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Clinical Description
Hepatocellular carcinoma is the most common type of primary liver cancer in adults. Each year, approximately 16,000 Americans develop this disease. The term "primary" means that the cancer begins in the liver. Metastatic liver cancer, which is cancer that begins in other parts of the body and spreads to the liver, is not discussed in this summary.
Hepatocellular carcinoma can begin as a single tumor that grows larger and eventually spreads beyond the liver. However, HCC may also begin in many spots throughout the liver and not as a single tumor. This is most often seen in people with liver cirrhosis and is the most common pattern seen in the United States.
Symptoms
There are often no symptoms in the early stages of the disease, making liver cancer difficult to diagnose until it is advanced. In some instances, jaundice (yellow skin and eyes, dark urine, pale stool), malaise, or a general feeling of poor health, loss of appetite, weight loss, fever, fatigue, bloating may be present. Abdominal pain or discomfort can also occur.
Risk Factors
Most patients with primary liver cancer have underlying liver disease related to alcohol intake, chronic viral hepatitis (B or C), or a metabolic abnormality that affects the liver. Males are twice as likely as females to develop liver cancer. Obesity has been linked to increased prevalence of liver cancer. People with a family history of liver cancer may be more likely to develop the disease.
How HCC is Diagnosed
Blood tests, diagnostic imaging, biopsy, or a combination of these may be used to diagnose and determine the extent (stage) of liver cancer.
The following tests and procedures may be used:
Blood Tests: Diagnosing liver cancer may begin with a blood test to measure the level of alpha fetoprotein (AFP), a protein produced by the liver. An elevated AFP level may be an indication of Hepatocellular carcinoma. Other cancers and certain noncancerous conditions, such as cirrhosis and hepatitis, may also increase AFP levels.
Diagnostic Imaging: Diagnostic imaging techniques can pinpoint the exact location of liver tumors and determine the condition of the liver and surrounding organs and blood vessels. Imaging studies help guide surgeons and Interventional Radiologists during therapeutic procedures. Among commonly used imaging studies are CT scan, MRI, and ultrasound. Additional studies to help determine the extent of cancer spread are PET scan and bone scan.
Biopsy: A biopsy usually is not needed to diagnose liver cancer, but in some cases, a sample of liver tissue is necessary. This sample may be obtained in one of several ways:
· A needle through the skin: a thin needle is inserted into the liver to remove a small amount of tissue. CT or ultrasound may be used to guide the needle.
· Laparoscopic surgery: The surgeon makes a few small incisions in the abdomen. A thin, lighted tube (laparoscope) is inserted through the incision. The laparoscope has a tool to remove tissue from the liver.
· Open surgery: The surgeon can remove tissue from the liver through a large incision.
Treatment Options for HCC at Tufts Medical Center
Treatment options for people with liver cancer are surgery (including a liver transplant), ablation, embolization, targeted therapy, radiation therapy and chemotherapy. A combination of treatments can be used. Your health care team can describe your treatment choices, the expected results of each, and the possible side effects.
The prognosis (chance of recovery) and treatment options depend on the following:
· The stage of the cancer (the size and location of the tumor, whether it affects part or all of the liver, or has spread to other places in the body).
· How well the liver is working.
· The patient’s general health, including whether there is cirrhosis of the liver.
At this time, liver cancer can be cured only when it's found at an early stage (before it has spread) and only if people are healthy enough to have surgery. For people who can't have surgery, other treatments may be able to help them live longer and feel better. For many patients, control of symptoms is just as important as treatment aimed at controlling the disease. When the tumor cannot be removed, palliative surgery may help prevent blockage of bile ducts and relieve symptoms.
Minimally Invasive Therapy
Cryosurgery: A treatment that uses an instrument to freeze and destroy abnormal tissue
Radiofrequency ablation: The use of a special probe with tiny electrodes that kill cancer cells. Sometimes the probe is inserted directly through the skin and only local anesthesia is needed. In other cases, the probe is inserted through an incision in the abdomen. This is done in the hospital with general anesthesia.
Surgery
The following types of surgery may be used to treat liver cancer:
· Partial Hepatectomy: Removal of the part of the liver where cancer is found. The remaining liver tissue takes over the functions of the liver.
· Total Hepatectomy and liver transplant: Removal of the entire liver and replacement with a healthy donated liver. A liver transplant may be done when the disease is in the liver only and a donated liver can be found. If the patient has to wait for a donated liver, other treatment is given as needed.
Radiation Therapy
Radiation therapy is a treatment that uses high-energy radiation to kill cancer cells or keep them from growing. Radiation therapy also may be used to help relieve pain from liver cancer that has spread.
Radiation therapy is given in different ways:
· External radiation therapy: The radiation comes from a machine and multiple shaped beams of radiation are aimed at the liver tumor. Using a technique called stereotactic body radiotherapy, or SBRT, the tumor can be precisely targeted with large doses of radiation, while safely sparing most of the unaffected liver. This is a non-invasive alternative available for treating HCC or metastatic liver tumors in some patients.
· Internal radiation therapy: The radiation comes from tiny radioactive spheres injected into hepatic artery. The spheres destroy the blood supply to the tumor.
Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Chemotherapy is not generally used to treat liver cancer because of a low response rate, but research is looking into novel ways to administer chemotherapy. The way the chemotherapy is given depends on the type and stage of the cancer being treated.
Chemotherapy drugs are usually given by vein, enter the bloodstream and travel throughout the body. The side effects of chemotherapy depend mainly on which drugs are given and how much. Common side effects include nausea and vomiting, loss of appetite, headache, fever and chills, and weakness. Many side effects may be relieved with medicine.
One type of chemotherapy is chemoembolization of the hepatic artery. The anticancer drug is injected into the hepatic artery through a catheter (thin tube). The drug is mixed with a substance that blocks the artery, cutting off blood flow to the tumor. Most of the anticancer drug is trapped near the tumor and only a small amount of the drug reaches other parts of the body. The blockage may be temporary or permanent, depending on the substance used to block the artery. The tumor is prevented from getting the oxygen and nutrients it needs to grow.
The patient is sedated for this procedure, but general anesthesia is not usually needed. This procedure can usually be done as an outpatient. Chemoembolization often causes abdominal pain, nausea, vomiting, and fever; however, medications can be used to help lessen these problems. Some people may feel very tired for several weeks after the treatment.
Targeted Therapy
People with liver cancer who can't have surgery or a liver transplant may receive drug therapy known as targeted therapy. Sorafenib (Nexavar) tablets were the first targeted therapy approved for liver cancer.
Targeted therapy slows the progression of liver tumors by affecting the tumor’s growth or blood supply. The drug is taken by mouth. Side effects include nausea, vomiting, mouth sores, and loss of appetite. Sometimes, a person may have chest pain, bleeding problems, or blisters on the hands or feet. The drug can also cause high blood pressure. Blood pressure will be monitored closely during the first 6 weeks of treatment.
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More information about Tufts Medical Center’s Hepatobiliary Cancer Program and our expert medical resources
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