What is liver cancer?
Liver cancer can be a primary cancer (starts in the liver) or a secondary cancer (starts in another part of the body and spreads (metastasises) to the liver).
Primary liver cancers
Primary liver cancer is one of the less common cancers.
Most primary liver cancers are hepatocellular carcinoma (HCC or hepatoma), as they start in liver cells called hepatocytes. Less commonly they may originate from the bile ducts and are called cholangiocarcinoma. In the western world, most people who develop HCC have underlying chronic liver disease. This includes viral hepatitis (hepatitis B or C), alcoholic cirrhosis, non-alcoholic fatty liver disease (NAFLD) or hereditary conditions such as hemochromatosis. Only a small proportion of people who have chronic liver disease develop liver cancer. Cholangiocarcinoma may occur sporadically or more commonly in patients with chronic inflammation fo their bile ducts, such as primary sclerosing cholangitis (PSC) or intrahepatic stones.
Secondary Liver Cancers
Secondary liver cancer is the most common form of liver cancer seen 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 colorectal, breast, and stomach. These liver cancers are named after the primary cancer from which they originate. For example, colon cancer that has spread to the liver is called metastatic colon cancer. Sometimes, the liver cancer is discovered first, which leads to the diagnosis of the primary cancer.
Symptoms of Liver Cancer
Liver cancer usually has no symptoms in the early stages.
The only sensate part of the liver is the capsule. 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.
Diagnosis methods for Liver Cancer
Liver cancer is usually diagnosed with a number of different tests, which may include:
Routine blood tests are not specific for liver cancer. Liver enzymes may be normal or abnormal. There are a number of tumour makers, including CEA, CA19-9 and AFP, that may help in making the diagnosis.
This is a non-invasive procedure, involving placing a probe on the skin surface and taking pictures of the liver using sound waves. It is not associated with any side effects.
Computer Tomography (CT) is a specialised x-ray taken from many different angles to build a two-dimensional picture in different planes of the body. It requires you to lie still on a table, and the scanner moves around your abdomen. You will have an intravenous (iv) line placed to administer contrast agent to help characterise the liver.
Magnetic resonance imaging (MRI)
MRI is similar to a CT scan but uses magnetic force instead of x-rays to build a picture of the body. Like CT, a intravenous (iv) line is needed to infuse a contrast agent at the time of the imaging.
Rarely small piece of liver tissue is removed with a needle and examined for cancer cells. This is usually performed by a radiologist under USS or CT guidance, under local anaesthetic.
See section on laparoscopy. This involves introducing telescope (laparoscope) into the abdomen, under general anaesthesia to look at the liver and take a sample of the liver tissue. It is also possible to perform a number of operations using the laparoscope including liver surgery or ablation.
Treatment options for Liver Cancer
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.
Liver Resection Surgery
Liver (hepatic) resection is the main treatment for primary liver cancer. It is only useful for secondary liver cancer if the cancer is limited to the liver or in the case where there is other disease, that it is also able to be effectively treated. The purpose of liver resection is to remove the cancer and leave as much uninvolved liver as possible. Depending upon the number, distribution and size of the tumours, it may be a minor or major operation. The operation can be performed either by an open technique, through an incision in the right upper abdomen, or by key-hole using laparoscopy. The advantage of laparoscopic approach in liver surgery is controversial, as it hasn’t demonstrated superiority in clinical trials. A/Professor Adam Bartlett performs both open and laparoscopic liver surgery. Not all insurance providers will cover laparoscopic liver surgery. The advantages and disadvantages of each approach will be discussed with you at the time of your consultation. Some people require more than one operation to get resect all of the cancer. Liver resection can be combined with other procedures, such as ablation, or surgery to other parts of the abdomen.
Chemotherapy may be indicated for liver cancer. In primary liver cancer, there is only one agent that has been demonstrated to be effective called Sorafenib. Sorafenib is not currently funded in New Zealand, but can be obtained if this is thought to be appropriate. In patients with secondary liver cancer, the type (tablets or injections) and dosing regimen (daily, weekly or monthly) depends upon the cancer type. The administration of the chemotherapy will be managed by an oncologist (cancer specialist) in consultation with A/Professor Adam Bartlett. If the primary tumour is beyond the liver, then it is likely that A/Professor Adam Bartlett will liaise with another surgical specialist to manage the primary tumour.
Ablation refers to treatments that destroy (ablate) the tumour 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) tumours but for whom surgery is not a good option or in combination with liver resection. 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 tumour, 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 tumour and destroys the cancer cells. This is a common treatment method for small tumours.
Microwave Ablation (MWA)
In this newer procedure, and the preferred method by which A/Professor Adam Bartlett ablates liver tumours. MWA 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 due to the higher rate of tumour recurrence and need for multiple procedures.
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.