Liver Cancer

Liver cancer : Liver cancer is the cancer arising from the liver cells. Commonest among these is Hepatocellular carcinoma which arises from hepatocytes. The other liver cancers that arise in the liver are Cholangiocarcinomas and secondaries (mean to say that the primary cancer is elsewhere but spread to the liver). The cholangiocarcinoma arise from the cholangiocytes or the cells that are part of the biliary system. The secondary liver cancers could be Adenocarcinomas or NeuroEndocrine Tumors (NET).

Hepatocellular carcinoma : Hepatocellular carcinomas (HCCs) originate in livers which face some form of insult. These are commonly seen in patients with cirrhosis of liver which could be of any cause (Hepatitis B, Hepatitis C, Alcohol), hemochromatosis, wilson’s disease, aflatoxins. Nowadays, we happen to see HCCs even in patients without cirrhosis but with long standing fatty changes in the liver. Nonalcoholic Steatohepatitis (NASH) is a form of liver condition which is mostly seen in patients with diabetes and or whose physical activity levels are low. NASH is a predisposing condition for liver cancer.

Unless regular screening is performed, these tumors will not be detected unless they are large in size or have metastases. Patients with HCC are asymptomatic and detected when screening is performed or incidentally detected. Most of the HCC in Indian scenario are detected in an advanced stage.

Patients with Hepatitis B and Hepatitis C without overt cirrhosis of liver can also harbor liver cancer. Smoking is an additional risk factor. The viruses by themselves are carcinogenic. Apart from liver cancer, Hepatitis B and Hepatitis C can predispose to Lymphomas (another form of cancer which affects the lymph nodes)

Extensive knowledge of the liver and its pathophysiological functioning is needed to make diagnosis, investigations and appropriate management algorithms.

Cholangiocarcinoma(CCA) : Cholangiocarcinomas arise from the cholangiocytes which are the cells of the bile ducts and biliary system. These tumors can arise both inside the liver(intrahepatic) and outside (Extrahepatic) along the biliary tract. Intrahepatic CCAs are asymptomatic till they are large and or have metastases. Patients usually present with weakness and loss of weight and appetite. Cholangiocarcinomas arising outside the liver along the biliary tract usually present as obstructive jaundice, pruritus (itching), loss of appetite and weight and pale colored stools.

Patients consuming alcohol and tobacco in any form are at high risk. No definite etiology can be ascertained in most.

Secondary cancer (Metastases) in the Liver: Cancers arising elsewhere in the human body can spread to the liver. These are called secondaries in the liver or liver metastases. Most commonly, the cancers of the large intestine and the rectum spread to the liver. Neuroendocrine tumors arising from special cells of the digestive tract form the second most common metastases to the liver. Cancers of the Stomach, Oesophagus, Pancreas, small intestine, breast, lymphomas are other organs from which the metastases are seen.

Evaluation: Comprehensive blood tests with Hemogram, Liver Function Tests, Renal Function Tests, Coagulation profile, Hepatitis B Surface Antigen, Antibodies to Hepatitis C, Serum Alfa Feto Protein (AFP), Serum CA 19-9 levels, Serum CEA levels, Computed Tomogram with four phases of the liver, and if required MRI and MRCP with Diffusion weighted images need to be performed. Diagnosis is a combination of Clinical history, laboratory values and radiological diagnosis. Biopsy will be performed as necessary.

Treatment options: In early stages, Surgical excision or removal is a curative option in most cases if they are ideal candidates. Alternatives are ablative procedures and palliative procedures. Quality of life is very important during decision making for treatment options.

HCC: Surgical resection, Microwave or Radiofrequency ablation, TACE (TransArterial ChemoEmbolization), TARE(TransArterial RadioEmbolization), Radiation with or without adjuvant therapy, Targeted therapy are options based on the stage and clinical situation

CCA: Surgical resection, Microwave or Radiofrequency ablation, TACE (TransArterial ChemoEmbolization), TARE(TransArterial RadioEmbolization), Radiation with or without adjuvant chemotherapy, Targeted therapy are options based on the stage and clinical situation.

Secondary cancer (Metastases):Solitary (single) or Oligo (less than 5-10) metastases of the liver usually are treated with a combination of treatment modalities. Chemotherapy followed by surgical resection or ablation, or simultaneous surgery of the primary and secondary followed by chemotherapy can be performed. In patients with poor performance status, decision making is based on a good communication between the family and clinicians.