indiacancer.org - Liver Cancer

Liver Cancer

		What is the Liver?
		What is adult Primary Liver Cancer?
		How does adult Primary Liver Cancer present?
		How is adult Primary Liver Cancer detected?
		What are staging and grading?
		How is adult Liver Cancer treated?
		What are the side effects of Liver Cancer treatment?
		What is the importance of follow up?

What is the Liver?

The liver is one of the largest organs resident in the body, which occupies the upper right corner of the abdomen, and it is protected partially by the rib cage.

The liver has multiple functions. The most important role of liver is in making food into energy and filtering and storing blood.
The liver also helps in detoxification of many toxic drugs produced as a result of metabolic activity in the body.

The liver receives a majority of its blood through a large vein draining almost the entire blood of the gut, which is called the portal vein. It also receives 20% approximately of the blood supply from the hepatic artery.

The Liver

What is Adult Primary Liver Cancer?

Liver Biopsy

Adult primary liver cancer is a cancer in which the malignant cells originate from the tissues of the liver.

Patients who have had either hepatitis C or hepatitis B, which are viral infections of the liver, or have suffered or are suffering from a disease called cirrhosis, which is quite commonly seen in alcoholics, are more prone than other people to get adult primary liver cancer.

Primary liver cancer is very different from cancer that has spread from another place in the body to the liver. The commonest kind of cancer seen in the liver is from the latter category, that is metastatic liver cancer, or cancer, which has originated from some other tissue in the body, and has migrated and now subsequently invaded the liver. These are not true liver cancers.

Liver cancers or hepatocellular carcinoma, or HCC as it is known as, has several variants, most of which arise from the glandular tissue of the liver.

How does Adult Primary Liver Cancer present?

	The following symptoms are associated with adult primary liver cancer:
		A swelling of the liver, which is felt along the lower side of the right rib cage. This swelling is usually hard in texture when there is a malignancy involved.
		It may be painless, but there may be a discomfort felt in the upper abdomen on the right side.
		There may be slight difficulty in breathing due to tenting of the diaphragm.
		There may be pain around the right shoulder blade.
		There also may be yellowing of the skin or jaundice.
		In the later stages, the patient may present with signs of liver cell failure, which include collection of fluid in the abdomen otherwise known as ascites.multiple vomits of blood which are due to a condition called portal hypertension, a large sized spleen which is palpable, altered mentation (changed cerebral functioning), or downright coma (hepatic encephalopathy).

How is Adult Primary Liver Cancer detected?

	If symptoms like the ones described above are noticed by the doctor, then special x-rays called CT scans are ordered by the doctor. CT scans are special x-rays in which very thin sliced radiographic images are taken, and which are digitally reintegrated and interpreted using a computer. The doctor may order prior to a CT scan, an imaging test that is simpler and cheaper, and this is known as ultrasonography. While ultrasonography is not the definitive investigation in case of liver tumors, but in far advanced cases where the disease aggressiveness and invasion of vital structures which cannot be removed is obvious, then, the patient can pay less money by going in just for a simple ultrasound. From the CT or the ultrasound or from direct palpation of the lump on the abdomen, the doctor preforms a biopsy of the liver, in which a needle is inserted into the abdomen and a small piece of liver tissue is taken out. Usually, this is done under some kind of imaging guidance such as CT scan or ultrasonography. Then, the tissue is examined by the pathologist. The type of cancer and the diagnosis depends on the histopathology report. In case the patient has a lower tolerance level, he may be given a small dose of local anaesthesia using lignocaine in order to prevent him from hurting after the procedure is over. The doctor would also perform several biochemistry investigations to find out:
		The level of haemoglobin in the body?
		To rule out infection by seeing the white blood cell counts.
		To check the degree of platelets and the coagulat ion profile of the patient in the form of bleeding time, clotting time, and prothrombin time. This is absolutely essential because all these factors are quite, to a great extent, dependent upon the functioning of the liver. An aberration in these investigations when taken in toto, could suggest early signs of liver cell failure. This can be even so when the patient at that point in time looks normal.
	Another investigation, which is done in certain centres is called laparoscopy, in which a small incision like a keyhole is made in the abdomen and a telescoping, self-illuminating, tube-shaped instrument is inserted into the abdomen. After insertion of the laparoscopic instrument, the liver and the surrounding tissues are directly visualised by the surgeon and the staging of the disease is carried out. The patient is usually given some kind of local anaesthetic which causes loss of feeling over that area for a short period of time. The doctor also usually orders an investigation called an angiography or even better a DSA or a digital subtraction angiography. During this examination, a small flexible tubing or a catheter is inserted into a large blood vessel and blood samples from the liver are taken. Then a dye is injected through the tube so that the blood vessels originating from and going through the liver are opacified in the x-ray. This shows the doctor whether the cancer is a primary liver cancer or a secondary liver cancer and secondly, how vascular the tumour is and thirdly, whether it can be removed safely. Angiography usually requires some amount of hospital stay. The doctor may also order certain special blood tests. These special blood tests include tests for liver function to see whether the liver is functioning properly or not and this could include total proteins, serum albumin, alkaline phosphatase and SGPT, SGOT and serum bilirubin. A very special test for primary liver tumours is something called a tumour marker in the form of alpha-fetoprotein or AFP which is a very sensitive test for most primary liver tumours.

