An Overview of Liver Cancer
Learning that you have liver cancer can cause an array of emotions and questions. Because liver cancer is initially hard to detect, you may have had no indication of the disease in your body. Or you may have experienced symptoms such as abdominal pain, nausea or weight loss. Unfortunately, the rate of liver cancer is increasing in the United States, probably due to the growing population infected with the hepatitis b and/or c virus. In areas such as Africa, Southeast Asia and China, liver cancer is a major health problem, causing up to 75% of all cancer cases because of the high percentage of hepatitis B virus carriers.
- Who's at Risk?
- Screening for Liver Cancer
- Signs of Liver Cancer
- Tests for Liver Cancer
- Staging
- Patient Evaluation
- Surgical Treatment Options
- Minimally Invasive Treatments
- Advanced Cancer Treatments
- Support for People with Liver Cancer
- Additional Resources
Who's at Risk?
While no one knows the exact cause of liver cancer, patients with certain risk factors are more likely to develop this disease. Specifically, a patient may develop liver cancer if he/she has:
- chronic infection with hepatitis B
- chronic infection with hepatitis C
- iron overload cirrhosis (hemochromatosis)
- alcoholic cirrhosis
- exposure to certain toxins and chemicals (i.e. aflatoxin and polyvinyl chloride)
- a rare inherited liver disease
- a family history of liver cancer
- non-alcoholic fatty liver disease
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Screening for Liver Cancer
Patients who have an increased risk of liver cancer—and who should undergo routine screening— include those with cirrhosis or long-term carriers of hepatitis B and C.
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Signs of Liver Cancer
Usually signs of liver cancer begin to appear when the cancer is in its later stages. These signs may include:
- Weight loss (for no apparent reason)
- Loss of appetite and feelings of fullness
- Pain in the upper abdomen on the right side (may extend to back and shoulder)
- Ongoing stomach pain or swelling
- Yellow skin and eyes, and dark urine from jaundice
- Weakness or feeling tired
- High alfa-fetoprotein (AFP) blood test
Once a patient shows symptoms of liver cancer, or AFP and ultrasound results reveal the possibility of liver cancer, patients undergo various other tests to help confirm a diagnosis.
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Tests for Liver Cancer
Doctors use a variety of tests to determine if a liver tumor(s) (also called a hepatoma) exists and its exact location. The majority of these are called ‘imaging tests’ because they provide detailed pictures of your liver and surrounding organs. Imaging tests can also help your doctors find out whether the liver cancer has spread. If doctors suspect you may have liver cancer, a combination of the following tests may be performed.
AFP Blood Test
Because of the liver’s size and location, it is impossible to detect liver tumors upon physical examination. Instead, an alpha-fetoprotein (AFP) blood test and ultrasound are used for initial screening. AFP is a protein produced by the liver and a high level can indicate tumor growth. A blood sample will show the level of AFP in your body.
Ultrasound (Sonogram)
An ultrasound uses sound waves to produce pictures (sonogram) of the liver and other abdominal organs. If a tumor exists, the ultrasound may produce a different echo pattern than it does with healthy tissue.
CT Scans (Triple Phase or Triphasic)
California Pacific and most institutions use CT scans as the main imaging test to evaluate the liver for cancer. The CT scan—which provides detailed, cross-sectional images of the liver—is done in three phases, taking about 20 min. in total. During each phase, different sections of the liver and surrounding abdominal organs are viewed to identify a tumor(s) location. When undergoing a CT scan, you may be asked to drink an oral contrast so the liver shows up clearly in pictures.
MRI (Magnetic Resonance Imaging)
To complement the CT scan, you may also undergo magnetic resonance imaging (MRI). An MRI uses radio waves and strong magnets linked to a computer to make detailed pictures of your abdominal area. An MRI scan takes longer than a CT scan. Sometimes, an MRI can tell a benign tumor from a cancerous one.
Tumor Marker
A tumor marker is a substance that can often be detected in higher-than-normal amounts in the blood, urine or body tissues of some patients with certain types of cancer. Tumor markers are produced either by the tumor itself or by the body in response to the presence of cancer or certain benign (noncancerous) conditions. Some tumor marker levels are measured before treatment to help doctors plan appropriate therapy. In some types of cancer, tumor marker levels reflect the extent (stage) of the disease and can be useful in predicting how well the disease will respond to treatment.
