Liver Cancer

When other cancers are present in the body (such as breast, colon, etc), some tumor cells sometimes "break off" and travel through the body. The migration of these cells often find themselves producing cancer in the liver. This migration of cancerous cells is referred to as Metastasis.
 

There are two categories of cancers that can develop - Benign and malignant. In general Benign Tumors (referred to as Hemangioma) are not dangerous and often do not cause symptoms. However, sometimes they can be the source of bleeding, or abdominal pain and may also present a risk of rupturing. In cases where there are symptoms, a physician may often elect to have surgery to remove it.

Another form of "tumor-like" growth is called Focal Nodular Hyperplasia or FNH. This benign grow is difficult to distinguish from actual tumors and are often removed surgically.

Malignant tumor cells are abnormal and grow uncontrollably without order. Unlike Benign tumors, malignant tumors require a more aggressive treatment approach. The most common form of malignant liver cancer in adults accounting for approximately 75% is Hepatocellular carcinoma or HCC and is also referred to as hepatoma.



Diagnosis

Diagnosis of primary liver cancer is generally made using blood tests, diagnostic imaging, surgical biopsy or laparoscopy, or in combination. The alpha-fetoprotein blood test and ultrasound imaging of the liver are also used to screen high-risk populations (including those with hepatitis B and hepatitis C infections) for the disease. Since the risk of liver cancer is relatively low for healthy individuals, these tests are not used to screen the general population.

The alpha-fetoprotein (AFP) blood test measures the level in the blood of a certain protein produced by the liver. Elevated levels of AFP can be an indication of hepatocellular carcinoma, the most common type of primary liver cancer. If liver cancer is suspected, other blood tests are done to measure liver function. These tests can help doctors determine the condition of the liver. Since successful treatment for liver cancer involves removing a substantial part of the normal liver tissue in addition to the cancer, other treatments might be used in people with blood tests that indicate a high degree of liver disease.

Diagnosing hepatocellular cancer can be difficult since this part of the body is complex and includes several organs and major blood vessels.

As non-invasive diagnostic imaging techniques have become more sophisticated, they can be used to gather important information about a newly diagnosed tumor -- including its exact size and density. These techniques can also be used to gauge how well a tumor will respond to treatment.

In some cases, diagnosis is performed invasively, by removing a small amount of tissue for a biopsy, or by laparoscopy (insertion of a small tube with an attached camera into the abdomen to survey the cancer site). Laparoscopy can also be used to remove a sample of tissue for biopsy.

Non-invasive Diagnostic Imaging Techniques

CT (computed tomography) scanning
Useful for determining the extent of tumor growth within the gallbladder or bile duct. It can also be used to tell whether tumor cells have spread into the lymph nodes or other nearby parts of the body.

MRI (magnetic resonance imaging)
Can be used to determine if a tumor can be surgically removed. It shows the extent of tumor growth within the gallbladder or bile duct, and reveals whether the tumor has invaded any blood vessels.

Magnetic resonance cholangiopancreotography (MRCP)
Gives a detailed examination of the bile ducts. It is useful for determining the stage of a tumor in the bile duct.

Ultrasound
Useful for detecting the location and number of tumors as well as tumor involvement with blood vessels (tumors situated close to blood vessels may be more difficult to remove). It can also be used to distinguish a cancerous mass from a benign tumor.

Invasive Diagnostic Techniques

Biopsy
A small amount of tissue is removed from a specific area of the body so it can be examined more closely.

Endoscopy
The interior lining of a body cavity, such as the esophagus, stomach, bile duct, or colon, is examined using a device called an endoscope.

Laparoscopy
Allows for the examination of the abdominal cavity and its contents. A tube with an attached camera (called a laparoscope) is passed through an incision made in the abdominal wall.

Cholangiography
A needle is inserted into the bile ducts within the liver. The ducts are injected with dye so they can be seen more clearly.


Treatment
 

Surgery
 

Most primary liver cancers are best treated by surgery to remove the diseased portion of the liver. Until the early 1980s, surgery to remove primary liver tumors was rarely done. But now, highly complex liver operations are performed at Memorial Sloan-Kettering with great frequency, success, and safety. Researchers have recently shown that hepatobiliary surgery can also be successfully performed in elderly patients. These patients can have outcomes comparable to those of younger patients, so age alone should not be the determining factor when deciding upon surgery in patients over the age of 70.

