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Liver cancer
Primary liver cancer also called
hepatocellular carcinoma or hepatoma may be the most
common cancer worldwide. It occurs with great frequency in Asia and
Africa and is becoming more common as a complication of chronic
Hepatitis C viral infection.
Far more common than primary liver cancer,
however, is cancer that occurs when tumors from
other parts of the body spread (metastasize) to the
liver. The liver is especially vulnerable to
invasion by tumor cells and with the exception of
the lymph nodes, is the most common site of
metastasis.
Because liver cancer is rarely discovered early,
the prognosis is often poor. Yet even in advanced
cases, treatment can help relieve symptoms and
improve quality of life. In addition to standard
treatments such as surgery, chemotherapy and
radiation, new and less invasive therapies may be an
option for some people.
But the most encouraging news about liver cancer
is that you can greatly reduce your risk by
receiving a vaccine that protects you from the
hepatitis B virus (HBV). Lifestyle changes can help
prevent other major causes of liver cancer, such as hepatitis C and
cirrhosis.
Signs and symptoms
Most people don't have signs and symptoms in the early stages of liver
cancer, which means the disease, may not be detected until it's quite
advanced. When symptoms do appear, they may include some or all of the
following:
-
Loss of appetite
and weight.
-
Abdominal pain,
especially in the upper right part of your abdomen, that may extend
into your back and shoulder.
-
Nausea and
vomiting.
-
General weakness
and fatigue.
-
An enlarged liver.
-
Abdominal swelling
(ascites).
-
Yellowing of your
skin and the whites of your eyes (jaundice) due to a buildup of
bilirubin the residue from the breakdown of red blood cells.
Normally, the liver processes bilirubin so that it can be eliminated
from your body. But liver disease can cause this substance to accumulate
in your blood, turning your skin and the whites of your eyes yellow and
your urine dark brown.
Causes
Weighing between 3 and 4 pounds and about the size of a football, your
liver is the largest internal organ in your body. It's located in the
upper right portion of your abdomen, beneath your diaphragm and above
your stomach. Your liver is divided into two main sections (lobes). Each
lobe is made up of thousands of smaller lobes (lobules), which are
connected to a network of ducts. The lobules are the functioning parts
of your liver and perform hundreds of tasks essential for your health
and well-being.
Your liver processes most of the nutrients absorbed from your small
intestine and determines how much sugar (glucose), protein and fat enter
your bloodstream. It also manufactures blood-clotting substances and
certain proteins and every day produces nearly a quart of bile a fluid
that helps your body digest fats.
Your liver also performs a vital detoxifying function by removing drugs,
alcohol and other harmful substances from your bloodstream. At any one
time your liver holds about 13 percent of your body's total blood, which
enters the liver through two vascular systems: the hepatic artery and
portal vein.
Because of the complexity of the liver and its exposure to so many
potentially toxic substances, it would seem especially vulnerable to
disease. But the liver has an amazing capacity for regeneration it can
heal itself by replacing or repairing injured tissue. In addition,
healthy cells will take over the function of damaged cells, either
indefinitely or until the damage has been repaired. Yet in spite of
this, your liver is prone to a number of diseases that can cause serious
or irreversible damage. One of these diseases is primary liver cancer.
In liver cancer some cells begin to grow abnormally. It's not completely
understood why this happens, but researchers believe that cancer starts
with damage to DNA the material that contains the instructions for
every chemical process in your body, including the rate of cellular
growth. DNA damage causes changes in these instructions. One result is
that cells may begin to grow out of control and eventually form a tumor
a mass of malignant cells.
Factors known to damage DNA in liver cells include:
-
hepatitis B and hepatitis C.
Worldwide, chronic infection with the hepatitis B virus (HBV) or
hepatitis C virus (HCV) is the most common cause of liver cancer.
Both types of hepatitis are highly contagious. HBV spreads through
unprotected sexual contact and shared contaminated needles. In
addition, a mother who has the virus can transmit it to her baby.
