Liver Cancer

What Is Liver Cancer?

Liver cancer occurs when cells in the liver begin to grow abnormally and uncontrollably and become cancerous. Cancer that starts in the liver is called primary liver cancer. Cancer that begins in another part of the body and later spreads to the liver is called metastatic liver cancer, or secondary liver cancer.

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Liver cancer

Primary Liver Cancer

Primary liver cancer can develop from different types of cells in the liver. For example:

  • Hepatocellular carcinoma (HCC) develops from liver cells called hepatocytes.
  • Cholangiocarcinoma develops from cells lining the bile ducts.

Primary liver cancer is one of the leading causes of cancer-related death worldwide. It is particularly common in areas where hepatitis B and hepatitis C are widespread, including parts of Southeast Asia, Africa, and China.

Metastatic Liver Cancer (Secondary Liver Cancer)

Cancer that starts in another organ can spread to the liver through the bloodstream or by directly extending into the liver. Cancers that commonly spread to the liver include cancers of the:

  • Colon
  • Rectum
  • Gallbladder
  • Pancreas
  • Stomach
  • Breast
  • Lung
  • Skin, including malignant melanoma

Metastatic cancer involving the liver is much more common than cancer that starts in the liver itself.

Liver Cancer in Children

The most common liver tumor in young children is hepatoblastoma. It usually occurs during the first three years of life and is more common in boys. Other types of liver tumors and cancers can also occur in children.

Causes and Risk Factors for Liver Cancer

Several conditions can increase the risk of developing liver cancer.

1. Liver Cirrhosis caused by any underlying condition can increase the risk of liver cancer.

2. Long-term infection with hepatitis B or hepatitis C, particularly when it leads to chronic liver inflammation and cirrhosis, is one of the major causes of liver cancer.

3. Long-term, uncontrolled alcohol consumption can cause alcohol-related cirrhosis, which increases the risk of liver cancer.

4. Fatty liver disease, alcohol-related fatty liver disease (AFLD), and NASH-related cirrhosis can increase the risk of liver cancer. The number of cases related to these conditions has been increasing.

5. Long-term use of birth control pills has been associated with the development of certain benign liver tumors, such as hepatocellular adenoma. In rare cases, these tumors may have the potential to become cancerous.

6. Long-term use of anabolic steroids can increase the risk of certain liver tumors and liver cancer.

7. Long-term exposure to arsenic may increase the risk of liver cancer and other serious health problems.

8. Aflatoxin is a toxin produced by certain types of fungi (mold). It can contaminate foods such as:

  • Moldy nuts
  • Corn
  • Areca nuts (betel nuts)
  • Seeds
  • Other improperly stored foods

Long-term exposure to aflatoxin can increase the risk of liver cancer.

Symptoms of Liver Cancer

Liver cancer often causes few or no symptoms in its early stages. In many cases, the cancer can continue to grow without causing noticeable problems.

Possible symptoms include:

  • Loss of appetite
  • Tiredness and fatigue
  • Unexplained weight loss
  • Pain in the upper abdomen
  • Nausea and vomiting
  • Jaundice (which causes the eyes and skin to become yellow and may make the urine dark)
  • Swelling of the legs
  • Buildup of fluid in the abdomen (ascites)

Diagnosing Liver Cancer

Several tests may be used to diagnose liver cancer and determine its size, location, and stage.

1. Blood Tests

Blood tests may include:

  • Liver function tests (LFTs)
  • Alpha-fetoprotein (AFP), PIVKA-II (Protein Induced by Vitamin K Absence-II)
  • Complete blood count (CBC)
  • Albumin level
  • Prothrombin time (PT/APTT/INR)
  • Viral markers (HBsAg/Anti-HBc Total/Anti-HCV)

2. Abdominal Ultrasound

3. CT Scan

4. MRI

5. CT Angiography

6. CT Volumetry

7. FNAC or Liver Biopsy

Treatment of Liver Cancer

Primary Liver Cancer

There are several treatment options for primary liver cancer. The treatment approach is determined by following a specific protocol that takes into account the location and stage of the liver cancer, liver function, and the patient's overall condition.

A. Liver Resection

Liver resection is a surgical procedure in which the part of the liver containing the cancer is removed. The remaining liver can grow and adapt after surgery. Much of this recovery occurs during the first several weeks, although the exact time varies from person to person. Different types of liver resection can be performed depending on the location and size and extent of the cancer and the condition of the remaining liver. Liver resection is generally considered for carefully selected patients with well-preserved liver function, such as those in Child-Pugh class A. It may be considered with great caution in selected patients with Child-Pugh class B disease and is generally not appropriate in patients with Child-Pugh class C cirrhosis because the remaining liver may not be able to function adequately after surgery.

The original source reports a 5-year survival rate of approximately 24%–70% after liver resection for liver cancer. Actual survival varies considerably depending on tumor stage, liver function, and other patient factors.