Operating on the liver can be difficult for several reasons. Many of the major blood vessels leading to and from the heart pass behind or through the liver, so in essence, the liver is "attached" to the heart. Also, the anatomy of the liver is not always obvious from the surface. The organ is large, dense, and delicate, and covered in part by the rib cage. It bleeds profusely when injured, and it tears easily. Since hepatocellular cancer is relatively rare in the United States, many surgeons may not be experienced in performing liver resections.

One unusual fact about the liver is that it has the capacity to regenerate, or grow anew. For example, up to 80 percent of the organ can be surgically removed and within several weeks, the liver will have entirely regenerated itself. If one lobe -- along with its associated blood vessels -- is surgically removed, the remaining lobe will compensate for the loss. New technique which stimulates regeneration before surgery are under evaluation. The technique is called pre-operative portal vein embolization. If doctors feel the portion of the liver remaining after resection would be too small to allow for a good outcome, they can shift the blood supply to the normal portion of the liver before the resection is done. That normal area grows larger, and when it reaches sufficient size, the resection can be performed.

Some doctors are also developing new liver sparing surgical techniques that leave more of the normal liver intact, aid regeneration, and result in less blood loss. Recent improvements in anaesthesia have also led to less blood loss during surgery. This results in a quicker and less complicated recovery.

Some surgeons are also pioneering laparoscopic surgical methods. In this type of surgery, a small incision is made and a tube with a small camera on its end is passed through the abdominal wall. This technique is sometimes used to stage or determine the extent of a cancer, which eliminates the need for exploratory surgery in some patients. It has also been used to biopsy cancers (by removing a small piece of the cancer to examine further) or, in selected cases, to remove part of the liver (partial hepatectomy). Since the procedure is less invasive than traditional surgery, recovery is quicker.

When the liver is burdened with another disease aside from the cancer, surgery is complicated and sometimes impossible. A disease such as cirrhosis dramatically weakens the liver and often leaves it permanently damaged, with limited regenerative capacity. A patient with a liver hampered by both cirrhosis and a tumor is more likely to be treated with a method other than surgery. Some of these treatments are listed below.

Ablative Therapies


Ablation uses a chemical agent or electrical current to destroy a tumor. Ablative procedures can be performed both percutaneously (through the skin without an incision) or during surgery. Procedures which can be performed percutaneously include cryosurgery (freezing and killing the tumor cells), radiofrequency (RF) ablation, alcohol ablation, and embolization (blocking the blood supply to a tumor). These therapies can be very effective, but they are usually intended to control cancer rather than cure it.

Ablative therapies can be used alone or in combination with surgical removal of a tumor. For example, a patient with hepatocellular cancer who is not a candidate for surgery may first be treated with embolization to shrink the tumor so that it is small enough to make another form of ablative therapy or surgery possible.

In cryosurgery, a needle is introduced into the middle of a tumor to freeze it. Residual, or remaining, tumor cells can be left behind, making this method less effective than surgery. It can also be difficult to keep the tumor at temperatures low enough to completely freeze it, since tumors are often near large blood vessels. Nevertheless, cryosurgery can be a very effective way to control liver tumors.

Radiofrequency ablation is the opposite of cryosurgery. Rather than freezing the tumor, physicians use radio waves to heat it up to such a high temperature that the tumor is destroyed. Radiofrequency ablation is effective, but can only be used for smaller tumors. This therapy is not curative; it is intended to control tumor growth.

Alcohol ablation, or PEIT (percutaneous ethanol injection treatment), is a way to administer toxins directly to a tumor. It is quite effective for small tumors of less than five centimeters. This treatment is usually selected for patients who are not candidates for surgery.

Radiation Therapy

Radiation therapy is used in selected cases to help control tumors. Radiation oncologists use new techniques to focus the radiation beam on the tumor and spare the normal liver from injury.

Embolization

Embolization is a procedure that cuts off the blood supply to the tumor. Physicians pack a branch of the hepatic artery -- the main artery that carries blood to the liver -- with tiny plastic particles, cutting off most of the blood flow and depriving the tumor of life-giving oxygen.

Rehabilitation Therapy

Rehabilitation therapy plays a role in improving the function and quality of life of patients with liver cancer. Patients are often given valuable techniques to increase mobility without increasing pain and discomfort and teach energy-conserving techniques to help patients decrease the fatigue they may experience during hospitalization and medical treatments. Occupational therapists educate patients about the changes they may experience during and after treatment and about adaptive equipment and compensatory techniques that can increase their independence during their daily routines. They also evaluate and treat patients' ability to perform basic daily activities such as bathing, dressing, and moving around their environment.