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Liver Cancer

Dr. Deepak Chhabra

MS. (Bom), DNB, M.R.C.S. (Edin. UK)

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FAQ

  1. What is cancer
  2. Cancer Risk factors
  3. Stages of Cancer
  4. Early signs of Cancer
  5. Early detection of Cancer

The world knows this man as a consultant oncosurgeon with vast experience in Gastrointestinal and Hepatobiliary-Pancreatic cancers,who specializes in stapled anastomosis for bowel cancers and sphincter saving resections for rectal cancers. In short, he is the person to be contacted for all kinds of cancer related cases.

Richa AgrawalPancreatic Cancer

Thank you Dr Deepak for all you have done for mum, for putting the smile back of her face. I wish you success in all your future endeavors and know that you will continue to touch peoples lives and help them be healthy - the way you have done for my mum….. and me.

Nicola MathiasStomach Cancer

For 67years I've led a very healthy life and thank the "Almighty" for it. However as I said all good things come to an end some time and so be it. Out of the blues was detected the dreadful illness "C" which had shown no signs or symptoms whatsoever..... Time had now come for me to choose a very efficient Oncologist for my treatment.

Patient

My mother was diagnosed of colon cancer, and I was recommended to see Dr Deepak Chhabra for consultation.
The first impression of Dr Chhabra was… he is so young! But after consulting him we realized his level of experience and there was a sense of confidence he spilt over us.We knew we could trust him.....

Neelu GroverColon Cancer
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What is Liver?

The liver is the largest organ inside your abdomen. It’s found behind your ribs on the right side of your body. The liver does important work to keep you healthy:

  • It removes harmful substances from the blood.
  • It makes enzymes and bile that help digest food.
  • It also converts food into substances needed for life and growth.

The liver gets its supply of blood from two vessels. Most of its blood comes from the portal vein. The rest comes from the hepatic artery.

About

What is Liver Cancer?

Cancer develops when healthy cells in the liver become abnormal and grow too quickly. The abnormal cells form a mass in the liver called a tumor. When a tumor has the ability to spread to other parts of the body, it is called malignant (cancer). Most primary liver cancers begin in hepatocytes (liver cells). This type of cancer is called hepatocellular carcinoma or hepatoma.

It is also common for cancer to spread to the liver from the intestines, lungs, breasts, or other parts of the body. When this happens, the disease is not liver cancer instead it is called metastasis. In this case, the cancer in the liver is named for the organ or the tissue in which it began. For example, colon cancer that spreads to the liver is metastatic colon cancer. It is not liver cancer. People with metastatic cancer in the liver have different treatment options than those with primary liver cancer. Treatment of such metastatic cancers depends mainly on where the cancer started.

Causes

What are the causes of Liver cancer?

When you get a diagnosis of cancer, it’s natural to wonder what may have caused the disease. Doctors can’t always explain why one person gets liver cancer and another doesn’t. However, we do know that people with certain risk factors may be more likely than others to develop liver cancer. A risk factor is something that may increase the chance of getting a disease. Studies have found the following risk factors for liver cancer:

  • Infection with hepatitis B virus (HBV) or hepatitis C virus (HCV): Liver cancer can develop after many years of infection with either of these viruses. Around the world, infection with HBV or HCV is the main cause of liver cancer. HBV and HCV can be passed from person to person through blood (such as by sharing needles) or sexual contact. An infant may catch these viruses from an infected mother. Although HBV and HCV infections are contagious diseases, liver cancer is not. You can’t catch liver cancer from another person.
  • Heavy alcohol use: Having more than two drinks of alcohol each day for many years increases the risk of liver cancer and certain other cancers. The risk increases with the amount of alcohol that a person drinks.
  • Aflatoxin: Liver cancer can be caused by aflatoxin, a harmful substance made by certain types of mold (fungus). Aflatoxin can form on peanuts, corn, and other nuts and grains. In parts of Asia and Africa, levels of aflatoxin are high.
  • Iron storage disease: Liver cancer may develop among people with a disease that causes the body to store too much iron in the liver and other organs.
  • Obesity and diabetes: Studies have shown that obesity and diabetes may be important risk factors for liver cancer. The more risk factors a person has, the greater the chance that liver cancer will develop. However, many people with known risk factors for liver cancer don’t develop the disease.

All the above risk factors damage the liver cells and replace it with scar tissue where in the liver becomes nodular and bumpy. This state of liver is called CIRRHOSIS


Almost all cases of liver cancer occur in people who first had cirrhosis, usually resulting from hepatitis B or C infection, or from heavy alcohol use.

