Liver Cancer: Symptoms, Screening, Treatment

Introduction

Liver cancer or hepatic cancer is cancer that originates in the liver. The liver can be affected by primary liver cancer, which arises in the liver, or cancer that forms in other parts of the body and then spreads to the liver. Liver tumors are discovered on medical imaging equipment (often accidentally) or present themselves symptomatically as an abdominal mass, abdominal pain, yellow skin, nausea, or liver dysfunction. The leading causes of liver cancer are cirrhosis due to hepatitis B, hepatitis C, and alcohol.

The U.S. Social Security Administration (SSA) has included Liver Cancer as a Compassionate Allowance to expedite a disability claim.

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There are as many as one in ten Asian and Pacific Islander Americans who have chronic Hepatitis B, and most of them are not aware that they are infected. One-fourth of hepatitis carriers will eventually die of liver cancer or liver failure. The two types of liver cancer include metastatic liver cancer, which starts in another part of the body, and primary liver cancer, which starts in the liver itself.

Hepatocellular Carcinoma

Hepatocellular Carcinoma, or HCC, is the most common form of liver cancer, and it is also a malignant form. HCC is not common in Europe and America, but it is one of the top three causes of death from cancer in many African and Asian nations. According to the World Health Organization (WHO), at least 550,000 people die yearly from HCC. Around 400,000 people who die from HCC live in the Pacific Rim and Southeast Asia. Many people in these nations live with chronic hepatitis B infections, some from birth and childhood, and this is a cause of eighty percent of the liver cancers people experience there. The remaining cases are caused by hepatitis C. The greatest health disparity between Caucasian Americans and Asian Americans, according to the Centers for Disease Control and Prevention, is liver cancer. Vaccination for hepatitis B could prevent eighty percent of these cases of liver cancer in Asian Americans, as well as Worldwide.

Symptoms of Liver Cancer

Most people who get liver cancer seem healthy and show no early signs or symptoms, so liver cancer is called 'The Silent Killer.' Liver cancer presents as small lumps that are nearly impossible to feel because of the shielded location of the liver, which is underneath the ribs. A person feels no pain until the tumor reaches a large size; sometimes, even large tumors do not cause pain or symptoms. In the latter stages of liver cancer, when tumors are large and liver function is impaired, a person may experience pain in the upper right abdomen. They may also lose weight and their appetite, and then finally develop a yellow color to their skin and eyes, as well as some abdominal swelling. Because of the difficulty in diagnosing liver cancer, until symptoms develop, the survival rate is quoted as three to six months. The only effective way to screen for an early diagnosis is to screen people who carry hepatitis B and people with cirrhosis of the liver, as well as people with hepatitis C regularly.

Liver cancer symptoms can include a lump or pain on the right side of your abdomen and yellowing of the skin. However, you may not have symptoms until the cancer is advanced. This makes it harder to treat. Doctors use tests that examine the liver and the blood to diagnose liver cancer. Treatment options include surgery, radiation, chemotherapy, or liver transplantation. Risk factors for primary liver cancer include;

• Heavy alcohol use
• Obesity and diabetes
• Having hepatitis B or C
• Having cirrhosis or scarring of the liver
• Having hemochromatosis, an iron storage disease

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Screening for Liver Cancer

Recognizing that people who have chronic hepatitis B infections and were infected early are at risk for liver cancer is critical. Men with a family history of liver cancer are at even greater risk. While people with chronic hepatitis B may develop liver cancer in their teens, the risk for liver cancer increases at age thirty. Regular liver cancer screening for chronic hepatitis B carriers is highly recommended once they age thirty.

Screening for liver cancer consists of a blood test that looks for Alpha-Fetoprotein (AFP) levels and should be performed every six months. An ultrasound should also be taken twice a year. Both tests must be done because either test alone can miss liver cancer. For example, the blood test for Alpha-Fetoprotein levels is increased in about sixty to seventy percent of people with liver cancer, so a blood test alone may not show an accurate result. Ultrasound can miss twenty percent of liver cancers that measure two centimeters, most notably if the images are hard to see in a cirrhotic liver. If a person has cirrhosis of the liver, they will need more frequent screening.

It is important to recognize that API chronically infected with hepatitis B who became infected early in childhood have a high risk of developing liver cancer. The risk is greater for men and those with a family history of liver cancer. Regular liver cancer screening in API hepatitis B carriers, although the role of Caucasian carriers who become infected later in life, is controversial. Although API carriers may develop liver cancer early in their teens, data from the US shows that the incidence of liver cancer increases around 30 years. A reasonable approach is to begin regular liver cancer screening for the API hepatitis B carriers starting at 30-40 years of age. This generally consists of a blood test for alpha-fetoprotein (AFP) level every six months and a liver ultrasound once a year (In Taiwan, ultrasound is recommended twice a year). Either test alone can miss the diagnosis. Alpha-fetoprotein is elevated in only 60-70% of liver cancer, so blood testing alone will miss 30-40% of liver cancers. Ultrasound can miss 20% of liver cancers measuring less than 2 cm, especially when the images are difficult to interpret in cirrhotic livers. Once the patient develops cirrhosis, more frequent screening is typically recommended.

