Liver cancer

Liver cancer is a form of cancer with a high mortality rate. Liver cancers can be classified into two types. They are either primary, when the cancer starts in the liver itself; or metastatic, when the cancer has spread to the liver from some other part of the body.

Primary liver cancer is a relatively rare disease in the United States, representing about 2% of all malignancies. It is, however, much more common in other parts of the world, representing from 10-50% of malignancies in Africa andparts of Asia. The American Cancer Society estimates that in 1998, at least14,000 new cases of liver cancer will be diagnosed. It will also cause roughly 13,000 deaths in the United States in 1998.

In adults, most primary liver cancers belong to one of two types: hepatomas,or hepatocellular carcinomas, which start in the liver tissue itself; and cholangiomas, or cholangiocarcinomas, which are cancers that develop in the bileducts inside the liver. About 90% of primary liver cancers are hepatomas. Inthe United States, about five persons in every 200,000 will develop a hepatoma; in Africa and Asia, over 40 persons in 200,000 will develop this form ofcancer. Two rare types of primary liver cancer are mixed-cell tumors and Kupffer cell sarcomas.

There is one type of primary liver cancer that usually occurs in children younger than four years of age and between the ages of 12-15. This type of childhood liver cancer is called a hepatoblastoma. Unlike liver cancers in adults,hepatoblastomas have a good chance of being treated successfully. Approximately 70% of children with hepatoblastomas experience complete cures. If the tumor is detected early, the survival rate is over 90%.

The second major category of liver cancer, metastatic liver cancer, is about20 times as common in the United States as primary liver cancer. Because blood from all parts of the body must pass through the liver for filtration, cancer cells from other organs and tissues easily reach the liver, where they canlodge and grow into secondary tumors. Primary cancers in the colon, stomach,pancreas, rectum, esophagus, breast, lung, or skin are the most likely to spread (metastasize) to the liver. It is not unusual for the metastatic cancerin the liver to be the first noticeable sign of a cancer that started in another organ. After cirrhosis, metastatic liver cancer is the most common causeof fatal liver disease.

The exact cause of primary liver cancer is still unknown. In adults, however,certain factors are known to place some individuals at higher risk of developing liver cancer. These factors include:

  • Male sex. The male/female ratio for hepatoma is 4:1.
  • Age over 60 years
  • Exposure to substances in the environment that tend to cause cancer (carcinogens). These include a substance produced by a mold that grows on rice and peanuts (aflatoxin);thorium dioxide, which was used at one time as a contrast dye for x rays of the liver; and vinyl chloride, used in manufacturing plastics.
  • Use oforal estrogens for birth control
  • Hereditary hemochromatosis. Hemochromatosis is a disorder characterized by abnormally high levels of iron storagein the body. It often develops into cirrhosis.
  • Cirrhosis. Hepatomasappear to be a frequent complication of cirrhosis of the liver. Between 30-70% of hepatoma patients also have cirrhosis. It is estimated that a patient with cirrhosis has 40 times the chance of developing a hepatoma than a person with a healthy liver.
  • Exposure to hepatitis B (HBV) or hepatitis C (HBC) viruses. In Africa and most of Asia, exposure to hepatitis B is an important factor; in Japan and some Western countries, exposure to hepatitis C is connected with a higher risk of developing liver cancer. In the United States,nearly 25% of patients with liver cancer show evidence of HBV infection. Hepatitis is commonly found among intravenous drug abusers.

The early symptoms of primary, as well as metastatic, liver cancer are oftenvague and not unique to liver disorders. The long lagtime between the beginning of the tumor's growth and signs of illness is the major reason why the disease has such a high mortality rate. At the time of diagnosis, patients are often tired, with fever, abdominal pain, and loss of appetite. They may look emaciated and generally ill. As the tumor grows bigger, it stretches the membrane surrounding the liver (the capsule), causing pain in the upper abdomen onthe right side. The pain may extend into the back and shoulder. Some patients develop a collection of fluid, known as ascites, in the abdominal cavity. Others may show signs of bleeding into the digestive tract. In addition, the tumor may block the ducts of the liver or the gall bladder, leading to jaundice. In patients with jaundice, the whites of the eyes and the skin may turn yellow, and the urine becomes dark-colored.

If the doctor suspects a diagnosis of liver cancer, he or she will check thepatient's history for risk factors and pay close attention to the condition of the patient's abdomen during the physical examination. Masses or lumps in the liver and ascites can often be felt while the patient is lying flat on theexamination table. The liver is usually swollen and hard in patients with liver cancer; it may be sore when the doctor presses on it. In some cases, thepatient's spleen is also enlarged. The doctor may be able to hear an abnormalsound (bruit) or rubbing noise (friction rub) if he or she uses a stethoscope to listen to the blood vessels that lie near the liver. The noises are caused by the pressure of the tumor on the blood vessels.