-
HCV is transmitted
primarily through transfusions with blood that hasn't been screened
for HCV, through contaminated needles used to inject drugs or, less
commonly, through needles used in tattooing or body piercing. In
some cases, HCV may be transmitted sexually.
-
Cirrhosis.
Alcohol abuse is the most common cause of
cirrhosis a process of scarring in the liver that may result from
several different conditions. Hereditary hemochromatosis which
causes excess iron to accumulate in your liver and other tissues
or chronic infection with HBV or HCV also can lead to cirrhosis.
-
Long-term
exposure to aflatoxins.
These highly toxic carcinogens are formed when certain crops or
foods are contaminated with the fungus Aspergillus flavus.
Aflatoxins can damage the p53 gene, which normally works to prevent
excessive cell growth. Although the risk from aflatoxins is slight, the toxins have been found in corn and corn
products, peanuts and peanut products, cottonseed, milk, Brazil
nuts, pecans, pistachios and walnuts. As a result, the Food and Drug
Administration has instituted a number of procedures to identify and
measure aflatoxins in the food supply.
-
Vinyl chloride
and thorium dioxide (Thorotrast).
Vinyl chloride is a chemical used to manufacture plastics.
Thorotrast was at one time given to people undergoing X-ray tests.
Both chemicals are known to play a role in the development of rare
cancers that begin in the liver's blood vessels (angiosarcomas or
hemangiosarcomas).
-
Arsenic.
Drinking water contaminated with arsenic, a known carcinogen,
increases your risk of liver cancer.
Types of primary liver cancer
The
various kinds of primary liver cancer and their causes include:
-
Hepatocellular
carcinoma.
This is the most common form of primary liver cancer in both
children and adults. It starts in the hepatocytes, the main type of
liver cell, but can spread in different ways as a single tumor
that slowly invades the rest of the liver or as cancer that
immediately spreads throughout the entire organ. The most common
causes of hepatocellular carcinoma include cirrhosis, hepatitis B or
C infection and ingestion of aflatoxin-contaminated food.
-
Cholangiocarcinoma.
This type of cancer begins in the small bile ducts within the liver.
You're at increased risk of developing cholangiocarcinoma if you
have gallstones or ulcerative colitis. Certain liver parasites
commonly found in parts of Southeast Asia also may contribute to
this type of cancer.
-
Hepatoblastoma.
This rare type of liver cancer affects children younger than 4 years
of age and may be caused by an abnormal gene. Fortunately, most
children with hepatoblastoma can be successfully treated.
-
Angiosarcoma or
hemangiosarcoma.
These rare cancers begin in the blood vessels of the liver and are
associated with exposure to industrial chemicals such as vinyl
chloride or the drug thorium dioxide (Thorotrast). They are much
less likely to occur today. Medical use of Thorotrast was
discontinued nearly 50 years ago, and workers are now better
protected from exposure to carcinogenic chemicals.
Metastatic cancer
Most cancer found in the liver has spread there
from another part of the body. Rather than being referred to as liver
cancer, this type of cancer is usually named after the organ where it
originated and is further described as "metastatic." For instance,
cancer that has spread to the liver from the colon is referred to as
metastatic colon cancer.
Metastatic cancers form when malignant cells detach from the primary
cancer and travel through the body in the circulatory or lymphatic
system. Because the liver is close to a number of significant organs
including the pancreas, gall bladder, stomach, colon, breasts and lungs
and because the liver is richly supplied with blood, it's especially
vulnerable to metastatic tumors. Secondary liver cancer occurs in more
than 75 percent of all people with advanced cancer in other organs.
Types of benign tumors
Noncancerous (benign) tumors also can develop in the liver. They
include:
-
Hemangioma.
This is the most common type of benign liver tumor. It affects the
liver's blood vessels and usually results from a malformation of
tissue during fetal development. Most hemangiomas of the liver don't
cause signs or symptoms and don't need treatment.
