Alt. names: Hepatocellular carcinoma. The liver will function normally with only a small portion of it in working order.
Liver cancer can be a primary cancer (starts in the liver) or a secondary cancer (starts in another part of the body and spreads to the liver).
Primary liver cancers
Primary liver cancer is one of the less common cancers in Victoria with about 170 people diagnosed each year. It is more common in men and people aged over 60 years. Most primary liver cancers are called hepatocellular carcinoma, as they start in liver cells called hepatocytes. Others start in a bile duct and are called cholangiocarcinoma.
In the western world, most people who develop primary liver cancer also have cirrhosis of the liver. This is scarring of the liver which is due to a variety of causes including heavy alcohol drinking over a long period of time. However, only a small proportion of people who have cirrhosis of the liver develop primary liver cancer. Infection with hepatitis B, C or D can also increase the risk of developing cirrhosis and, later, primary liver cancer.
Secondary liver cancers
Secondary liver cancer is the most common liver cancer in the western world. A secondary liver cancer is a cancer that starts somewhere else in the body and spreads (metastasises) to the liver. Most cancers can spread to the liver but the common ones are breast, stomach and bowel cancers. These liver cancers are named after the primary cancer for example, breast cancer that has spread to the liver is called metastatic breast cancer. Sometimes, the liver cancer is discovered first, which leads to the diagnosis of the primary cancer.
Liver cancer usually has no symptoms in the early stages. Symptoms can include:
- Pain in the upper right side of the abdomen
- Yellowing of the skin and eyes (jaundice)
- Weight loss
- Loss of appetite
- Swelling of the abdomen.
Liver cancer is usually diagnosed with a number of different tests, which may include:
- Blood tests - to check your general health and to check for a chemical (AFP), which is usually found in increased levels in people with a certain type of primary liver cancer.
- Ultrasound - a picture of the liver is taken using sound waves.
- CT scan - a specialised x-ray taken from many different angles to build a three-dimensional picture of the body.
- Magnetic resonance imaging (MRI) - similar to a CT scan but uses magnetism instead of x-rays to build a picture of the body.
- Liver biopsy - a small piece of liver tissue is removed with a needle and examined for cancer cells.
- Laparoscopy - a small cut in the lower abdomen allows a thin mini-telescope (laparoscope) to be inserted to look at the liver and take a sample of the liver tissue. If the tests show you have secondary liver cancer (and you did not know that you had a primary cancer), you may need further tests to find out where the primary cancer is.
Treatment for liver cancer will depend on whether it is a primary or secondary (metastatic) cancer. The treatment requires multi-disciplinary management with doctors from different specialties, and can involve surgery, ablation, chemotherapy and/or radiation therapy.
- Surgery - to remove the cancer and as much damaged tissue as possible. This is the main treatment for primary liver cancer. It is only useful for secondary liver cancer if the cancer cells only affect one part of the liver.
- Liver (hepatic) resection - Most patients who require a liver resection have metastases from a colorectal (bowel) cancer. Less commonly other secondary cancers from neuroendocrine tumors (like carcinoid), renal cancer or melanoma are resected. The most common primary liver cancer that is resected is hepatocellular carcinoma (HCC or Hepatoma). This is a cancer that originates in liver cells (primary), and is usually associated with underlying chronic liver disease. Primary cancers of the bile ducts, cholangiocarcinoma, are less commonly resected. There are a number of benign lesions that occur in the liver. Most don’t cause any symptoms or problems and can be monitored or left alone. Sometimes it is not possible to be sure of a diagnosis and resection is undertaken to establish the diagnosis. Biopsy of the liver is not routinely recommended as it has the potential to cause bleeding and spread of the cancer.
