LIVER CANCER

LIVER CANCER FACTS

 Liver cancer is one of most rapidly increasing types of cancer and it is more common in men than in women. It also is more prevalent in developing countries in sub-Saharan Africa and Southeast Asia.

Liver is Essential

The largest organ in the body, the liver is pyramid-shaped and located under your right ribs. It has two sections called lobes. It is different from most organs because it has two blood sources:

  • The hepatic artery brings in oxygen-rich blood
  • The portal vein supplies nutrient-rich blood from the intestines


The liver is vital. You can’t live without it. Some of its important functions are to:

  • Break down and store nutrients from the intestine
  • Manufacture some of the clotting factors your body needs to stop bleeding
  • Make bile that helps the intestine absorb nutrients
  • Help get rid of waste


Liver Cancer Types

Liver cancer can begin in the liver or other parts of the body. Primary liver cancer begins in the liver. Metastatic liver cancer starts somewhere else in the body and metastasizes (spreads) to the liver.

The liver is a common place where cancer spreads. Its large size and high blood flow make it a prime target for tumor cells moving through the bloodstream. Colorectal, breast and lung cancers are the most common sources of metastatic liver cancer.

Some tumors in the liver are benign (non-cancerous) but grow large and cause problems. Usually these can be removed by surgery.

The main types of primary liver cancer are:

Hepatocellular carcinoma (HCC): Most primary liver cancers are HCC. They begin in hepatocyte cells. Sometimes they begin as a single tumor; other times they start in multiple spots in the liver. The latter is more common in people with liver damage, such as cirrhosis.

Fibrolamellar HCC is a rare subtype that often has a higher chance for successful treatment than other types of liver cancer.

Bile duct cancers (cholangiocarcinomas): One or two of every 10 cases of liver cancer start in the bile ducts, which are small tubes that carry bile to the gallbladder. They are treated in the same way as HCC.

Angiosarcomas and hemangiosarcomas begin in blood vessels in the liver.  These fast-growing liver cancers usually are not diagnosed until they are in advanced stages.

Hepatoblastoma: A very rare type of liver cancer, this most often is found in children. The survival rate is more than 90% if the cancer is caught early.


LIVER CANCER SYMPTOMS


​Liver cancer usually does not cause symptoms in the early stages. When it does have symptoms, they vary from person to person. As the tumor grows, it may cause:

  • Weight loss
  • Pain in the right side of the upper abdomen or around the right shoulder blade
  • Loss of appetite
  • Swelling or bloating in the abdomen
  • Hard lump below the ribs on the right side
  • Tiredness or weakness
  • Nausea or vomiting
  • Fever
  • Jaundice, which causes yellow skin and eyes, and dark urine
  • Feeling of fullness after a small meal
  • Itching
  • Swollen veins on the abdomen
  • Becoming sicker if you have hepatitis or cirrhosis


Certain types of liver cancer produce hormones that may cause:

  • High blood-calcium levels that may cause constipation, nausea or confusion
  • Low blood-sugar levels that may cause tiredness or faint feeling
  • Enlarged breasts or shrinking of testicles in men
  • High red-blood cell count that may cause redness in the face


These symptoms do not always mean you have liver cancer. However, it is important to discuss any symptoms with your doctor, since they may signal other health problems.

In rare cases, liver cancer can be passed down from one generation to the next. Genetic counseling may be right for you. 

Some people have an elevated risk of developing liver cancer. 



LIVER CANCER DIAGNOSIS


​Liver cancer often is challenging to diagnose. It usually has no symptoms in the early stages, and tumors often cannot be felt from outside the body. If you have been diagnosed with liver cancer, it is essential to find out exactly where the cancer is and if it has spread. This helps doctors choose the best treatment for you.


Liver Cancer Diagnostic Tests


If you have symptoms of liver cancer, the first step is a physical exam. The doctor will:

  • Feel your abdomen to examine the liver, spleen and nearby organs
  • Check your abdomen for ascites, an abnormal accumulation of fluid
  • Examine your skin and eyes for signs of jaundice


If the doctor suspects liver cancer, you may have one or more of the following tests to diagnose it and find out if it has spread.