-
Hepatic
adenoma.
This benign tumor originates in the hepatocytes the main type of
liver cell. In most cases, hepatic adenomas don't cause signs or
symptoms, but occasionally you may experience abdominal pain, a mass
in the abdomen or blood loss. You're more likely to develop this
type of benign tumor if you use birth control pills, but simply
stopping the pill often causes the tumor to shrink.
-
Focal nodular
hyperplasia.
This tumor is a combination of several types of cells, including
hepatocytes, bile duct cells and connective tissue. Like other
benign tumors, it's more common in women than in men and usually
doesn't cause signs or symptoms.
Risk factors
Liver cancer can affect people of all ages and races, but certain
factors may increase your risk, including:
-
Sex.
Men are two to three times as likely to develop liver cancer as are
women.
-
Race.
Overall, Asian have the highest rate of liver cancer. Black and
Hispanic also have higher
rates than do whites.
-
Chronic
infection with HBV or HCV.
Infection with hepatitis B or C is by far the most important risk
factor for liver cancer. Worldwide, HBV infection causes 80 percent
of cases of hepatocellular carcinoma.
-
Having
cirrhosis.
This progressive and irreversible condition causes scar tissue to
form in your liver and increases your chances of developing liver
cancer.
-
Exposure to
aflatoxins.
For people living in Africa and parts of Asia, consuming foods
contaminated with aflatoxins greatly increases the risk of liver
cancer.
-
Excessive
alcohol consumption.
Consuming more than a moderate amount of alcohol can lead to
irreversible liver damage and increase your risk of liver cancer.
Moderate consumption is defined as no more than two drinks a day for
men and one for women. A drink is one 4- to 5-ounce glass of wine,
12 ounces of beer or a 1.5-ounce shot of liquor.
-
Smoking.
Smoking tobacco of any kind makes it more likely that you'll develop
liver cancer.
-
Exposure to
vinyl chloride, thorium dioxide (Thorotrast) and arsenic.
Exposure to any of these chemicals can contribute to liver cancer.
Screening and diagnosis
No completely accurate screening test for liver cancer exists. Doctors
sometimes use a blood test that checks for the presence of
alpha-fetoprotein (AFP) a type of protein not normally found in adults
to screen people at high risk of the disease. Unfortunately, the test
isn't perfect. Not all malignant liver tumors produce AFP, and those
that do may be advanced by the time protein levels become elevated. In
addition, other types of cancer and even some noncancerous liver
diseases can raise AFP levels.
Although AFP screening can detect small tumors in some people, most
liver cancer isn't diagnosed early. That's because symptoms usually
don't appear until late in the disease and because liver cancers grow
quickly. The most common type of liver cancer, hepatocellular carcinoma,
doubles in size every four months. Diagnosis is also difficult because
the effects of some liver tumors may resemble those of other medical
conditions.
If you experience any of the symptoms of liver cancer, such as
unexplained weight loss, persistent abdominal pain or swelling or
jaundice, see your doctor as soon as possible. He or she will interview
you about your medical history and perform a physical exam. Your doctor
will also likely recommend one or more of the following tests:
-
Ultrasound (ultrasonography).
This noninvasive test uses sound waves to produce a picture of
internal organs, including the liver. Ultrasound is painless and
usually takes less than 30 minutes. While you lie on a bed or
examining table, a wand-shaped device (transducer) is placed on your
body. It emits sound waves that are reflected from your liver and
transformed into a computer image. Ultrasound is especially good at
providing information about the shape, texture and makeup of tumors.
-
Computerized
tomography (CT) scan.
