Liver Cancer

1. What is the liver and what does it do?

The liver is largest organ inside the body. It is situated on the right side of the abdomen below the right lung and lies behind the lowest ribcage. It lies close to the colon, intestines, and right kidney. The liver is essential for survival. It plays an important part in the daily functioning (metabolism) of the body. It is required for digestion, stores nutrients, helps in detoxification, and produces proteins required for blood clotting among many other vital functions.

2. What is liver cancer?

Both benign (non-cancerous) and malignant (cancerous) tumors can develop in the liver. The most common caner that originates in the liver is hepatoocellular carcinoma (HCC). Cancer can also spread to the liver from other organs such as the colon, pancreas, or breast, This type of cancer is more common than HCC, but it is not considered to be "primary liver cancer" but secondary or metastatic cancer.

3. Is there a reason I have developed liver cancer?

The cause for liver varies from person to person and, in some patients, may never be found. The most common cause is cirrhosis (a progressive disorder that leads to scarring of the liver). Cirrhosis is caused by chronic viral hepatitis B and C, alcohol abuse, and certain genetic disorders. Food contaminants, long term use of steroids, and exposure to certain chemicals have also been linked with liver cancer.

4. What are the symptoms of liver cancer?

Most symptoms of liver cancer are non specific and overlap with other cancers as well as less serious condition. The sooner a person seeks medical evaluation and confirms the diagnosis, the sooner effective treatment can be started. These symptoms include unexplained weight loss, persistent lack of appetite, abdominal pain, increase in abdominal girth, and jaundice. In a person with hepatitis or cirrhosis, dramatic change in the general condition may point to the development of liver cancer.

5. What test will I be required to undergo?

Specific blood tests that are important in planning treatment are liver function tests, tests for hepatitis, as well as tumor markers such as alpha-fetoprotein (AFP) and CA 19.9. Specialized imagining for the liver in the form of ultrasound, CT scan and / or MRI scan can helps in accurately defining the tumor. A liver biopsy is often is often required when there is some uncertainty in diagnosis and is mandatory when treatment other than surgery is being contemplated. A biopsy is sometimes performed to rule out cirrhosis. If hepatitis or cirrhosis is suspected, an endoscopy, hepatitis viral load, and other tests may be needed.

6. How will the course of my treatment be decided?

The treatment planning is complex and involves a multi-disciplinary team which includes doctor which are specialized in the treatment of liver cancer. This team usually includes a liver surgeon, hepatologist (physician), radiation and medical oncologist, interventional radiologist, and pathologist. Together these specialists plan treatment taking into consideration various aspects including the stage of the disease, the presence or absence of cirrhosis, the severity of cirrhosis, if present, and the general condition of the patient. The severity of cirrhosis is determined by a scoring system. BY this system, points are allotted based on parameters such as serum Bilirubin levels albumin levels prothrombin time, ascites and encephalopathy. These points are then totaled based on which a patent is determined to have child's A, B or C cirrhosis with A indicating early disease and C advanced disease.

7. Should I undergo an operation for liver cancer?

The best and possibly only cancer for a cure is well done surgery. This may not always be possible and depends on the size and location of the tumour. The operation entails removing the part of the liver which is involved by the tumor. Complete removal of the tumour is essential for favourable long-term results. Whether or not an operation can be performed again depends on the stage of the disease, the general condition of the patient and fitness for surgery, the amount of functioning liver expected to remain after surgery, and the quality of the liver itself. In an otherwise, normal liver, a remnant liver volume of around 25% is sufficient to carry out the required functions of the body. If the liver is cirrhosis, a minimum expected remnant of 40% is necessary. These assessments are made prior to the operation. In the event hat resection (removal of part of the liver) is not feasible, or even when used as an alternative to resection, liver transplantation is a viable option option in a highly selected group of patients. Unfortunately, all patients are not eligible for surgery and alternative treatment modalities which are best suited under the circumstances will be offered in efforts to control the disease.

8. What are other treatment options?

When surgery is not feasible, several other suitable treatment options are available: Detailed information on each of these modalities is available separately.

