MBBS, MD
General Physician, Ahmedabad
What Are The Signs And Symptoms Of Bile Duct Cancer?

Cholangiocarcinoma (Bile duct cancer), like any other cancer, leaves a person physically, mentally and emotionally drained. It has been mostly found to affect people above 60 years of age. The signs and symptoms associated are so common that very few people consult a physician. A delayed diagnosis implies delayed treatment. This goes on to aggravate and complicate the situation further. One needs to be a little alert. Any symptoms, no matter how common, should not be taken lightly. Look for the early signs and symptoms and bile duct cancer can be fully cured.

Signs and symptoms associated with Cholangiocarcinoma:
Bile duct cancer can be Extrahepatic (occurs in the duct outside the liver) or Intrahepatic (cancer develops within the smaller ducts inside the liver). It must be noted that Intrahepatic Bile duct cancer and Liver cancer are different.

  • Bile duct cancer results in blocking the bile duct. This blockage severely effects the secretion of bilirubin and bile from the liver. Thus, the secretions (bile and bilirubin) which are supposed to flow into the intestine move back into the bloodstream. An elevated level of bilirubin in the blood gives rise to a condition, known as Jaundice (a condition resulting in yellowing of the eyes and the skin). The problem lies in the fact that many other factors can equally contribute to Jaundice. Consulting a physician at the earliest is the best resort.
  • A sudden or drastic weight loss and loss of appetite is an alarming sign of Cholangiocarcinoma.
  • Excessive itching can be an indication of something as big as bile duct cancer. Itching can be an outcome of the increased bilirubin (blood) reaching the skin.
  • At an advanced stage of Cholangiocarcinoma, a patient may experience severe abdominal pain.
  • At times, the tumour in the bile duct might exert immense pressure on the nearby organs. This can give rise to an enlarged abdominal mass. Bloated feeling is also very common amongst the patients.
  • An unusual change in the colour of the stool and urine should not be neglected. The elevated bilirubin level from the intestine is usually eliminated out of the system through the urine.  Thus the stool appears lighter and the urine a shade darker.
  • A cholangiocarcinoma patient can, at times feel nauseated. Fever is also a common but an extremely important indication.

In case you have a concern or query you can always consult an expert & get answers to your questions!

4550 people found this helpful

Liver Cancer - Common Myths & Facts About It!

Dr. Mangesh Mekha 90% (32 ratings)
MBBS, MD, DM - Oncology
Oncologist, Pune
Liver Cancer - Common Myths & Facts About It!

The liver is a critical organ as it plays a vital role in body metabolism and digestion. Liver diseases are a challenge for medical professionals, as often, these symptoms are not obvious until the disease has progressed to quite an advanced stage. In most cases, diagnosis in the early stage is very difficult, which can help in early intervention and disease arrest. It is not just the disease, but the causes and treatment of liver cancer are also surrounded by myths.

Read on to know some of the myths and facts about liver cancer.

  1. Liver cancer is caused by alcohol: This is one of the most common myth, which is not true. While alcohol definitely has a role to play in liver cancer, not all victims are alcoholics. Non-alcoholic fatty liver disease (NAFLD) which puts a person at risk for liver cancer is not related to alcohol and is seen in people who are obese, diabetic, high cholesterol and have no connection with alcohol. There is also no correlation between the amount of alcohol and the severity of liver damage. However, stopping alcohol consumption altogether definitely helps in improving liver condition.
  2. Liver cancer can be detected on routine tests: While abnormal protein levels on routine blood tests indicate abnormal liver, it is most often ignored and does not get diagnosed further. However, this should be taken up in detail and should be diagnosed. Early diagnosis greatly improves prognosis and can reduce treatment costs significantly. The chances of liver regeneration also would be greatly improved.
  3. Routine medications can lead to liver cancer: Liver plays a very important role in metabolism, and most drugs are liver-toxic. Taken over a period of time, they can cause incremental damage and lead to liver cancer. Some are more toxic than others, so asking for the effect of liver is always a good question.
  4. Cirrhosis is a precursor to liver cancer: This is definitely true, as left untreated, liver cirrhosis can lead to cancer. The added danger is that cirrhosis also is a silent disease, with often no symptoms and gets detected quite late. Periodic tests for cirrhosis in a patient who has a family history and alcohol consumption is a must.
  5. Lifestyle has no connection to liver cancer: Absolutely wrong. A good healthy lifestyle including healthy weight, good portions of fresh fruits and vegetables, proper exercise, minimal alcohol use, and no smoking helps not just the liver but overall health. These play a cumulative effect on liver health, and having a good lifestyle, can help in delaying onset even in a person who is predisposed to cirrhosis and/or liver cancer through family history.

Liver cancer is definitely a silent killer, but keeping eyes open definitely, helps.

In case you have a concern or query you can always consult an expert & get answers to your questions!

1938 people found this helpful

Liver Cancer

Dr. Swarup Kumar Ghosh 88% (82 ratings)
MD - Bio-Chemistry, MF Homeo (London), DHMS (Diploma in Homeopathic Medicine and Surgery), BHMS
Homeopath, Kolkata
3 people found this helpful
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