Angiogram
In some patients, an angiogram is used to help doctors better visualize a mass in the liver. During an angiogram, a dye is injected in the artery, which outlines blood vessels. This helps show which blood vessels supply blood to the liver. This information can help surgeons decide whether the cancer can be removed and, if so, how to best plan the operation. Usually a local anesthetic is used with an angiogram.
Laparoscopy and Endoscopy Ultrasound (EUS)
If there is a question of cancer outside the liver, a doctor may use diagnostic laparoscopy or endoscopic ultrasound (EUS) to look at the liver and other organs. Laparoscopy and endoscopic ultrasound allow a doctor to look directly at your liver and nearby organs. These images are used to stage gastrointestinal and pancreatic cancers.
Biopsy
A liver biopsy is a tissue sample removed with a fine needle. While this test can definitively show the presence of cancer cells, it is rarely used because of the small risk of spreading cancer cells (about 3%). Also, this procedure alone may miss a cancer diagnosis.
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Staging
The tests you undergo for liver cancer help your doctors learn the stage, or extent, of the disease to plan the best treatment. Specifically, staging refers to the process of determining the size of the tumor, whether the disease has spread, and if so, to what parts of the body. Careful staging shows whether the tumor can be removed with surgery. This is very important because most liver cancers cannot be removed with surgery.
Liver cancer generally falls into two categories:
Localized Resectable Cancer: Localized respectable cancer means that the tumor(s) is located within the liver and has not spread to nearby lymph nodes or other parts of the body. Because the liver is still working well, surgery can typically be performed to remove the tumor(s).
Localized Unresectable Cancer: Localized unresectable cancer means that even though the cancer has not spread to nearby lymph nodes or other parts of the body, surgery is not possible due to cirrhosis, the location of the tumor within the liver, or other health problems. Patients with localized unresectable cancer are typically treated with therapies such as radiofrequency ablation, percutaneous ethanol injection therapy or chemoembolization.
If cancer has spread to both lobes of the liver, lymph nodes or other parts of the body, it is called advanced cancer. Descriptions of advanced cancer treatments are described at the end of the “Treatment Options” section.
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Patient Evaluation
At California Pacific, patients undergo an evaluation by an oncologist, hepatologist and surgeon on their first visit. This visit may also include additional imaging and/or X-ray tests.
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Surgical Treatment Options
At this time, surgery — either to remove the tumor or liver transplantation — offers the only chance to cure liver cancer. If all of the cancer that the surgeon can see at the time of the operation can be removed, you have the best outlook for survival. Unfortunately, complete removal of most liver cancers is not possible. Often the cancer is large, is found in many different parts of the liver, or has spread beyond the liver. Also, many people with cirrhosis do not have enough healthy liver tissue left to make surgery an option.
Surgical Resection (Hepatectomy)
Patients with an operable tumor(s) and no cirrhosis may be candidates for surgery to remove part of the liver where the tumor(s) resides. This surgery is called resection because the surgeon removes (resects) one or more of the liver’s cancerous sections. The extent of the surgery depends on the size, number and location of the tumors, as well as how well one’s liver is working. Our surgeon’s goal is to remove the tumor(s) and as little liver as possible.
For surgical purposes, the liver is divided into eight sections (see illustration). A branch of the hepatic artery and portal vein supply each section. Typically, surgeons can remove up to 70% of a cancerous liver (if there is no fibrosis). The remaining healthy tissue will take over the functions of the liver. Following surgery, the liver will grow back.
Prior to surgery, some resection patients undergo pre-operative portal vein embolization, a procedure in which a coil is inserted into the portal vein of the cancerous sections to block blood flow to those sections. This procedure is done by an interventional radiologist, under sedation and local anesthesia. Following portal vein embolization, the other liver sections on which the patient will depend following surgery enlarge. This is important for patients who may not have enough liver reserve for sufficient re-growth following resection.
