Primary Liver Cancer
There are different types of primary liver cancer which include:
- Hepatocellular carcinoma is the most common type (about 9 in 10 cases). This type of cancer originates from a liver cell (hepatocyte) which becomes cancerous. (The bulk of the liver is made up from hepatocytes). Hepatocellular carcinoma most commonly develops as a complication of liver diseases such as scarring of the liver (cirrhosis) or types of liver inflammation (hepatitis).
- Cholangiocarcinoma. This is much less common. It develops from cells which line the bile duct.
- Hepatoblastoma. This is a rare cancer which occurs in some young children.
- Angiosarcoma. This is rare. It develops from blood vessel cells within the liver.
What causes primary liver cancer?
A cancerous (malignant) tumor starts from one abnormal cell. The exact reason why a cell becomes cancerous is unclear. It is thought that something damages or alters certain genes in the cell. This makes the cell abnormal and multiply out of control. Most people who develop a primary liver cancer have one or more of the following risk factors which seem to make liver cells more prone to becoming cancerous:
- Scarring of the liver (cirrhosis). It tends to progress slowly. Common causes of cirrhosis are heavy alcohol drinking, and infection with hepatitis C. However, there are various other causes of cirrhosis. Note: most people with cirrhosis do not develop liver cancer - it occurs in only a small number of people with cirrhosis.
- Long-term infection with the hepatitis B or hepatitis C virus. It typically takes 20-30 years after first becoming infected to develop primary liver cancer. Ingesting some poisons or toxins. For example, a known risk factor is a poison called aflatoxin which contaminates some foods (for example, moldy peanuts), mainly in developing countries.
- Some conditions which cause persistent inflammation of the gut increase the risk slightly of developing an uncommon type of primary liver cancer (called cholangiocarcinoma) - for example, ulcerative colitis.
- There is some evidence that smoking can increase the risk.
- A parasitic infection (liver fluke) which mainly occurs in Africa and Asia increases the risk of developing a cholangiocarcinoma.
What are the symptoms of primary liver cancer?
There may be no symptoms in the early stage of the disease. As the cancer grows, the first symptoms to develop may be quite vague and nonspecific. For example, feeling generally unwell, feeling sick (nausea), appetite loss, weight loss and tiredness. Many people who develop primary liver cancer will already have symptoms associated with scarring of the liver (cirrhosis). If you already have cirrhosis and your health becomes worse quite quickly, the cause may be a liver cancer which has developed.
As the cancer develops further, more specific symptoms which may also develop include:
- Tummy (abdominal) pain over the liver area.
- Yellowing (jaundice). You tend to first notice this condition when the whites of your eyes become yellow. It is due to a build-up of the chemical bilirubin which is made in the liver. This occurs if the bile duct becomes blocked by the cancer. Bile and bilirubin cannot drain out from the liver and so leak into the bloodstream.
- Itch (caused by the jaundice).
- Swelling of the abdomen. This can be due to the growing cancer itself. It may also be due to ascites which is fluid that builds up in the abdomen which occurs with various liver disorders.
How is cancer of the liver diagnosed and assessed?
Screening using ultrasound, and sometimes also a blood test for alpha-fetoprotein (AFP), at 6- to 12-monthly intervals, has been recommended for people at high risk of liver cancer. This includes people with scarring of the liver (cirrhosis) associated with infection with hepatitis B or hepatitis C virus. This can detect liver cancer at an earlier stage and therefore improve the chance of successful treatment.
If liver cancer is suspected, you are likely to have a number of tests. These aim to:
- Confirm that you have a cancer in the liver. Also, that the cancer is a primary liver cancer and not a secondary liver cancer.
- Assess the stage of the cancer. That is, how much of the liver is affected and whether the cancer has spread to other parts of the body.
- Assess the state of your liver function and your general health.
Therefore, a range of tests is usually needed. Tests may include:
- Scans such as ultrasound scan, CT scan or MRI scan. These can help to show the exact location and extent of the cancer.
- A liver biopsy. This is usually done to confirm the type of cancer. A biopsy is a procedure in which a small sample of tissue is removed from a part of the body. The sample is then examined under the microscope to look for abnormal cells.
- Blood tests help to assess the liver function and your general health.
- Other tests may be done if the above do not clarify the situation. For example, a laparoscopy is sometimes done. This is a small operation to look inside the tummy (abdomen) with a flexible telescope.
What are the treatment options for primary liver cancer?
