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12 / 12 / 2017
Cancer Liver
 
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Liver cancer

 
DIGESTIVE SYSTEM

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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