Liver Cancer

Liver Cancer (Hepatoma, HCC)

November 19, 2024

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:

Surgical Resection: For early-stage liver cancer, a partial hepatectomy (removal of part of the liver) is considered curative.
Liver Transplantation: In patients with early-stage cancer, a liver transplant can cure both cancer and underlying liver disease.
Ablation Therapies: Techniques such as radiofrequency ablation (RFA) and microwave ablation use heat to destroy cancer cells in patients who are not surgical candidates.
Transarterial Chemoembolization (TACE): A procedure that delivers chemotherapy directly to the tumor while blocking its blood supply.
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.

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.