What are staging and grading?

	These are terms with which you must become familiar, if you are dealing with any form of cancer. When we stage a cancer, we try to establish carefully degree of spread of the cancer and if indeed there is spread, to what extent and involving which organs. The grading of a cancer is a microscopic issue, in which the pathologist lets you know how aggressive this particular type of cancer is; well differentiated means less aggressive, moderately differentiated intermediately aggressive and poorly differentiated more aggressive. Both grading and staging help your clinician to establish the prognosis or how serious your disease is and what is going to be the likely outcome. Staging may require additional imaging tests such as CT Scan, MRI, Sonography of the abdomen, IVU, Bone scan or chest X-ray. From the patient's point of view a working staging classification could be the following:
		Localised and resectable tumours in which the cancer is found only in one place in the liver and can be completely removed in the surgery.
		It is localised and unresectable. This means although the cancer is found only in one part of the liver but the cancer cannot be completely removed.
		Advanced, in which the cancer is spread through most of the liver and to other parts of the body.
		Recurrent in which the cancer has come back after the primary treatment is over. It may have come back to the liver or it has appeared in other parts of the body in which case it is known as metastatic liver cancer.

How is Adult Liver Cancer treated?

A lot depends on the patient's constitution, the grade of his disease and its staging. Patients are usually treated by a team of specialists which utilizes a multipronged approach. This includes a hepatologist, an oncosurgeon and a radiotherapist. The plan of treatment is tailored to fit a patient's requirements. If necessary, chemotherapy may become an add on. Treatment strategies. The bastion for treatment of adult liver cancer is surgery, in which the surgeon woud attempt to take out the entire cancer along with a healthy margin of liver tissue. Surgery for liver cancer is known as liver resection or hepatectomy. The type of hepatectomy depends on the amount of liver which is being removed and also the lobe of the liver from which it is being removed. The alternative local therapy to surgery is radiation therapy. This involves the use of high energy, penetrative rays to destroy cancer cells. It affects cancer cells only in the zone treated. Radiation therapy is also employed for palliation i.e. control of symptoms alone in an advanced cancer. Radiation therapy can also be used in adjunct to surgery or chemotherapy, either before or after. Teletherapy or external radiation is given via a machine remote from the body while brachytherapy or internal radiation is given by implanting a radioactive source within the involved tissues. Patients may or may not require both modalities of radiation. Radiotherapy, after initial planning, usually takes just 5 to 10 minutes per day, 5 days a week for about 6 weeks. This time period is flexible depending upon the modality of radiation used. Besides local therapy, the best attempt to control cancer cells circulating in the body and lodged at places other than the liver is by using systemic therapy (therapy which affects the entire systems of the body) which is in the form of injections or oral drugs. This form of treatment is called chemotherapy. This form of treatment is given in a cyclical manner (each set of drugs is repeated usually after every 3-4 weeks). Chemotherapy can also be used in combination with surgery, radiotherapy or both, either before or after. Chemoembolisation of the hepatic artery, blocking the hepatic artery, the major artery that supplies the blood to the liver, and then injecting chemotherapy drugs between the blockade and the liver using the liver arteries to distribute the chemotherapy throughout the liver is one more option. The other interesting option which is seen in liver cancers is liver transplantation in which the entire diseased liver is removed by the surgeon and a donor liver, that is a liver from another person is transplanted into the body of the recipient. Yet another interesting modality of treatment is hyperthermia, in which the body is warmed above normal temperatures in order to kill the cancer cells. Hyperthermia uses a special machine in which the body is heated for a certain period of time to kill cancer cells. The principle behind this therapy is that cancer cells are extremely sensitive to heat, much more so than normal cells and thus their susceptibility to heat is remarkable, resulting in tumour shrinkage. Biological therapy is one more option in which the body's immune system is augmented to fight cancer. Cryosurgery is also an option in which the cancer cells are killed by sudden extreme freezing using a device called a cryoprobe. The advantage of cryosurgery is that the surrounding liver is rarely ever damaged. Locally resectable adult primary liver cancer.
	Surgery.
	Liver transplantation in certain patients.
	Systemic or regional chemotherapy following surgery.
Locally unresectable adult primary liver cancer.Treatment may be one of the following:
	Hepatic artery blockade and then injecting chemotherapy drugs into the artery and liver (chemoembolisation).
	Cryosurgery.
	Ethanol injection into the tumour.
	Use of highly focal radio waves designed to destroy the tumour.
	Liver transplantation.
	Regional chemotherapy directed solely to the tumour.
	Systemic chemotherapy.
	Surgery with or without chemotherapy subsequently usually followed by radiation.
	Injection of alcohol directly into the tumour.
	Radiation therapy plus special radio sensitizer drug that make the tumour more receptable to radiation.
Advanced adult primary liver cancer treatment.
It is important to realize that advanced adult primary liver cancer is a pretty unforgiving disease and usually treatment fails.




