Liver Cancer

Liver Cancer

Overview

Liver cancer, also known as hepatocellular cancer, is a cancer that originates in the liver itself. If the cancer originates in another part of the body and spreads to the liver, it is known as liver metastases. Tumours that originate in the colon, lung, breast, pancreas, stomach and other organs and spread to the liver through the bloodstream can also give rise to liver cancer.

Risk Factors

Patients with cirrhosis have the highest risk of developing HCC. 90-95% of people who develop HCC have underlying cirrhosis but non-cirrhotic HCC does occur.

Cirrhosis may be due to:

  • HBV or HCV infection:
  • Chronic HBV infection is the most common cause of HCC worldwide. HCV is a common cause of HCC too. There is a 3-5% per year risk of developing HCC if someone has either HBV or HCV infection. Co-infection with both HBV and HCV increases the risk of HCC further. HCC may also be associated with a high concentration of aflatoxins, a group of mycotoxins produced by the fungi Aspergillus flavus and Aspergillus parasiticus in food
  • Alcoholism
  • Genetic hemochromatosis
  • Primary biliary cirrhosis
  • The metabolic syndrome, diabetes and smoking also increases cancer risk
  • Rare associations include: androgenic steroids, primary sclerosing cholangitis, alpha-1-antitrypsin deficiency or oral contraceptives

What are the signs and symptoms?

Early symptoms and signs include

  • Abdominal pain/ abdominal distention
  • Jaundice or Yellowish discolouration of skin or eyes
  • Loss of weight and appetite
  • Pale stools

Those presenting late, carry symptoms of advancing cirrhosis and liver failure.

Symptoms

  • Pruritus
  • Splenomegaly
  • Bleeding oesophageal varices
  • Weight loss
  • Jaundice
  • Confusion and hepatic encephalopathy
  • Abdominal distension due to ascites
  • Right upper quadrant abdominal pain

Signs

  • Jaundice
  • Hepatomegaly
  • Ascites
  • Spider naevi
  • Peripheral oedema
  • Anaemia
  • Periumbilical collateral veins
  • Flapping tremor

Metastases can develop in the lung, portal vein, periportal nodes, bone or brain.

Evaluation

A focal liver lesion in someone with cirrhosis is highly likely to be HCC.If a >2 cm mass is detected on ultrasound and AFP is also raised, this is diagnostic. Further investigation is only needed to determine the best treatment. CT of the liver can look for local spread and CT of the thorax can look for metastases.

MRI scanning with contrast or angiography with Lipiodol® injection with follow-up CT may also be used in assessment.

Other investigations

  • AFP is elevated in 75% of cases.
  • LFTs may be consistent with cirrhosis.
  • Check for clotting abnormalities.
  • Albumin may be low.
  • CXR / CT may show lung metastases.

Treatment options

Treatment for primary liver cancer depends on the location and stage of the cancer and how well liver function is preserved. Treatment options include surgical resection, thermal ablation, systemic chemotherapy, transarterial chemoembolisation and selective internal radiation therapy. Liver transplantation may be appropriate for some patients. In patients with primary liver cancer, surgical removal with curative intent may be possible. Before treatment of the primary tumour, any complications of cirrhosis or liver failure must be treated. These include ascites, encephalopathy or spontaneous bacterial peritonitis and oesophageal varices.

  1. Liver transplantation
    • Only a minority of people with HCC are suitable for transplantation.
    • Because of limited donors, the 'Milan criteria' help to select transplantation candidates carefully.
    • Liver transplantation is most beneficial for individuals who are not good candidates for resection, especially those within Milan criteria (solitary tumour ≤5 cm and up to three nodules ≤3 cm).
    • For patients being considered for liver transplantation, a Model for End-stage Liver Disease (MELD) score is mandatory.
  2. Tumour resection
    • Resection is the treatment of choice for hepatocellular carcinoma in individuals without cirrhosis.
    • In the short term, resection produces similar results to transplantation but, at three years, there is a higher chance of tumour-free survival after transplantation.
    • Very good liver function is needed if resection is to be considered.
    • Also, the liver that is left behind after resection still has malignant potential and recurrence rates are 50-60% after five years.
  3. Ablative therapy
    • Image-guided tumour ablation is now a standard treatment option for patients with early-stage HCC and also Liver metastasis from other primary sites
  4. Alcohol (ethanol) injection
    • This is done percutaneously and has been carried out on small tumours in those with good underlying liver function. This may be the best treatment for those with small, inoperable HCCs.
  5. Radiofrequency ablation
    • High-frequency ultrasound probes are placed into the tumour mass. This is a relatively new technique that produces tumour necrosis.
    • Radiofrequency ablation is an alternative therapy for hepatocellular carcinoma and liver metastases when resection cannot be performed or, in the case of HCC, when transplant cannot be performed in a timely enough manner.
    • Radiofrequency ablation is considered as a possible first-line treatment for patients with a single small HCC tumour up to 3 cm.
    • Microwave ablation - It destroys tumour cells by heat and results in localised areas of necrosis and tissue destruction.
  6. Chemoembolization
    • This is the delivery of high concentrations of chemotherapy drugs directly to the tumour via the hepatic artery, using embolising agents such as cellulose.
    • It tends to be used in those with preserved liver function with large or multifocal tumours without vascular invasion or extrahepatic spread, and who have no symptoms.
    • It seems to be effective in reducing tumour size as well as treating pain or bleeding.
    • Careful patient selection is crucial prior to trans arterial chemoembolization, as the procedure may be associated with an increased risk of liver failure.
    • Median survival is >2 years and there is work to improve this by using better embolic agents and increasing the local exposure to chemotherapy.
  7. Systemic chemotherapy or Targeted therapy
    • This may be used in advanced disease but HCC is relatively chemotherapy-resistant.
    • Treatments with molecular targeted therapies, such as sorafenib, are also being investigated and are so far very promising.
    • Sorafenib is the standard systemic therapy for HCC. It is indicated for patients with well-preserved liver function and with advanced tumours or those tumours progressing despite loco-regional therapies.
  8. Other treatments
    • Selective internal radiation therapy is recommended as a treatment option for primary HCC but uncertainties remain about its comparative effectiveness.
    • Image-guided transcatheter treatments are based on selective intravascular delivery of radio therapeutic drugs into the arterial vessels supplying the tumour.
    • These treatments are considered for patients with large cancers or multifocal disease that is not amenable to curative treatments.
    • Chemotherapy drugs, embolic particles or radioactive materials can be injected and induce tumour necrosis.

What we offer in our centre?

All above treatment options are offered for primary Liver tumours and metastatic liver tumours including

  • Liver tumour resections (primary and metastatectomy)
  • Laparoscopic Liver resections for solitary liver metastasis
  • Living Donor Liver Transplantation
  • Transarterial chemoembolization
  • Transarterial Radioembolisation
  • Ablative therapies
  • Systemic Chemotherapy
  • Targeted therapy

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