It takes time to heal after surgery and for each person, the time needed to recover is different. Patients are often uncomfortable during the first few days following surgery. However, medicine can usually control their pain. You should feel free to discuss pain relief with your doctor or nurse. It is common to feel tired or weak for a while. Also, patients may have diarrhea and a feeling of fullness in the abdomen. The health care team watches the patient for signs of bleeding, infection, liver failure, or other problems requiring immediate treatment.
Liver Transplantation
Liver transplantation may be an option for a patient with a few small tumors (3 or less) that can’t be totally removed by resection, either because of the tumors’ location or because not enough normal liver remains. During a liver transplant, the surgeon removes your entire liver and replaces it with a healthy liver. Following surgery, anti-rejection medications are required lifelong to prevent the body from rejecting the new liver.
A patient with liver cancer must meet certain criteria to get on the national waiting list for a liver transplant. This criteria includes the size and number of tumors. If you have a single tumor that is up to 5 cm. in size, or 2-3 tumors that are up to 3 cm. in size, your status on the national waiting list may be elevated. This is due to the United Network for Organ Sharing’s
(UNOS) MELD score system, which is used to rank the disease severity of patients awaiting liver transplantation. Other criteria for liver transplantation stipulate that one’s disease cannot have spread outside the liver, because then a transplant couldn’t cure it. Currently, patients at California Pacific with liver cancer who are candidates for liver transplant wait about 8 to 12 months for a transplant following their diagnosis. The four-year overall transplant survival rate for patients with HCC is 85 percent and the recurrence-free survival rate is 92 percent.
Liver transplantation is a major surgery, requiring a typical hospital stay of 7 to 10 days. After a liver transplant, patients are required to stay in San Francisco for one month if they live more than 50 miles away. California Pacific has an apartment complex near the Medical Center that usually has rooms available in this situation. During this post-transplant period, the liver team checks for signs of how well the patient’s body is accepting the new liver. The patient takes drugs to prevent the body from rejecting the new liver. These drugs may cause puffiness in the face, high blood pressure, or an increase in body hair.
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Minimally Invasive Treatments
For patients with localized unresectable liver cancer, there are several minimally invasive treatments to control the disease and extend one’s life. These treatments are options if surgery is not possible due to cirrhosis (or other conditions that cause poor liver function), the location of the tumor within the liver, or other health problems.
Radiofrequency Ablation
Radiofrequency (RF) ablation involves the use of a probe to deliver extreme heat that destroys cancer cells. During this procedure, general anesthesia is used. Surgeons make a small incision in the upper abdomen, into which a laparoscope (a type of telescope) is inserted. A tiny camera is attached to
the laparoscope, which gives the surgeon an ultrasound image of the tumor’s location. The surgeon makes a second small incision, into which a probe is inserted (see illustration). With this RF probe, the surgeon delivers microwave energy to the tumor, causing the cancer cells to die. Because radiofrequency ablation uses smaller incisions than traditional surgery, recovery is generally faster and less painful. Also, infection and bleeding are not as likely.
Percutaneous Ethanol Injection Therapy (PEIT)
Percutaneous ethanol injection is another option for patients who are not surgical candidates. This procedure, performed by an interventional radiologist, involves the injection of alcohol (ethanol) directly into the liver tumor to kill the cancer cells. Usually local anesthesia is used, but if the patient has many tumors in the liver, general anesthesia may be needed.
Following the PEIT procedure, patients may have fever and pain. Your health care team can suggest medicines to relieve these problems. PEIT has been shown to completely destroy liver tumors in up to 75% of selected patients with HCC less than 5 cm in size.
Chemoembolization
Patients with liver cancer and cirrhosis are frequently treated with hepatic artery chemoembolization, a process in which a tiny catheter is inserted into an artery in the leg and threaded up to the hepatic artery off the aorta. The doctor then injects an anticancer drug (chemotherapy) into the artery, followed by tiny particles to block the flow of blood through the artery. Without blood flow, the drug stays in the liver longer. Depending on the type of particles used, the blockage may be temporary or permanent. Although the hepatic artery is blocked, healthy liver tissue continues to receive blood from the hepatic portal vein. The response rates for chemoembolization are 60%-80% with an average duration of one year. This therapy can be repeated multiple times before transplantation with excellent disease-free survival.