The most common method of removing part of the liver is by an open operation (laparotomy). In some instances it is possible to undertake the operation laparoscopically (keyhole surgery). The open technique is the preferred method for major resections particularly and in those tumors that are difficult to access. Only a minority of liver resections can be performed laparoscopically. A camera, known as a Laparoscope, connected to a high intensity light is introduced through a small incision and a further three puncture wounds are made to allow the surgical instruments to be introduced. Once the liver has been resected a small incision is made low down in the abdomen to allow the tumour to be extracted. Irrespective of the method used the principals are the same: The liver is mobilized. The vessels to the portion being resected are isolated and controlled. A cut is then made through the liver substance (parenchyma) and care is taken to seal off the blood vessels and bile ducts that pass across the plane of transection.
There are risks with all surgery. Complications occur in about 20% of cases and most are mild and easily resolved. Rare but severe complications that are specific to undergoing liver resection include;
- Bile leak from the cut surface occurs in 5-10% of patients. This is usually self-limiting and is treated by external drainage. It may require an endoscopic procedure to decompress the bile ducts, and rarely re-operation is required.
- Bleeding either at the time of surgery or soon after, may require blood transfusion or re-operation. In most instances it resolves without further intervention.
- Liver failure may occur if the liver remnant is insufficient to support normal function. This is one of the most severe complications of undergoing liver surgery. Liver failure leads to progressive jaundice (yellow), ascites (fluid collection in the abdomen) and coagulopathy (abnormality in blood clotting). It may result in death if the liver is unable to regenerate in a timely manner.
- Respiratory complications (infection, collapse, fluid collections) are not uncommon as a result of prolonged ventilator support and poor inspiratory effort post-operatively. This may require antibiotic treatment or drainage.
General risks of surgery including wound infection, deep vein thrombosis (DVT), pulmonary embolism, or development of a hernia at the incision site. There is an increased risk of post- operative complications if you are overweight or if you smoke.
- Chemotherapy - The type (tablets or injections) and dosing regimen (daily, weekly or monthly) depends upon the type of liver cancer, and will be managed by an oncologist (cancer specialist). Colorectal (bowel) cancer is usually treated using a combination of agents, either before, after or both before and after surgical resection of the liver secondaries. Many of the other metastatic cancers that spread to the liver are not responsive to chemotherapy and surgery is the only treatment available. Hepatocellular carcinoma (HCC) has been shown to be responsive to oral treatment with Sorafenib, but it is only used in patients not amenable to curative resection (palliative management).
- Ablative Therapy - Ablation refers to treatments that destroy (ablate) liver tumors without removing them. It can be administered through the skin (percutaneous), at the time one undergoes an operation (laparotomy) or with keyhole surgery (laparoscopically). Ablation is often used in patients with a few small (<3cm) tumors but for whom surgery is not a good option or in combination with liver resection. Ablation is less likely to cure the cancer than resection, but it can can still be very helpful for some people. Ablation can be performed by a variety of techniques including;
- Radiofrequency ablation (RFA). This uses high-energy radio waves to produce thermal ablation. A fine needle is inserted into the tumor, either through the skin or at laparotomy under ultrasound guidance. A high-frequency current is then passed through the tip of the probe, which heats the tumor and destroys the cancer cells. This is a common treatment method for small tumors.
- Microwave ablation (MWA). In this newer procedure, which uses high intensity microwaves to heat and destroy the tumour. Like RFA it uses a fine needle that can be inserted through the skin or directly into the tumour at the time of laparotomy or laparoscopy. The main advantage of MWA or RFA is the ability to treat tumours close to blood vessels, and shorter time to reach thermal ablation.
- Ethanol (alcohol) ablation. Percutaneous ethanol injection (PEI) is the original method that was used to ablate liver tumours. It involves direct injection of concentrated alcohol into the tumor to kill cancer cells. This is usually done through the skin using a needle guided by ultrasound or CT scans. It is rarely performed now days.
- Radiation Therapy External radiation therapy is rarely used to treat liver cancers, as the background (normal) liver is more sensitive to radiation damage that the tumour. A newer technique, selective internal radiation therapy (SIRT), whereby the radiation is administered directly into the tumour by injecting radioactive beads into the blood vessel supplying the cancer is currently being investigated in a number of trials to see whether it is more effective than chemotherapy. The main advantage of SIRT over conventional chemotherapy is that it treats only the cancer within the liver.