Blood tests: One common blood test detects alpha-fetoprotein (AFP), which can be a sign of liver cancer. Other blood tests may measure how well the liver is working.

Imaging tests, which may include:

  • CT or CAT (computed axial tomography) scans: This is usually the most reliable test for evaluating the extent of liver                cancer. Our technology includes the precise triple-phase CT scan.
  • Ultrasound
  • Angiogram: The doctor injects dye into an artery. This allows the blood vessels in the liver to be seen on an X-ray.


Biopsy: A sample of tissue from the tumor or the healthy part of the liver is removed and looked at under a microscope. Healthy tissue may be tested to see how well the liver is working. A biopsy may be obtained by:

  • Fine needle aspiration (FNA): A thin needle is inserted into the liver to remove a small amount of tissue.
  • Core biopsy: This is similar to FNA, but a thicker needle is used to remove small cylinder-shaped samples (cores).
  • Laparoscopy: A small incision (cut) is made in the abdomen, and a thin, lighted tube (laparoscope) is inserted to view the       tumor.
  • Surgical biopsy: Tissue is removed during an operation.




​LIVER CANCER STAGING

If you are diagnosed with liver cancer, your doctor will determine the stage of the disease. Staging is a way of classifying cancer by how much disease is in the body and where it has spread when it is diagnosed. This helps the doctor plan the best way to treat the cancer. Once the staging classification is determined, it stays the same even if treatment is successful or the cancer spreads.


LIVER CANCER STAGES


​Stage I: There is one tumor, and it has not spread to nearby blood vessels.

Stage II: One of the following is found:

  • One tumor that has spread to nearby blood vessels
  • More than one tumor, none of which is larger than 5 centimeters


Stage IIIA: One of the following is found:

  • More than one tumor larger than 5 centimeters
  • One tumor that has spread to a major branch of blood vessels near the liver


Stage IIIB: There are one or more tumors of any size that have either:

  • Spread to nearby organs other than the gallbladder
  • Broken through the lining of the peritoneal cavity


Stage IIIC: The cancer has spread to nearby lymph nodes.

Stage IV: The liver cancer has spread beyond the liver to other places in the body, such as the bones or lungs. Tumors may be any size and also may have spread to nearby blood vessels and/or lymph nodes.

For adult primary liver cancer, stages also are grouped by how the cancer may be treated:

Localized resectable: The cancer is found in the liver only, has not spread and can be removed completely by surgery.

Localized and locally advanced unresectable: The cancer is found in the liver only and has not spread, but it cannot be removed completely by surgery.

Advanced: Cancer has spread throughout the liver or has spread to other parts of the body, such as the lungs and bone.


​TREATMENT


In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. 

Treatment options and recommendations depend on several factors:

  • How much of the liver the cancer is affecting
  • Whether the cancer has spread
  • The patient’s preferences and overall health
  • The damage to the remaining cancer-free area of the liver


When a tumor is found at an early stage and the patient’s liver is working well, treatment is aimed at trying to eliminate the cancer. The care plan may also include treatment for symptoms and side effects, an important part of cancer care. 

The various disease-directed treatment options can be grouped according to whether they may cure the cancer or will improve survival but will most likely not eliminate the cancer. Descriptions of the most common treatment options, both disease-directed and those aimed at managing side effects and symptoms, are listed below. 

Disease-directed treatments to eliminate HCC

These treatments are generally recommended when the tumor has been found at an early stage. Many doctors will not use these treatments if the tumor is larger than 5 cm.

Surgery

Surgery is the removal of the tumor and some surrounding healthy tissue during an operation. It is likely to be the most successful disease-directed treatment, particularly for patients with a tumor smaller than 5 cm. If the tumor has spread outside the liver, or if the patient has other serious illnesses, surgery may not be an option. A surgical oncologist is a doctor who specializes in treating cancer using surgery. 

Two types of surgery are used to treat HCC:

Hepatectomy. When a portion of the liver is removed, the surgery is called a hepatectomy. A hepatectomy can be done only if the cancer is in one part of the liver, and the liver is working well. The remaining section of liver takes over the functions of the entire liver and may regrow to its normal size within a few weeks. A hepatectomy may not be possible if the patient has advanced cirrhosis, even if the tumor is small.