Chemoembolization and hepatic arterial infusion cause fewer side effects than systemic chemotherapy because the drugs do not flow through the entire body. Chemoembolization sometimes causes nausea, vomiting, fever and abdominal pain. Your doctor can give medications to help lessen these problems. Some patients may feel very tired for several weeks after the treatment.
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Advanced Cancer Treatments
Once liver cancer has spread to other parts of the body, advanced cancer treatments may be used to try to slow the progress of the disease. You should discuss the possible benefits and side effects of these treatments with your doctor. At this stage, palliative care is also offered to all patients to reduce their pain and control other symptoms.
Chemotherapy
Systemic chemotherapy uses a mixture of anti-cancer drugs injected into a vein or taken by mouth. Typically, this alternative is reserved for patients with metastatic disease or those who are not candidates for other procedures. Depending on any underlying disease, different drugs are applied. Usually, chemotherapy is an outpatient treatment given at the hospital or doctor’s office. However, depending on which drugs are given and the patient’s general health, the patient may need to stay in the hospital.
Hepatic Arterial Pumps
Chemotherapy can also be delivered to the liver through a pump, called a hepatic arterial pump. This pump is generally filled with chemotherapy once a month and slowly delivers the drug via a catheter placed in the patient’s hepatic artery. This pump is mainly used for metastatic disease to the liver rather than primary liver cancer. The pump is implanted under the skin and the catheter is typically inserted via laparoscopic or open surgery.
The side effects of chemotherapy depend mainly on the drugs and doses a patient receives. Side effects may include a higher chance of infections, including liver abscess with chemoembolization, bruising or bleeding more easily, hair loss, poor appetite, nausea and vomiting, mouth sores and reduced energy. Usually, these side effects go away gradually during the recovery periods between treatments or after treatment is complete. The health care team can suggest ways to relieve side effects.
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Support for People with Liver Cancer
Having a serious disease such as liver cancer is not easy. Some people find they need help coping with the emotional and practical aspects of their disease. Support groups can help. In these groups, patients or their family members get together to share what they have learned about coping with the disease and the effects of treatment. Patients may want to talk with a member of their health care team about finding a support group. Groups may offer support in person, over the telephone, or on the Internet.
Patients may worry about caring for their families, holding on to their jobs, or keeping up with daily activities. Concerns about treatments and managing side effects, hospital stays, and medical bills are also common. Doctors, nurses, and other members of the health care team will answer questions about treatment, working, or other activities. Meeting with a social worker, counselor, or member of the clergy can be helpful to those who want to talk about their feelings or discuss their concerns. Often, a social worker can suggest resources for emotional support, financial aid, transportation, or home care.
The Community Health Resource Center at California Pacific Medical Center offers a Cancer Support Group twice a month. Individuals with various types of cancer can use this forum to talk about cancer treatments and side effects. For more information, visit www.cpmc.org/chrc or call (415) 441-5128.
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Additional Resources
The following organizations can provide additional information and resources.
American Liver Foundation
Telephone: 1-800-GO-LIVER (465-4837)
Internet Address: www.liverfoundation.org
National Cancer Institute
Telephone: 1-800-4-CANCER
Internet Address: www.cancer.gov
American Cancer Society Publications
Books
• Caregiving -- A Step-by-Step Resource For Caring For the Person with Cancer at Home
• Cancer in the Family: Helping Children Cope with a Parent’s Illness
• Coming to Terms with Cancer: A Glossary of Cancer-Related Terms
• American Cancer Society’s Guide to Pain Control
• Consumers Guide to Cancer Drugs
• Informed Decisions, 2nd Edition: The Complete Book of Cancer Diagnosis, Treatment, and Recovery
Brochures
• After Diagnosis: A Guide for Patients and Families (Booklet; Code #9440)
• Caring for the Patient with Cancer at Home (Booklet; Code #4656)
• Questions and Answers About Pain Control (Booklet; Code #4518)
Parts of this information were adapted from:
National Cancer Institute – What You Need to Know About Liver Cancer
American Cancer Society—Overview: Liver Cancer
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