The main treatments used for primary liver cancer are surgery and chemotherapy. Other techniques are sometimes used. The treatment advised in each case depends on various factors such as:
- The exact site of the primary tumor in the liver.
- How large the cancer is and whether it has spread (the stage of the cancer).
- Your general health. In particular, the general state of your liver and liver function. Many people with primary liver cancer also have poor liver function due to scarring of the liver (cirrhosis).
You should have a full discussion with a specialist who knows your case. They will be able to give you the pros and cons, likely success rate, the possible side-effects, and other details about the possible treatment options for your type of cancer.
You should also discuss with your specialist the aims of treatment. For example:
- In some cases, treatment aims to cure the cancer. The best chance of a cure for primary liver cancer is when it is diagnosed and treated at an early stage. (Doctors tend to use the word remission rather than the word cured or NED, which stands for No Evidence of Disease). Remission, or NED, means there is no evidence of cancer following treatment. If you are in remission, you may be cured. However, in some cases a cancer returns months or years later. This is why doctors are sometimes reluctant to use the word cured.)
- In some cases, treatment aims to control the cancer. If a cure is not realistic, with treatment it may be possible to limit the growth or spread of the cancer so that it progresses less rapidly. This may keep you free of symptoms for some time.
- In some cases, treatment aims to ease symptoms (palliative treatment). For example, if a cancer is advanced then you may require painkillers or other treatments to help keep you free of pain or other symptoms. Some treatments may be used to reduce the size of a cancer, which may ease symptoms such as pain.
Surgery which aims to cure the cancer is an option in some cases. If the cancer is small, has not spread outside the liver and the rest of the liver is healthy, it may be possible to cut out the part of the liver which contains the cancer. Healthy liver tissue will regrow to its full size within a few weeks if a section of liver is cut out. However, this operation is not suitable if your liver is damaged with severe cirrhosis (which is the case in many people with primary liver cancer).
A liver transplant is another option but again only suitable for a small number of cases.
Surgery also has a role in palliative care. For example, if yellowing (jaundice) is severe, it may be possible to relieve the blockage of the bile by inserting a stent. This is a narrow tube which allows the bile to drain into the gut. Another example is to ease fluid in the tummy (abdomen) - called ascites - if it is severe. The ascites can be drained by inserting a tube through the wall of the abdomen.
Chemotherapy is a treatment which uses anti-cancer medicines to kill cancer cells, or to stop them from multiplying. It is not likely to be curative for primary liver cancer but may shrink the tumor down to slow the progression of the disease.
There are new medicines being developed for the treatment of liver cancer. For example, sorafenib is a type of medicine called a multi-targeted kinase inhibitor. It interferes with the growth of cancer cells. Research has shown that sorafenib can be beneficial for people with advanced hepatocellular carcinoma.
Clinical trials are research studies in which people help doctors find ways to improve health and cancer care. Each study tries to answer scientific questions and to find better ways to prevent, diagnose, or treat cancer. To find a clinical trial visit: www.bmsstudyconnect.com/s/US/English/USenHome
Various other treatment techniques are sometimes used - for example:
- Radiofrequency ablation. For this treatment, a needle is inserted into the tumur. High-intensity radio waves or laser light are then passed through the needle. This heats the cancer cells and kills them.
- Cryotherapy. For this treatment, a small metal object filled with liquid nitrogen is placed into the tumor. The liquid nitrogen makes it very cold which destroys cancer cells.
- Chemoembolization. For this treatment, medicines used for chemotherapy are mixed with another oily chemical. The mixture is then injected into branches of the liver artery (hepatic artery) which are supplying the tumor with blood. The oily chemical helps to hold the chemotherapy medicines longer in the liver and make them more effective in killing cancer cells.
- Radioembolization. For this treatment, radiation beads (or Yttrium 90) target liver tumors through the liver artery (hepatic artery) which are supplying the tumor with blood. The radiation beads attack the liver tumor and leave the healthy liver tissue healthy.
- Radiotherapy - a treatment which uses high-energy beams of radiation which are focused on cancerous tissue. This kills cancer cells, or stops cancer cells from multiplying. Radiotherapy is not often used for primary liver cancers apart from the uncommon cholangiocarcinoma type of cancer.
- Immuno-Oncology - Immuno-Oncology (I-O) is an innovative area of research that seeks to help the body's own immune system fight cancer. The goal is to address the unmet need for long-term survival in patients with advanced cancers.