The side effects of a hepatectomy may include pain, weakness, fatigue, and temporary liver failure. 

Liver transplantation. Sometimes, a liver transplantation can be done. This procedure is possible only when the cancer has not spread outside the liver, a suitable donor is found, and very specific criteria are met in terms of tumor size and number.

Liver transplantation is a particularly effective treatment for people with a small tumor because transplantation removes the tumor and the damaged liver. However, there are few donors, and people waiting for a liver transplant may have to wait for a long time before a liver becomes available. During this time, the disease may get worse. 

Thermal Ablation

Radiofrequency ablation (RFA) and microwave therapy both use heat to destroy cancer cells. They may be given through the skin, through laparoscopy, or during a surgical operation while a patient is sedated. Sedation is giving medication to become more relaxed, calm, or sleepy.

Percutaneous ethanol injection

Percutaneous ethanol injection uses alcohol injected directly into the liver tumor to destroy it. Side effects include fever and pain after the procedure. In general, though, the procedure is simple, safe, and particularly effective for a tumor smaller than 3 cm. However, if the alcohol escapes from the liver, a person may have brief but severe pain. 


Chemoembolization

This is a type of chemotherapy treatment that is similar to hepatic arterial infusion. During this procedure, drugs are injected into the hepatic artery, and the flow of blood through the artery is blocked for a short time so the chemotherapy stays in the tumor longer. Blocking the blood supply to the tumor also destroys cancer cells.


Radiation Therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist.

There are two types of radiation therapy used to treat HCC:

Stereotactic body radiation therapy (SBRT). SBRT is a term that describes several methods of delivering high doses of radiation to a tumor while limiting the amount of radiation exposure to healthy tissues. This is important because healthy liver tissue can be damaged by radiation as well. SBRT effectively treats tumors that are approximately 5 cm or smaller. However, it is still considered relatively investigational compared to thermal ablation  because little long-term information about response rates exists.

Radioembolization. During radioembolization, a doctor places radioactive beads into the artery that supplies the tumor with blood in a way that’s similar to chemoembolization (see above). The beads deliver radiation directly into the tumor when they become trapped in the small blood vessels of the tumor. 


Targeted Therapy

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.


For HCC, anti-angiogenesis drugs are the most common targeted therapy. Anti-angiogenesis therapy is focused on stopping angiogenesis, which is the process of making new blood vessels. Because a tumor needs the nutrients delivered by blood vessels to grow and spread, the goal of anti-angiogenesis therapies is to “starve” the tumor. This is one of the ways sorafenib (Nexavar) is thought to work. Sorafenib is one of the treatment options for advanced HCC that cannot be completely removed with surgery. It is taken as pill that is swallowed (orally). The side effects of sorafenib include diarrhea and certain skin problems. 

Other Treatment Options

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication.

Systemic chemotherapy gets into the bloodstream to reach cancer cells throughout the body. Systemic chemotherapy is typically given through an intravenous (IV) tube placed into a vein using a needle, but it can also be given orally (by mouth).

A chemotherapy regimen usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of drugs at the same time. However, chemotherapy is less widely used nowadays for HCC.

The side effects of chemotherapy depend on the individual and the dose used, but they can include nausea and vomiting, hair loss, loss of appetite, diarrhea, fatigue, low numbers of blood cells, bleeding or bruising after minor cuts or injuries, numbness and tingling in the hands or feet, headaches, hair loss, and darkening of the skin and fingernails. These side effects usually go away once treatment is finished.

Learn more about the basics of chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. 

Cryosurgery

This treatment uses extreme cold to freeze and destroy cancer cells.

Immunotherapy

Immunotherapy, also called biologic therapy, is designed to boost the body's natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. Currently, immunotherapy is mainly being researched in clinical trials for HCC and is not considered a standard treatment option.

Side effects of biologic therapy are similar to the flu and can include fatigue, fever, chills, muscle pain, and headache.