Symptoms

What are the common symptoms of Liver cancer?

Early liver cancer often doesn’t cause symptoms. When the cancer grows larger, people may notice one or more of these common symptoms:

  • Pain in the upper abdomen on the right side
  • A lump or a feeling of heaviness in the upper abdomen
  • Swollen abdomen (bloating)
  • Loss of appetite and feelings of fullness
  • Weight loss
  • Weakness or feeling very tired
  • Nausea and vomiting
  • Yellow skin and eyes, pale stools, and dark urine from jaundice
  • Fever

If you have not been diagnosed with liver cancer and are just looking through this site, please be aware that most symptoms of liver cancer are nonspecific and can be caused by several different problems. It is important to see your doctor if any of these symptoms occur and do not resolve with simple management.

Swelling of the abdomen can happen in liver cancer for 2 reasons. The liver itself can get bigger from the growing cancer. This can cause swelling over the right side of your abdomen. Or you can have generalized swelling of the abdomen caused by a build up of fluid. This is called ascites.

The fluid builds up because the liver is congested. This squeezes the blood vessels inside the liver and the blood that normally flows through it gets backed up in the veins. The pressure in these veins increases and forces fluid to leak from the veins into the abdomen. The veins may grow in size so much that they can be seen underneath the surface of the skin. If the liver is not able to make blood proteins as it should, fluid also tends to leak out of the veins and into the abdominal cavity.

Formation of fluid in the tummy is not a good sign esp when it is associated with cancer. It indicates that the liver is not functioning to its optimum and the patient is landing into liver failure.

Tests

What tests are carried out by a doctor to diagnose liver cancer?

This section lists common tests. It is not necessary for all the tests to be performed and your doctor will select the tests that will provide maximum information about the tumor/ disease.

Physical examination

Your doctor will check your abdomen to for any lumps or changes in their shape or size of liver, spleen, and other nearby organs. Your doctor also checks for ascites, an abnormal build-up of fluid in the abdomen. Also, your skin and eyes may be checked for signs of jaundice.

Ultrasound of the abdomen

This test may be done as one of the initial tests to find out if there is really some problem with the liver and it also gives some idea about its texture.

Computerised tomography (CT) scan

A CT scan is a type of x-ray that gives a picture of organs and other structures (including any tumours) in your body. It is used to see more details of a cancer and its relation to the surrounding organs in your body. It also gives information related to cancer spread.

Magnetic resonance imaging (MRI)

This test is like a CT scan, but it uses magnetism instead of x-rays to build up pictures of the organs in your abdomen. Like a CT scan, MRI is painless and the magnetism is harmless.

Blood Tests

Apart from haemoglobin and liver function tests, a specific tumor marker test called AFP (alphafetoprotein) will also be done. This blood test looks for a substance (AFP) that is produced in high quantities by liver cancer cells. You may also be checked for markers for Hepatitis B and C viral infections. (HBsAg and Anti HCV). Another blood test called Ca19-9 may be done if the doctors suspect that the tumor is arising out of the bile ducts or gallbladder and not the liver cells.

Tumor Biopsy

A biopsy means a diagnosis made under a microscope by a pathologist using a small bit of tissue removed from a suspicious area or lump that is found to be abnormal. A biopsy is not always needed to diagnose liver cancer, but in some cases, the doctor may remove a sample of tissue that can then be examined under a microscope.

The doctor may obtain tissue in one of several ways:
  • A needle through the skin: (FNAC) The doctor inserts a thin needle into the liver to remove a small amount of tissue. CT or ultrasound may be used to guide the needle.
  • Laparoscopic surgery: The surgeon makes a few small incisions in your abdomen. A thin, lighted tube (laparoscope) is inserted through the incision. The laparoscope has a tool to remove tissue from the liver.
  • Open surgery: The surgeon can remove tissue from the liver through a large incision.

Treatment

What is the treatment of liver cancer?

Many years of treating cancer patients and testing treatments in clinical trials has helped doctors know what is likely to work for a particular type and stage of cancer. You will be advised on the best treatment for your cancer. This will depend on the type of cancer you have, where it is and how far it has spread and your general health.

Treatment options for people with liver cancer are surgery, ablation, chemo-embolization, targeted therapy and radiation therapy. Often a combination of treatments may be required.

The treatment that’s right for you depends mainly on the following:

  • The number, size, and location of tumors in your liver
  • How well your liver is working and whether you have cirrhosis
  • Whether the cancer has spread outside your liver?

