Liver cancer or Hepatocellular carcinoma (HCC) is one of the commonest cancers in the world especially in countries like India which have a high incidence of Hepatitis B infection. Apart from Hepatitis B, it may be caused by other diseases that lead to cirrhosis of the liver (see below) such as Hepatitis C infection, and alcohol abuse.

Unfortunately, like many other cancers, liver cancer may go undetected until a late stage. It is often brought to attention by an ultrasound or CT scan done for pain in the upper abdomen or another unrelated symptom. It may also develop in a person previously known to have cirrhosis of the liver. Once suspected, Alpha feto protein (AFP) is a simple blood test to confirm its presence. At times, a malignant tumour in the liver may be due to a secondary spread from a cancer elsewhere, commonly the large intestine. .

What can be done about it?

The best possible treatment a liver cancer is surgery wherein the affected portion of the liver is removed (“hepatectomy”). Dr. Soin’s Unit at Medanta Liver Institute are among the teams with the largest experience of hepatectomy in India, performing nearly 50 such operations annually with 95% success.. If surgery is performed at a time when the cancer is confined to a removable portion of the liver and has not spread elsewhere, there is a high chance of cure. Traditionally, considered to be a high risk surgery until 10 years ago, a hepatectomy can now be performed with high degree of success in India, thanks to the bloodless liver splitting techniques devised by surgeons.

A combination of low venous pressure anaesthesia, an experienced surgeon adept at using a special machine called CUSA (see figure) along with special tissue burning equipment can facilitate the division the liver with hardly any bleeding. Two unique features of the liver help in good recovery of patients. One is the tremendous reserve due to which liver function remains normal even if upto 70% liver is removed as long as the remaining liver is not diseased. The second is the power of regeneration due to which the liver recovers its original weight within few weeks after removal of up to 60-70% of liver.

In some suitable cases, especially those where the liver has cirrhosis along with cancer, liver transplantation is also possible. This procedure can treat both liver cirrhosis and cancer at the same time.

Treatment without operation

If an operation is not possible or safe, there are now several other treatment options available. Alcohol injection and radiofrequency thermoablation (RFA, burning the tumour with a special probe without operation) are two excellent options. Both these procedures destroy the tumour without any significant harm to the rest of the liver or the body and can be done on an outpatient basis without the need for admission to hospital. However, their major limitation is that they are only effective for cancers less than about 2 inches in size and fewer than three in number.

Injection of chemotherapy drugs through the liver arteries (transarterial chemotherapy or TAC) can be done if the cancer is widespread within the liver. This way the drugs are delivered directly to the tumour greatly enhancing their effectiveness and at the same time, markedly reducing their side effects on the rest of the body.

Another method by which liver surgeons can deal with large or multiple tumours that are confined to one side of the liver is by blocking the blood supply of the cancerous area of the liver with chemotherapy impreganted material (transarterial chemo-embolization or TACE) resulting in death of tumour cells. All above treatments can and should only be carried out in specialized liver centres by experienced liver surgeons, physicians and radiologists.

Liver Cancer Prevention

Prevention of liver cancer is possible at two levels. The first level of prevention is to avoid alcohol abuse and to prevent the occurrence of Hepatitis B or Hepatitis C. These are acquired from infected individuals via blood or rarely other secretions, by sharing of infected needles among drug addicts, or by the sexual route. Their transmission can be avoided by use of disposable needles in hospitals, by strict and universal screening of all blood donors in blood banks and refusing donations from infected persons. The spread of Hepatitis B can be curbed by universal vaccination of all newborns and the rest of the non-infected population.

The second level of prevention is in patients who have liver cirrhosis. A significant proportion of them will develop cancer. This can be avoided if they undergo a timely liver transplant and the diseased liver can be removed. All those with cirrhosis should see a liver specialist to find out if a liver transplant is suitable for them.

Primary Risk Factors for Liver Cancer (Hepatocellular Carcinoma)

The primary cause of liver cancer is chronic liver damage, commonly associated with hepatitis B (HBV) and hepatitis C (HCV) infections. Persistent viral infection causes long-term liver inflammation and damage, significantly increasing cancer risk. Cirrhosis, a scarring of the liver from chronic liver disease, is another major risk factor and can arise from:

• Chronic alcohol abuse
• Non-alcoholic fatty liver disease (NAFLD), closely linked with obesity and type 2 diabetes.
• Hemochromatosis (genetic iron overload)
• Autoimmune liver diseases

In addition, exposure to aflatoxin, a toxic substance from improperly stored food (e.g., grains, nuts), smoking, family history of liver cancer, and environmental toxins like vinyl chloride or thorium dioxide (historically used in industrial settings) further elevate the risk.

How Can Liver Cancer Be Prevented?