Liver Cancer Evaluation

CT Scans and ultrasounds are two of the main diagnostic tools used in evaluating HCC, yet these tools can sometimes be too insensitive. Occasionally, a Biphasic Spiral CT Scan of the entire abdomen is required. The person is given an intravenous bolus of a contrast solution, and the fast spiral scanner is used to scan the liver at the arterial phase. Present tumors will typically take in contrast, allowing even small HCC to be detected, which could be missed using more conventional CT scan techniques or slower scanners.

Hypervascular lesions, which are enhanced at an arterial phase and fade at a venous phase of scanning, are characteristic of HCC. Liver tumors that have these characteristics in a person who is a chronic hepatitis B carrier or someone with cirrhosis and associated rising AFP levels over 500 is a person that is already diagnostic of HCC - a biopsy isn't needed. If a person's doctor is unsure whether they have a metastatic liver tumor, a fine needle biopsy might be something to pursue if it can be performed safely. A liver biopsy can be dangerous or even life-threatening due to bleeding if a person has cirrhosis; low platelet count, prolonged clotting time, and enlarged blood vessels with high pressure can make the process risky. For the most part, liver lesions are rare in people with cirrhosis.

HCC Treatment

Liver cancer treatment presents challenges compared to other forms of cancer because many people have damage from hepatitis to their livers in addition to cancer, resulting in different degrees of liver failure. The results are that many of these people have a liver in a precarious state, and treatment for liver cancer may do more harm than good. Treating some people with liver cancer presents doctors with the potential that their patient may die from the treatment for it before they die. This presents the doctor with individualized decisions for each person with liver cancer. The doctor must choose between the benefits of treatment for cancer and its effects on the quality of their patient's life.

Surgical Treatment of Liver Cancer

If a tumor in the liver is small or something that a surgeon calls 'resectable' and the patient's liver is in a condition that is seen as being fit for a resection, then surgical intervention to remove the tumor may be an option. Surgery to remove the tumor offers the best chance for long-term survival. With improved anesthetic management and surgical techniques, mortality risks have dropped to less than two-five percent. Most people can be discharged from the hospital within three or four days. Yet even though a tumor has been removed, a person is still at risk for a recurrence of liver cancer and needs to be followed very closely over a long-term period. In the first year after a surgery of this kind, the risk of a recurrence is greatest, and follow-up is of the highest importance.

Forms of Nonsurgical Treatment

People with liver cancer, but not surgical candidates, still have options through non-surgical treatments. There are several alternative treatment options available that can improve the quality of life for people with liver cancer and are presented to people on an individual basis. Chemotherapy is ineffective with liver cancer; it causes several side effects that mar a person's quality of life and usually don't prolong a person's survival. Liver tumors are hypervascular; the opportunity to cannulate the tributaries feeding the tumor is unique. A form of treatment called 'Intrahepatic Arterial Chemoembolization' or 'Chemo Infusion' (TACE or TAC) can be performed on unresectable lesions. The treatment can be performed every four months until the AFP levels have returned to normal or until there are no more appearances of Hypervascular Lesions. One of the benefits of this form of treatment is that it only requires an overnight stay, purely for observation, and that it is well-tolerated. TACE or TAC treatments have become associated with prolonged patient survival. Another good news is that people who have gone through TACE or TAC treatments may go on to become surgical candidates when they may not have been before.

Liver Transplants

If a person has unresectable liver medically or surgically, they may qualify for a liver transplant. In a report by the Asian Liver Center at Stanford University, it was reported that people who had a good response to TACE or TAC treatments also had excellent survival rates where liver transplants were concerned. People with more extensive tumors were at higher risk for an early recurrence and death after a liver transplant. People who have had a liver transplant must receive one or both of two things, Hepatitis B Immunoglobulin (HBIG) or Lamivudine, to prevent a re-infection of their new liver.

Treating liver cancer is still difficult, requiring several disciplines, a good understanding of them, surgery, transplants, radiology, and more. The only effective way to improve the outcome of liver cancer is through early diagnosis, which involves high-risk screening populations.

Liver Cancer Facts and Statistics

• Globally, as of 2010, liver cancer resulted in 754,000 deaths, up from 460,000 in 1990, making it the third leading cause of cancer death after lung and stomach.
• In 2012, it represented 7% of cancer diagnoses in men, the 5th most diagnosed cancer that year. Of these deaths, 340,000 were secondary to hepatitis B, 196,000 were secondary to hepatitis C, and 150,000 were secondary to alcohol.
• HCC, the most common liver cancer, shows a striking geographical distribution. China has 50% of HCC cases globally, and more than 80% of cases occur in sub-Saharan Africa or East Asia due to the hepatitis B virus. Cholangiocarcinoma also has a significant geographical distribution, with Thailand showing the highest rates worldwide due to liver fluke.