B. Liver Transplantation

Liver transplantation is an advanced treatment option for selected patients with primary liver cancer. During transplantation, the diseased liver is removed completely and replaced with a partial or whole donor liver. This is a complex procedure that requires careful evaluation of both the donor and recipient. Liver transplantation is generally considered only for selected patients with primary liver cancer who meet specific criteria. Whilst there are many criteria, one of the most widely used sets of criteria for selecting patients for liver transplantation is the Milan criteria.

The criteria generally include:

1. Only one tumor measuring 5 cm or less

2. Up to three tumors, with each tumor measuring 3 cm or less

3. The cancer has not invaded the major blood vessels of the liver (no vascular invasion)

4. The cancer has not spread outside the liver (no extra hepatic metastasis)

For liver cancer, when a liver transplant is performed based on the MELD score and Milan criteria, the probability of survival for five years post-transplant is approximately 70%. After the transplant, the patient requires immunosuppressants and must receive regular follow-up care.

C. Liver Cancer Ablation (Ablation Therapies)

Ablation is a treatment that destroys cancer cells without removing the entire tumor through conventional surgery. Different ablation techniques are used depending on the size, location, and characteristics of the tumor. Each technique has specific indications and limitations.

1. Radiofrequency Ablation (RFA)

In tumors where surgical removal is not possible or when another curative treatment is not suitable, radiofrequency ablation is used where extreme heat (High Frequency Alternating Current) is applied to destroy the liver cancer cells.

The heat can be delivered using guidance from:

  • CT scans
  • Ultrasound
  • Laparoscopy
  • Directly during surgery

Before treatment, doctors consider:

  • Tumor size
  • Number of tumors
  • Tumor location
  • Involvement of nearby blood vessels
  • Whether the cancer has spread outside the liver
  • Overall liver function

RFA is not appropriate for every liver tumor (liver cancer). It generally provides better results for smaller tumors, particularly those less than 5 cm.

2. Transarterial Chemoembolization (TACE)

For liver tumors (cancers) that cannot be treated curatively through resection or other methods, interventional radiology is employed to deliver cancer-destroying medication directly to the tumor via the liver's blood vessels and to induce thrombosis within the vessels.

A catheter is inserted into a blood vessel and guided to the artery supplying the liver tumor. Chemotherapy medicine is then delivered directly to the tumor, along with material that blocks or reduces its blood supply. This can help destroy cancer cells and slow tumor growth.

The original source reports that this approach can stop or slow tumor growth in approximately 60% of cases, although results vary.

The effectiveness of TACE depends on:

  • Tumor size
  • Tumor location
  • Blood-vessel involvement
  • Whether the cancer has spread outside the liver
  • Liver function
  • The patient's overall condition

TACE is not appropriate for every liver tumor (liver cancer).

3. Ethanol Injection

Ethanol injection involves injecting ethanol (alcohol) directly into a liver tumor. The ethanol damages and destroys tumor cells.

4. Transarterial Radioembolization (TARE)

Transarterial radioembolization delivers tiny radioactive particles directly to the blood vessels supplying a liver tumor. The radioactive material damages cancer cells while limiting exposure to surrounding healthy liver tissue.

Medicines for Liver Cancer (Targeted Drug Therapy)

When liver cancer cannot be completely removed or treated with a potentially curative procedure, medicines may be used to slow the cancer and help patients live longer.

Examples include:

  • Lenvatinib
  • Sorafenib

Both of these medicines are targeted therapies that can help slow the growth and spread of certain liver cancers.

Immunotherapy: Treatments using Nivolumab and Pembrolizumab may result in tumor improvement or response in approximately 15% to 20% of patients.

Metastatic Liver Cancer (Secondary Liver Tumor)

When cancer has spread to the liver from another part of the body, the original (primary) cancer must first be identified and treated.

Possible treatments include:

  • Liver resection in carefully selected patients
  • Ablation in selected cases
  • Chemotherapy based on the type of primary cancer
  • Other systemic treatments appropriate for the original cancer

In general, liver transplantation is not used to treat metastatic liver cancer.

Preventing Liver Cancer

Important preventive measures include:

  • Take comprehensive measures to prevent hepatitis B and hepatitis C.
  • People with hepatitis B or C should receive appropriate medical evaluation and treatment.
  • Avoid alcohol and smoking.
  • Prevent and treat NASH and fatty liver disease by properly managing:
    • Diabetes
    • Dyslipidemia
    • Hypothyroidism
    • Obesity
    • Fatty liver disease
  • People with chronic hepatitis B or C should follow their doctor's recommendations for regular liver tests (ALT/AFP/PIVKA-II) and ultrasound examinations, often every six months, to detect liver cancer at an early stage.
  • Avoid unnecessary long-term use of hormonal medicines (birth-control pills) and anabolic steroids, and use them only under appropriate medical supervision.

Remember

Liver cancer is an increasing global health problem. Protecting the liver, preventing hepatitis, avoiding harmful alcohol use, maintaining a healthy weight, and treating chronic liver disease can help reduce the risk. Early diagnosis and timely, appropriate treatment can help save lives.