To reduce liver cancer risk, addressing underlying causes is crucial:

• Hepatitis B Vaccination: This is a highly effective way to prevent HBV-related liver cancer.
• Early Detection and Treatment of HCV: Antiviral treatments for hepatitis C can cure the infection and reduce cancer risk. Preventative vaccines for HCV are still not available.
• Monitor Cirrhosis or Chronic Liver Disease: Regular ultrasound and alpha-fetoprotein (AFP) blood tests help detect early liver damage and cancer in at-risk individuals.
• Limit Alcohol: Reducing alcohol consumption can prevent cirrhosis and lower cancer risk.
• Manage NAFLD: Maintaining a healthy weight through exercise and a balanced diet helps prevent NAFLD-related cirrhosis and liver cancer.
• Quit Smoking: Smoking increases liver cancer risk, especially when combined with other risk factors.
• Avoid Aflatoxin Exposure: Ensure proper food storage to minimize exposure to this toxin.

Taking these steps, along with regular screening, can greatly lower the incidence of liver cancer, especially in high-risk populations.

Common Symptoms of Liver Cancer

Liver cancer often remains asymptomatic in its early stages, but as it progresses, the following symptoms may appear:

• Unexplained weight loss
• Loss of appetite
• Chronic fatigue
• Abdominal pain or swelling, especially in the upper right quadrant
• Ascites (fluid accumulation in the abdomen)
• Jaundice (yellowing of skin and eyes)
• Nausea and vomiting
• Unexplained bruising or bleeding due to impaired liver function

These symptoms warrant immediate medical evaluation.

How is Liver Cancer Diagnosed?

Diagnosis begins with a medical history and physical examination, especially for individuals with known risk factors like cirrhosis or hepatitis. Diagnostic steps include:

• Blood Tests: An elevated alpha-fetoprotein (AFP) level may indicate liver cancer, although it is not always specific.
• Imaging Tests: Ultrasound, CT scans, or MRI are used to detect and assess liver tumors.
• Liver Biopsy: A tissue sample may be taken to confirm the diagnosis and stage the cancer.
• Liver Function Tests: These help determine the extent of liver damage, which influences treatment options.

Treatment Options for Liver Cancer

Treatment depends on the stage, size, and location of the tumor, as well as the patient’s overall health. Common treatments include:

1. Surgical Resection: For early-stage liver cancer, a partial hepatectomy (removal of part of the liver) is considered curative.
2. Liver Transplantation: In patients with early-stage cancer, a liver transplant can cure both cancer and underlying liver disease.
3. Ablation Therapies: Techniques such as radiofrequency ablation (RFA) and microwave ablation use heat to destroy cancer cells in patients who are not surgical candidates.
4. Transarterial Chemoembolization (TACE): A procedure that delivers chemotherapy directly to the tumor while blocking its blood supply.
5. Systemic Therapy:
   • Targeted therapies: Drugs like sorafenib or lenvatinib target specific cancer pathways and are used in advanced cases.
   • Immunotherapy: Drugs like nivolumab and pembrolizumab help the immune system fight cancer cells and show promise in advanced liver cancer.
6. Radiation Therapy: External beam radiation or newer techniques like stereotactic body radiation therapy (SBRT) are sometimes used.

Can Liver Cancer be Treated with a Liver Transplant?

Yes, a liver transplant can be a curative treatment for early-stage liver cancer, especially when the cancer is confined to the liver and meets certain criteria, such as the Milan criteria. The Milan criteria stipulate:

• One tumour smaller than 5 cm or
• Up to three tumors all smaller than 3 cm

If these criteria are met, transplantation significantly improves survival outcomes. However, not all patients are eligible due to tumor size, number, or metastatic spread.

Moreover the cancers limited to liver can be downstaged to benefit from liver transplantation.

Prognosis for Liver Cancer

Prognosis depends on tumor stage, liver function, and overall health. If liver cancer is diagnosed early and treated surgically or with transplantation, the 5-year survival rate is 60-70%. For advanced-stage liver cancer, survival drops significantly, with 5-year survival rates around 10-20%. However, emerging therapies, including targeted drugs and immunotherapy, are improving outcomes in some patients.

Screening for High-Risk Individuals

High-risk individuals, such as those with cirrhosis or chronic HBV/HCV infection, should undergo screening every 6 months. Screening typically includes:

• Ultrasound
• AFP blood tests

Regular screening increases the chances of detecting liver cancer at a treatable stage.

Advancements in Liver Cancer Treatment

Recent advancements in liver cancer treatment include:

• Targeted Therapies: Drugs that inhibit specific cancer growth pathways, such as regorafenib and cabozantinib, are improving outcomes in advanced stages.
• Immunotherapy: Checkpoint inhibitors, such as nivolumab and atezolizumab, are helping some patients mount stronger immune responses against liver cancer.
• Robotic and Minimally Invasive Surgery: These approaches allow for precise tumor removal with quicker recovery times.
• Gene Therapy and Personalized Medicine: Emerging fields that may offer more tailored treatments based on genetic profiles.

Supporting a Loved One Undergoing Liver Cancer Treatment

Supporting a loved one with liver cancer involves both emotional and practical assistance. This includes:

• Offering emotional support by being present and listening.
• Helping with daily tasks, such as cooking, managing medications, and arranging medical appointments.
• Encouraging healthy lifestyle choices, such as balanced nutrition and exercise.