Radiofrequency Ablation (RFA) is appropriate for smaller tumours (<3cms) as an alternative to surgery or as a 'bridge' to resection or transplantation. This method uses a needle which is placed into the tumour and delivers rapidly alternating current to kill tumour cells.

Transarterial chemoembolization (TARE) is the best method of treatment for larger or multiple tumours which have not spread beyond the liver and in which the blood vessels supplying the liver are not blocked. It can also be used to 'shrink' the tumour to allow for an operation, or even as a 'bridge' to surgery or transplantation. In this technique, chemotherapy is injected directly into the blood vessel supplying the tumour.

Transarterial radioembolization (TARE) uses a radioisotope (Y90) to deliver radiotherapy to the tumour employing a similar method as is used in TACE. This method is used when a blood vessel supplying the liver is blocked and TACE is not possible. Chemotherapy is sometimes used. Commonly used drugs are doxorubicin, cisplatin, 5-fluorouracil and gemcitabine. This is not suitable for everyone and can only be given if the liver function is reasonable.

Targeted therapy (sorafenib) is used when the above options are not possible and the liver function is reasonable. The dose of this tablet may have to be adjusted according to any side-efects that may be experienced.

Chemotherapy and targeted therapy will not cure the cancer.
Many other treatment options are being studied such as interferon therapy and alternate forms of radiotherapy with encouraging results. They may benefit selected patients.

9. If I am to undergo surgery how do I prepare myself for it?

Preparation for liver surgery is similar to preparation for any major surgery. From the perspective of the patient, breathing exercises should be practiced as instructed. Smoking should be stopped. A nutritious diet should be implemented. Follow the anaesthiologist's instructions regarding your regular medications. Necessary arrangements regarding the logistics of hospital stay for 10-14 days after the operation, or even longer in the event of any complications, should be made.

10. What are the risks involved if I get operated.

As is the case with all major operations no matter how well done, there is a minimal but definite risk of complications associated with the surgery. Liver surgery is considered to be one of the most major operations in the domain of the abdomen. There is almost operations in the domain of the abdomen. There is almost a 10% chance that the recovery after the operation may be affected due to complications such as liver failure or bleeding. If complications do occur, adequate and timely intervention will solve such problems in the vast majority of cases. Upto 2% of patients are at risk of death during or immediately after surgery. These risk should be understood by the patient and relatives. These risks are significant but are acceptable even in the best centers world-wide.

11. How long can I except to live after treatment?

Some patients may want to know the survival statistics of patients in similar situations. Others may not find the numbers helpful, or even might not want ot know. T is up to you whether you want to read about the survival statistics in patients with liver cancer. These figures are at best a rough estimate of your life-span after treatment.

Studies have shown that patients with small tumours that can be removed, who do not have cirrhosis or other serious health problems, are likely to do well if their cancers are removed. Their overall 5 year survival is over 50% (the percentage of patients that will live at least 5 years after the cancer is diagnosed). For all stages combined, the relative 5-year survival rate is about 10%. Part of the reason for this low survival is that many patients have cirrhosis which can be fatal itself. Keep in mind that every person's situation is unique and statistics cannot predict exactly what will happen in your case.

12. Is there any chance of the cancer coming back?

Despite optimal treatment, the risk of the cancer returning is significant. The likelihood of tumour recurrence is highly subjective. After completion of treatment, reporting for regular chek-ups as advised is the best way to detect and treat any tumour that has come back at an early stage.

13. How often do I have to come back to the hospital for routine check-ups after the completion of treatment?

In the absence of significant symptoms, routine check-up is performed every 3-4 months for the first 2 years, very 6 monthly for 2 years after that, and annually thereafter. The check-up includes a few questions regarding any problem you might be facing, a physical examination, blood tests including liver functions and tumour markers, as well as an ultrasound. Further tests may be required if any problem is suspected.

14. Will I be able to adjust to this disease well?

Each patient's experience with liver cancer is different. Once you undergo an operation, you will be able to return to regular activity within a month of surgery. This will be with little or no dietary/lifestyle restrictions. Completing treatment can be both stressful and exciting. It may help to know that many cancer survivors have learnt to live with the uncertainty of the future and are leading full lives. Finally, in liver cancer, as in many other cancers, the dictum holds true: : Cancer is curable if detected early".