Recurrent adult primary liver cancer treatment.
This treatment has to be tailor made depending on the:
		Whether patient has already received treatment or not and if so, what treatment?
		In which part of the body has the disease come back?
		Whether the liver is a cirrhotic one and does the patient have liver cell failure?

What are the side effects of Liver Cancer treatment?

	Unfortunately treatment for cancer does cause damage to the healthy tissues. Please ask the clinician about any possible side effects before any form of treatment commences. The effects of radiation depend upon the dose of radiation, the size of the area radiated, and the number and size of each fraction. The commonest side effect is extreme fatigue. Although bed rest is good, most radiotherapists advise the patient to be as mobile as possible. Another common problem is that of radiation dermatitis in which the skin covering the radiated area becomes red, dry, itchy, and may show signs of scaling off. This will slowly settle down after radiation ceases, but there may be a permanent 'bronzing' of the skin. It is important to note here that this skin problem is associated only with teletherapy or external radiation therapy. Radiation also may cause nausea and vomiting, diarrhea, urinary discomfort. There may also be a fall in the white blood cells, which are needed by humans to fight infection. Usually the radiotherapist can suggest the drugs and diet necessary to alleviate such problems. The various drugs in chemotherapy cause a varied spectrum of side effects. The severity and variability of these symptoms are very individualistic, changing from patient to patient. Some of the common side effects are:
		Skin rashes.
		Loss of hair.
		Diarrhea.
		Vomiting.
		Tingling and numbness in the fingers and toes.
		Hearing loss.
	Most are temporary and recede after therapy is over. Hair growth gradually starts after cessation of chemotherapy. The medical oncologist will usually be able to reduce the severity and spectrum of these side effects. The psychology of the patient is very important during therapy. Better psychologically prepared the patient is, better are his chances of having decreased side effects. The patient should drink large quantities of water while the therapy is in progress, and preferably avoid uncooked or raw food. Water should be filtered or boiled. Any relative or person who has any sort of infection such as common cold should be asked to desist from coming close to the patient.

	What is the importance of follow up?

The importance of follow-up cannot be overemphasized. It is a fatal fallacy to assume on the patient's part that once the primary or the first phase of treatment is over, then he or she is cured. It must be stressed here that cancer has a notorious proclivity of coming back again and again. The only way to fight this is to pick up any problem when it is still early, so that it can be nipped in the bud. And the only way to do this is to follow up when the doctor calls you for the next visit. Each such visit will include a detailed history, a physical examination (including an internal i.e. a rectal or vaginal examination ), a chest x-ray, an ultrasonography or a CT scan, and various other blood studies as indicated.