Blood tests may be used to test liver function or to evaluate risk factors inthe patient's history. Between 50-75% of primary liver cancer patients haveabnormally high blood serum levels of a particular protein (alpha-fetoproteinor AFP). The AFP test, however, cannot be used by itself to confirm a diagnosis of liver cancer, because cirrhosis or chronic hepatitis can also producehigh alpha-fetoprotein levels. Tests for alkaline phosphatase, bilirubin, lactic dehydrogenase, and other chemicals indicate that the liver is not functioning normally. About 75% of patients with liver cancer show evidence of hepatitis infection. Again, however, abnormal liver function test results are notspecific for liver cancer.

Imaging studies are useful in locating specific areas of abnormal tissue in the liver. Liver tumors as small as an inch across can now be detected by ultrasound or computed tomography scan (CT scan). Imaging studies, however, cannot tell the difference between a hepatoma and other abnormal masses or lumps of tissue (nodules) in the liver. A sample of liver tissue for biopsy is needed to make the definitive diagnosis of a primary liver cancer. CT or ultrasound can be used to guide the doctor in selecting the best location for obtaining the biopsy sample.

Chest x rays may be used to see whether the liver tumor is primary or has metastasized from a primary tumor in the lungs.

Liver biopsy is considered to provide the definite diagnosis of liver cancer.A sample of the liver or tissue fluid is removed with a fine needle and is checked under a microscope for the presence of cancer cells. In about 70% of cases, the biopsy is positive for cancer. In most cases, there is little riskto the patient from the biopsy procedure. In about 0.4% of cases, however, the patient develops a fatal hemorrhage from the biopsy because some tumors aresupplied with a large number of blood vessels and bleed very easily.

The doctor may also perform a laparoscopy to help in the diagnosis of liver cancer. A laparoscope is a small tube-shaped instrument with a light at one end. The doctor makes a small cut in the patient's abdomen and inserts the laparoscope. A small piece of liver tissue is removed and examined under a microscope for the presence of cancer cells.

Treatment of liver cancer is based on several factors, including the type ofcancer (primary or metastatic); stage (early or advanced); the location of other primary cancers or metastases in the patient's body; the patient's age; and other coexisting diseases, including cirrhosis. For many patients, treatment of liver cancer is primarily intended to relieve the pain caused by the cancer but cannot cure it.

Few liver cancers in adults can be cured by surgery because they are usuallytoo advanced by the time they are discovered. If the cancer is contained within one lobe of the liver, and if the patient does not have either cirrhosis,jaundice, or ascites, surgery is the best treatment option. Patients who canhave their entire tumor removed have the best chance for survival. Unfortunately, only about 5% of patients with metastatic cancer (from primary tumors inthe colon or rectum) fall into this group. If the entire visible tumor can be removed, about 25% of patients will be cured. The operation that is performed is called a partial hepatectomy, or partial removal of the liver. The surgeon will remove either an entire lobe of the liver (a lobectomy) or cut out the area around the tumor (a wedge resection).

Some patients with metastatic cancer of the liver can have their lives prolonged for a few months by chemotherapy, although cure is not possible. If the tumor cannot be removed by surgery, a tube (catheter) can be placed in the main artery of the liver and an implantable infusion pump can be installed. Thepump allows much higher concentrations of the cancer drug to be carried to the tumor than is possible with chemotherapy carried through the bloodstream. The drug that is used for infusion pump therapy is usually floxuridine (FUDR),given for 14-day periods alternating with 14-day rests. Systemic chemotherapy can also be used to treat liver cancer. The medications usually used are 5-fluorouracil (Adrucil, Efudex) or methotrexate (MTX, Mexate). Systemic chemotherapy does not, however, significantly lengthen the patient's survival time.

Radiation therapy is the use of high-energy rays or x rays to kill cancer cells or to shrink tumors. Its use in liver cancer, however, is only to give brief relief from some of the symptoms. Liver cancers are not sensitive to radiation, and radiation therapy will not prolong the patient's life.

Removal of the entire liver (total hepatectomy) and liver transplantation areused very rarely in treating liver cancer as of 1998. This is because very few patients are eligible for this procedure, either because the cancer has spread beyond the liver or because there are no suitable donors. Further research in the field of transplant immunology may make liver transplantation a possible treatment method for more patients in the future.

Liver cancer has a very poor prognosis because it is often not diagnosed until it has metastasized. Fewer than 10% of patients survive three years after the initial diagnosis; the overall five-year survival rate for patients with hepatomas is around 4%. Most patients with primary liver cancer die within several months of diagnosis. Patients with liver cancers that metastasized fromcancers in the colon live slightly longer than those whose cancers spread from cancers in the stomach or pancreas.

There are no useful strategies at present for preventing metastatic cancers of the liver. Primary liver cancers, however, are 75-80% preventable. Currentstrategies focus on widespread vaccination for hepatitis B; early treatment of hereditary hemochromatosis; and screening of high-risk patients with alpha-fetoprotein testing and ultrasound examinations.

Lifestyle factors that can be modified in order to prevent liver cancer include avoidance of exposure to toxic chemicals and foods harboring molds that produce aflatoxin. Most important, however, is avoidance of alcohol and drug abuse. Alcohol abuse is responsible for 60-75% of cases of cirrhosis, which isa major risk factor for eventual development of primary liver cancer. Hepatitis is a widespread disease among persons who abuse intravenous drugs.

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