Joining support groups or counseling to provide a sense of community and additional resources for both the patient and caregivers.

Stages of Liver Cancer

Liver cancer progresses in stages, each representing the severity and spread of the disease. Accurate staging helps determine the most effective liver cancer treatment options, guiding both doctors and patients through appropriate care steps. With the expertise of Dr. A.S. Soin, a leading pioneer in liver transplants, patients can access comprehensive guidance and support.

Stage 1: Localized Tumor

In stage 1, liver cancer presents as a single tumour localised to the liver without spreading to blood vessels or lymph nodes. At this stage, liver cancer treatment in india often includes surgery or localised treatments, with higher chances of success and effective recovery.

Stage 2: Tumor Spread to Blood Vessels

Stage 2 involves a single tumour that may begin affecting nearby blood vessels or multiple small tumours within the liver. Treatment options may include surgery, ablation, or radiation to control tumour growth and reduce symptoms. Dr. A.S. Soin’s expertise in hepatocellular carcinoma management helps patients explore the best care strategies in India.

Stage 3: Spread to Large Blood Vessels

In stage 3, liver cancer spreads to larger blood vessels or nearby lymph nodes. Treatment focuses on limiting the cancer’s spread and managing symptoms, often through targeted therapies or chemotherapy. Consulting Dr. Soin helps patients navigate complex treatment choices.

Stage 4: Advanced Cancer Spread

Stage 4 liver cancer indicates cancer has spread to other organs or areas beyond the liver. Treatment options aim to control symptoms and improve quality of life. Dr. Soin provides personalised support, helping patients understand stage 4 liver cancer and available treatments.

Dietary and Lifestyle Modifications for Liver Cancer Patients

Diet and lifestyle changes play a crucial role in managing liver cancer. Tailored recommendations can enhance the body’s ability to cope with liver cancer treatment, supporting patients’ overall well-being. With guidance from Dr. A.S. Soin, patients receive effective advice on nutritional and lifestyle adjustments.

• Importance of a Balanced Diet

A balanced diet rich in lean proteins, whole grains, and fruits can strengthen the immune system and improve energy levels. Avoiding processed foods, alcohol, and excessive sugars can benefit liver function and help manage hepatocellular carcinoma symptoms. Dr. Soin ensures that each patient’s dietary plan aligns with their treatment needs.

• Staying Hydrated

Adequate hydration is crucial, especially during treatments like chemotherapy, which can cause dehydration and fatigue. Drinking water throughout the day helps flush out toxins, supports organ functions, and reduces the likelihood of treatment-related fatigue. In addition to water, nutrient-rich fluids like herbal teas and clear broths can provide additional hydration and essential minerals. Dr. Soin advises patients to maintain optimal hydration to help support liver function and enhance overall comfort.

• Low-Fat, Nutrient-Dense Foods

Low-fat, nutrient-dense foods reduce strain on the liver, helping it function better. Including foods rich in antioxidants, like berries and leafy greens, can also protect against cell damage. Dr. Soin emphasises the role of dietary choices in boosting liver cancer treatment outcomes.

• Regular Physical Activity

Light exercise, such as walking or yoga, supports mental well-being and physical strength. Engaging in regular activity, as recommended by healthcare providers, can ease treatment side effects, improve mood, and maintain energy levels.

• Stress Management

Managing stress is key for liver cancer patients, as chronic stress can affect immunity and overall health. Techniques like meditation, deep breathing, and counselling can help reduce stress levels. Dr. Soin encourages patients to incorporate stress-relief practices to support mental well-being and complement their treatment journey.

Living with Liver Cancer: Tips for Daily Life and Management

Living with liver cancer requires adjustments to daily routines, focusing on physical and emotional well-being. Simple lifestyle changes, paired with expert guidance from specialists like Dr A.S. Soin, can help patients lead fulfilling lives even during treatment.

• Prioritising Rest and Energy Conservation

Rest is essential for managing fatigue, a common symptom during liver cancer treatment. Setting a manageable daily routine and taking frequent breaks can make a difference in conserving energy for essential activities.

• Building a Support System

A reliable support system of family, friends, and healthcare professionals is invaluable. Dr. Soin encourages patients to lean on loved ones and join support groups, providing a network for emotional and practical assistance.

• Coping with Symptoms

Dealing with nausea, pain, or fatigue may require specific strategies like dietary adjustments or meditation techniques. Dr. Soin offers guidance on managing symptoms helping patients find comfort through personalised care.

• Setting Realistic Goals

Setting achievable goals, both big and small, can offer a sense of purpose and accomplishment. Whether it’s enjoying a favourite hobby or completing simple tasks, having goals can positively impact mental well-being.

• Practicing Mindfulness and Relaxation Techniques

Mindfulness practices like meditation or deep breathing can reduce stress and improve mental clarity. Simple relaxation techniques can help patients manage anxiety and stay grounded, even on challenging days. Dr. Soin encourages patients to integrate these practices as part of a balanced, supportive approach to living with liver cancer.

These practical steps, coupled with expert care, make living with liver cancer manageable and meaningful.