This test uses X-rays to produce cross-sectional images of your
body. You may also have a variation of the test known as a CT
angiogram in which contrast dye is injected into one of your
liver's arteries. X-rays then track the dye as it flows through the
blood vessels in your liver. A CT angiogram, which may take up to an
hour to perform, can provide detailed information on the number and
location of liver tumors. The test's greatest risk is a possible
allergic reaction to the contrast dye. It can also be uncomfortable
because a tiny catheter is inserted into an artery in your groin and
threaded into an artery leading to your liver.
-
Magnetic
resonance imaging (MRI).
Instead of X-rays, MRI creates images using a magnetic field and
radio waves. Sometimes a contrast dye also may be used. The test can
take from 15 minutes to an hour. You may find an MRI more
uncomfortable than a CT scan. That's because you will likely be
enclosed in a tube that is quite confining and because the machine
generates a thumping noise many people find disturbing. Headphones
or earphones can help with the noise, and a more open scan may be an
option if you have claustrophobia.
-
Liver scan.
In this imaging test, small amounts of radioactive tracers
(radioisotopes) are attached to various substances and injected into
a vein in your arm. A special camera (gamma camera) then records
images of the radioisotopes that have been taken up by your liver. A
liver scan can reveal damage caused by cirrhosis or hepatitis as
well as the presence of primary or secondary cancer.
-
Liver biopsy.
In this procedure, a sample of tissue is removed from your tumor and
examined under a microscope. It's the only way to learn whether a
tumor is malignant. Your doctor may use a thin needle or a tiny,
lighted instrument (laparoscope) to obtain the sample. If the tumor
is small, an ultrasound or CT scan is often used to help pinpoint
the area to be biopsied. Needle or laparoscopic biopsies are
relatively simple procedures requiring only local anesthesia. Risks
include bruising, bleeding and infection.
-
Blood tests.
If tests reveal that you have liver cancer, your doctor may perform
additional blood tests to check the condition of the liver tissue
not affected by cancer. This information may play a role in
determining the best treatment for you.
Staging tests
Staging tests help determine the size and location of cancer and whether
it has spread. They are the most important factor in determining your
treatment options. Liver cancer may be staged in different ways. One
method uses the numbers I through IV, with higher numbers indicating
cancers that are more advanced. A stage I tumor is small and confined to
one lobe of the liver. By stage IV, several tumors may exist in
different lobes, or malignant cells may have spread to other parts of
the body.
Doctors may also use the following stages to describe primary liver
cancer in adults:
-
Localized
resectable.
At this stage, the tumor is confined to one lobe of your liver and
can be completely removed in an operation. The term resectable
refers to a tumor that can be surgically removed.
-
Localized
unresectable.
The cancer is found in only one part of your liver, but can't be
completely removed because either the noncancerous portion of your
liver isn't healthy or the cancer is located near your liver's main
arteries, veins and bile ducts.
-
Advanced.
This stage of cancer has spread throughout the liver or to other
parts of your body, particularly the bones or lungs. You're more
likely to have advanced cancer if you also have cirrhosis or chronic
hepatitis.
-
Recurrent.
This means the cancer has returned to your liver or to another part
of your body after it has been treated.
Stages of primary cancer in children
Doctors use the following stages to describe childhood liver cancer:
-
Stage I.
At this stage, the cancer can be removed with surgery.
-
Stage II.
Most stage II liver cancers can be removed with an operation, but
microscopic amounts of cancer remain in the liver following surgery.
-
Stage III.
At this stage, some of the cancer may be surgically removed, but
some will remain in the lymph nodes or abdomen.
-
Stage IV.
This stage cancer has spread to other parts of the body.
-
Recurrent.
This means the cancer has returned after it has been treated. It may
recur in the liver or in another part of the body.
Complications
People with liver cancer may sometimes experience liver failure, which
occurs when the liver is no longer able to function adequately. It
usually develops when there is extensive damage to liver cells. The
kidneys may also fail, losing their ability to filter fluids and waste
and causing dangerous levels of these substances to accumulate in the
body. Perhaps the most serious complication, however, is the spread of
cancer to other organs.
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