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What you need to know about liver cancer

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Primary liver cancer is the fifth most common cancer worldwide and the third most common cause of death from cancer, resulting in more than 600,000 deaths per year.

Risk factors for primary liver cancer include hepatitis B, alcohol consumption, fatty liver and hepatitis C. In Bangladesh, an estimated 6% and 20% of the general population have chronic hepatitis B and fatty liver disease, respectively and hence, hepatitis B and fatty liver are the commonest causes of liver cancer in Bangladesh.

Our liver is an organ of magnificent reserve and abundance. We can even function well even if we lose 65-70% of the liver volume. Hence, in a patient with small liver cancer, the cancer would not have affected the liver function. Neither does liver cancer cause pain when they are small. In other words, while small liver cancers are mostly curable, they do not cause any symptoms.

Because liver cancer often develops in patients with risk factors, we advise patients with viral hepatitis B, hepatitis C, fatty liver disease and those who consume alcohol regularly to see their doctors every 6 monthly for screening of liver cancer. Screening of liver cancer consists of an ultrasound scan of the upper abdomen and a blood test called alpha fetoprotein (AFP).

When the liver cancer becomes bigger, it compromises liver function and patients start to lose weight, become jaundiced (having yellowing in the eyes), experience pain over the right upper abdomen. A cure is still possible at this stage but if the tumour continues to progress, it may spread, which would make it beyond cure.

Tests and diagnosis
Tests are divided into 3 categories:

1. Liver biopsy: Biopsy is the gold standard in diagnosing liver cancer. It involves putting a needle, under local anesthesia, through the skin and muscle into the liver to aspirate some tissues from the tumour. It is not routinely done as it causes pain and is also associated with more than 5% of the tumour spreading along the biopsy tract.

2. Blood tests: Alpha fetoprotein (AFP) is often elevated in patients with liver cancer. AFP is tested every 6 monthly among patients with hepatitis B or other liver diseases to screen for early cancer.

3. Imaging:
a) Ultrasonography (USG): Liver cancer often presents as a nodule on the ultrasonogram (USG). USG is cheap, readily available, and absolutely safe. Hence, it is the first line investigation for patients with liver diseases.

The disadvantage of USG is firstly it is operator-dependent. If the ultrsonographer is inexperienced or un-meticulous, liver tumour can be missed. Secondly, findings on USG are non-specific. USG cannot differentiate with certainty among liver cancer, liver blood cysts (hemangioma), or cancer spread from elsewhere.

b) Triphasic computed tomography (CT): Triphasic CT is an accurate way to confirm liver cancer, as liver cancer shows up certain characteristics of a liver cancer. CT also shows up other important features such as degree of liver cirrhosis, cancer spread to rest of abdomen. At the Liver Centre at Gleneagles Hospital, triphasic CT is the commonest way of confirming liver cancer.

c) Contrast enhanced magnetic resonance imaging (MRI): Contrast enhanced MRI is even more accurate than triphasic CT in confirming cancer and ascertaining degree of liver cirrhosis. However, MRI is more costly; so triphasic CT remains as the main mode of imaging studies. At the Liver Centre at Gleneagles Hospital, we reserve contrast enhanced MRI for cases where CT findings are inconclusive.

d) Positron emission tomography-computed tomography (PET-CT) scan: PET-CT scan can diagnosed unsuspected spread of liver cancer. But it is expensive so it is not performed routinely. Besides, small liver cancer can be missed by PET-CT. At the Liver Centre, PET-CT is mainly used in pre-liver transplant assessment, to search for cancer spread.

Can liver cancer be cured?
Yes, liver cancer can be cured. The two curative methods are surgical resection or liver transplant. But patients must be aware that both treatments are very operator-dependent. Good surgeons with vast experience and good supportive team members such as hepatologist, intensivist, and anesthetist, and solid infrastructure are essential to success.

1. Surgical resection: Surgical resection means taking out the cancer from rest of the liver. The cancer must be located at one part of the liver, and rest of the liver must be healthy.

2. Liver transplant: If the liver cancer occupies both lobes of the liver, or if the non-cancerous liver is not healthy, then surgical resection cannot be performed. Liver transplant means removing the whole liver, together with the cancer, followed by replacement with half a liver from a healthy donor. Liver transplant is the best treatment option for liver cancer when the cancer has not spread outside the liver. At our centre, 85% of liver cancer patients can be expected to liver beyond 5 years.

What are my alternative treatment options if I cannot undergo curative treatment?
Palliative treatment for liver cancer can control the tumour growth but very often, cancer cannot be completely eradicated and long term (more than 5 years) survival is unlikely.

1. Transarterial chemo-embolisation (TACE): During TACE, a thin catheter is inserted through an artery in the leg, into the blood vessel supplying the liver. The catheter is then carefully put to the blood vessel of the liver cancer. Chemotherapy is then injected directly into the cancer, and the blood vessel supplying the cancer is then blocked by chemicals. Part of the normal liver surrounding the cancer will also be damaged, hence patients could complain of pain and fever later. Besides, tumour more than 3 cm is unlikely to be completely destroyed.

2. Radiofrequency ablation (RFA): At RFA, a metallic rod is inserted through the skin into the cancer and the cancer is then burned by the rod. Again, normal liver adjacent to the cancer will also be damaged by the burning and big tumours are unlikely to be completely destroyed.

3. Oral chemotherapy, Sorafenib: Sorafenib (Nexavar®, Bayer Pharmaceutics) is the latest chemotherapy approved by the FDA in USA. It is taken orally and it is effective in prolonging life and improving quality of life. For patients with unresectable liver cancer or patients whose cancer has spread beyond the liver, Nexavar® is the best choice. However, even with this new medication, half the patients died within a year and survival beyond 2 years is unlikely. In addition, this medicine is very expensive, costing about US$5-7,000 every month.

What are my treatment options if I have liver cancer?
Many factors need to be considered, such as age and health status of the patient, degree of the liver disease and extent of the cancer.

But the most important consideration is the experience and skills of the doctors involved. All the treatments are operator dependent and the doctor in-charge has to make the decision to choose the best treatment for the individual patient. For example, at the Liver Centre at Gleneagles Hospital, all these treatment are available and we tailor the best treatment for the individual patient.

Liver cancer is a major cause of death worldwide. In Asia where hepatitis B is common, liver cancer is particularly common. Early liver cancers are curable but are also without symptoms. Patients with chronic liver disease must see their doctors regularly to screen for early cancer. Many treatment options are now available but the only curative options are surgical resection or liver transplantation. Lastly, the most important consideration for patients is the experience and skills of the managing doctor.

The writer is a Consultant Hepatologist and Gastroenterologist at Asian Centre for Liver Diseases and Transplantation, Singapore.