At this time, liver cancer can be cured only when it’s found at an early stage (before it has spread) and only if people are healthy enough to have surgery. For people who can’t have surgery, other treatments may be able to help them live longer and feel better.

Surgery

Surgery For Liver Cancer

Surgery is the best option for people with an early stage of liver cancer. A person with liver cancer may have part of the liver removed if lab tests show that the liver is working well and if there is no evidence that the cancer has spread. The extent of the surgery depends on the size, number, and location of the tumor.

The affected part of the liver is removed after confirming that the remaining amount of liver is sufficient for an adequate functioning of the body. Surgery to remove part of the liver is called Partial hepatectomy (Liver resection) and depending on whether the right or left part of the liver is removed it is called right or left hepatectomy respectively. As much as 70 percent of the liver may be removed if the remaining liver is healthy. The remaining healthy liver can then take care of the body functions. Also, the liver can re-grow some of the missing part. The new cells grow over several weeks.

The surgeon may sometimes remove the whole liver. If the whole liver is removed, it is replaced with healthy liver tissue from a donor. Such type of surgery is called Liver Transplant. To have a liver transplant you need a liver from a donor. It can sometimes take months to find a donated liver that closely matches yours. During this delay, the cancer may continue to grow and you may need to have other treatment to try to control it. Moreover there are strict criteria as to which patient can undergo liver transplant in the setting of cancers. Also after a liver transplant, you have to take drugs to stop your body rejecting the donated liver. These drugs damp down the activity of your immune system and reduce its ability to control the cancer

In certain cases, surgery to remove the tumor may not be possible because of cirrhosis or other conditions that cause poor liver function, the location of the tumor within the liver, or other health problems. In such cases some form of local destruction is used and is called ablation.

The most common method of ablation is Radiofrequency ablation (RFA). The doctor uses a special probe that contains tiny electrodes which open like an umbrella. Radio waves pass down this needle and around the tumor to kill the cancer cells with heat. Tumors of 3-5 cm size are best treated with this technique but even 7 cm probes are now available to ablate larger tumors.

This procedure is best done under ultrasound (sonography) guidance as it becomes necessary to see whether the needle is hitting the tumor properly. (CT scan may be used to guide as well). This procedure is ideally performed in the operation theatre and under suitable anaesthesia. The probe may be inserted directly through your skin (percutaneous RFA), or through a small incision in your abdomen (open RFA technique). The procedure generally involves a short hospital stay and can be repeated multiple times if necessary.

This type of treatment gives the chemotherapy directly to the area of the liver that contains the cancer. Depending on the drugs used, you usually have to stay in hospital overnight or longer. Your doctor may recommend it if you cannot have your tumour removed by surgery. It is also sometimes used to shrink a tumour so that it is small enough to remove with surgery at a later time.

This treatment is done in the X-ray department or a specialized room in the hospital called the Cathlab. The procedure is done under a local anaesthetic injection and possibly a mild sedative. The doctor puts a tube called a catheter into the large artery at the top of your leg called the femoral artery. The doctor can then thread the catheter along the femoral artery until it reaches the hepatic artery that supplies blood to the liver.

The doctor will check that the catheter is in the right place in the liver. Then they inject the chemotherapy (anti-cancer medicines) into the tube following which the doctor also injects something to block the blood flow to the tumour. This might be tiny plastic beads or a type of gel. Blocking the flow of blood allows the anti-cancer drug to remain in the liver for a longer duration to kill the cancer cells as it cuts off the tumour’s food and oxygen supply.

Chemoembolization can cause side effects. You may feel or be sick. Or you may have some pain or a raised temperature after the treatment. Your doctor will give you painkillers or anti sickness drugs (antiemetics) to control these side effects.

You may have chemoembolization more than once if your doctor thinks it will help.

This treatment is similar to chemo-embolization and differs from it by use of radiation particles instead of anti-cancer drugs through a catheter. Millions of tiny beads (sometimes called microspheres) are fed into the hepatic artery, the main blood vessel which supplies the liver. These beads block the supply of blood to the cancer. They contain a radioactive substance called Yttrrium-90, which works by sending out radiation. This helps to kill off the cancer cells. One has to be careful about shunting of blood from the liver to the lungs in which case the radiation particles may travel to lungs and destroy some part of it. Hence it always becomes mandatory to perform this procedure in two steps; first to determine the extent of shunting of blood from liver to the lungs and second the actual procedure if the shunting is within acceptable limits. This procedure cannot be done if there is excessive blood shunting to the lungs.