Cancer of the liver: Hepatocellular Carcinoma (HCC)
Cancers in the liver can be either primary (originating in the liver) or secondary (for example, from intestine). If it starts from liver cells it is called hepatocellular carcinoma or HCC. If it starts from cells of the bile ducts in liver then it is called as cholangiocarcinoma or if starts in the gallbladder, then it is known as gallbladder carcinoma. Cancers in the liver which have spread from another part of the body are usually named after the primary site (for example, liver metastases from a bowel primary).
HCC is the sixth most common cancer in the world. Liver cancer usually develops in a cirrhotic liver, where the cells have been destroyed and replaced by tough scar tissue. The viral infections like hepatitis C (HCV) and hepatitis B (HBV) are the main cause of liver cirrhosis. The other causes include fatty liver disease, auto-immune hepatitis. Liver cancer/HCC is more common in people over 50, and men are slightly more likely to develop it than women. Due to the high prevalence of HCV and HBV in Pakistan; liver cancer is increasingly being diagnosed in younger patients. Twenty percent of the liver cancers are found in a liver that does not have cirrhosis,.
DIAGNOSIS OF THE LIVER CANCER:
Clinical evaluation by the doctor to look for any signs of chronic liver disease, such as ascites (fluid in your abdomen) and/ or jaundice.
Blood tests: measure the level of liver enzymes in your blood because your liver may release more if there is a problem.
Check for hepatitis B and hepatitis C
Check for the amount of iron because cancer can cause you to become anemic.
Check for clotting levels because liver plays a role in blood clotting
Tumor markers in the blood: These are substances normally found in your blood, but if you have cancer they may be high. The tumor marker associated with HCC is called alpha-feta protein (AFP). However, the cancer does not always release this protein and there are also certain blood types which do not produce AFP.
CT scan: To get the size, location and number of cancers in the liver and also helps to plan the best possible treatment
MRI (magnetic resonance imaging): some cancers are more clearly visible on MR scan
PET scan: occasional done to look for the spread of cancer outside the liver
Angiography: This type of scan is not used often, but can help us take a better look at the blood vessels in and around your liver.
Biopsy: We can usually identify HCC using a combination of clinical assessment, blood tests and scans. But sometimes we have to do a biopsy; if the diagnosis is not clear. During biopsy a thin needle is inserted into your liver using a scan for guidance. A sample of tissue is taken to examine closely under a microscope.
TREATMENT OF THE LIVER CANCER:
There are different treatments and therapies available;
Liver transplantation: Liver transplantation be a potential cure for you. Not all patients are suitable candidates for liver transplantation. There are certain agreed international guidelines which are followed to decide whether you are a potential candidate for a liver transplant. These rules consider how large tumor is and whether it has spread outside the liver or invaded in to the blood vessels. If you are considered a as a suitable transplant candidate then you will undergo a full assessment. A big advantage of a liver transplant is that it not only potentially cures the liver cancer, it also cures the underlying liver disease.
Liver resection: Liver resection involves complete removal of the tumor. This treatment can offer potential cure in few patients. To have a resection, the tumor needs to be restricted to one lobe of the liver and there should be no sign of it spreading to blood vessels or other organs. In addition, the base line liver function needs to be good.
Ablation therapies: radio-frequency ablation (RFA), microwave ablation, cryoablation and percutaneous ethanol injection (PEI). These treatments involve the local destruction of cancer. The most commonly used local ablative therapies are radio-frequency ablation (RFA) and percutaneous ethanol injection (injecting pure alcohol into your tumor). These can also be used as a ‘bridge treatment’ while you await liver transplantation or as a treatment prior to liver resection surgery.
With RFA a thin needle is inserted into the tumor using a ultrasound or CT scan to guide us and then use radio-frequency or micro waves to damage the tumor tissue. You have this treatment under a local or general anesthesia.
With PEI, we inject a sterile and highly concentrated alcohol solution directly into the tumor to produce a similar effect to RFA.
Both techniques can control tumors long term if they are small in size and number. We can also use them together with other treatments as part of an overall plan to manage your condition.
Trans-arterial chemo-embolisation (TACE): TACE (or chemoembolisation) is generally used if the tumor is too advanced to consider a treatment that could potentially cure you. It may also be used as a ‘bridging treatment’ while you await liver transplantation or as a treatment prior to liver resection surgery.
In TACE a thin tube called a catheter is passed via a blood vessel in your groin to the blood vessels supplying the liver. A chemotherapy drug is injected directly into the tumor and block the blood vessel supplying it. The drug and the ischemia (blocking the blood supply to the tumor) damage the tumor tissue. TACE will not cure you but aims to shrink your tumor and stop it from getting bigger.
Trans-arterial embolization (TAE): TAE in exactly the same as TACE and with the same aim, but without the chemotherapy drug. It will be offered to you if it is not appropriate to use a chemotherapy drug.
Trans-arterial radioembolization (TARE): TARE in exactly the same as TACE and with the same aim, but with radioactive isotope (small radiation emitting particle) instead of chemotherapy drug. It will be offered to the patients if it is not appropriate to use a chemotherapy drug.
Drug treatment (Sorafenib): This is an oral medicine. It has been shown to prolong the lives of some patients with liver cancer in whom the liver cancer is advanced to cure. It is generally considered it if the tumor is too advanced for treatments that could potentially cure you and TACE is either ineffective or not possible for technical reasons. Sometime this drug is used as an adjunct treatment to TACE
Currently there are multiple other drugs being tested in research (trials). The medical community is constantly researching new ways to treat cancer. Clinical trials are a way of assessing and/or comparing new treatments and new combinations of treatment. If we think you may benefit from any trial treatment we will explain what it involves when we offer it to you.