20 May Complete guide to liver cancer
This guide contains everything you need to know about liver cancer, including: what it is, its symptoms, diagnosis, treatments and alternative therapies.
What is liver cancer?
The liver is the largest organ inside the body. It is the size of a football and is found in the upper right portion of the abdomen. More specifically, it sits under the diaphragm and behind the rib cage, on the right handside of the body.
This organ carries out a number of vital functions, such as:
- Storing most of the nutrients absorbed by the small intestine
- Breaking down (metabolizing) these nutrients into parts small enough to be used by the body
- Producing most coagulation factors that are essential for controlling bleeding
- Producing a liquid called bile and distributing it around the body to help it absorb nutrients (especially fats)
- Breaking down alcohol, medication and toxins in the blood, which then leave the body in urine or faeces.
Liver cancer starts when liver cells start to grow in an uncontrolled way and form a tumor, which is considered primary liver cancer.
The most common type of primary liver cancer is hepatocellular carcinoma, which starts in the hepatocytes (main type of liver cells). Other liver cancers include intrahepatic cholangiocarcinoma and hepatoblastoma, but these are much less common.
The liver can become affected by metastatic cancer that has spread from other organs, but this is not considered primary cancer (as it does not start in the liver). Once liver cancer is discovered, a complete full-body examination must be carried out to check for lesions in other organs.
Types of liver cancer
Hepatocellular carcinoma (HCC): this is the most common type of liver cancer. It can form in an isolated mass that grows gradually, or as multiple small lesions throughout the liver.
These multiple lesions develop in about 85% of patients with chronic liver disease and cirrhosis of any kind, especially in people infected with hepatitis B and C.
Intrahepatic cholangiocarcinoma (bile duct cancer): does not originate in the liver cells, but in the ducts that transport bile (liquid produced in the liver that breaks down fat) to the biliary vesicle. Intrahepatic cholangiocarcinoma is found both inside and outside of the liver.
Angiosarcoma and hemangiosarcoma: very rare types of cancer that originate in the cells that line the blood vessels in the liver.
Usually, they occur due to exposure to carcinogenic chemicals such as thorium dioxide (Thorotrast) or a genetic alteration known as hereditary hemochromatosis. In about half of all cases, no likely cause can be found.
Hepatoblastoma: this is a very rare type of cancer that mostly affects children under the age of 4. These tumors respond well to surgery and chemotherapy, but are more difficult to treat if they have spread outside of the liver. Hepatoblastoma is the most common primary liver tumor in children.
However, hepatocellular carcinoma is the most common primary liver tumor in adults, therefore, in the rest of this article, we will refer to this type of cancer as liver cancer.
The symptoms are usually not very obvious in the early stages of the disease and as there are no symptoms that are specific to the disease, it is sometimes detected by coincidence during an abdominal ultrasound. You should have a special follow-up if you have previously been diagnosed with fatty liver disease.
Symptoms of liver cancer can include:
- Abdominal pain, especially on the right side
- Unexplained weight loss
- Loss of appetite
- Feeling full after eating very little
- Bloating or water retention in the abdomen
- Excessive fatigue
- Jaundice (yellowing of the skin and eyes)
- Constant dizziness
- Nausea and vomiting
- White stool
- Lump under the rib cage on the right side
- Pain in the abdomen or near the right shoulder blade
- Increase in the size of the veins of the abdomen (they become visible under the skin)
Causes of liver cancer
The exact causes of liver cancer are unclear. What we do know is that liver cancer occurs when liver cells develop mutations in their DNA, which cause the cells to grow in an uncontrolled way and form a tumor. However, it is very difficult to know exactly why this happens.
In some cases, liver cancer is caused by chronic infections of certain types of the hepatitis virus.
The main risk factor for liver cancer is cirrhosis of the liver. Therefore, the other factors are also based on suffering from this disease. Below are the the primary and secondary risk factors:
- Cirrhosis: scarring of the liver, which affects the proper functioning of liver cells. Some causes are: poor metabolism of fats, usually in overweight or obese people (fatty liver disease); alteration or obstruction of the bile ducts, causing damage to the liver (primary biliary cirrhosis); and due to hereditary metabolic diseases (hemochromatosis – excessive iron accumulation)
- Chronic infection with hepatitis B or C: these infections cause cirrhosis of the liver. The risk is even greater in people who consume excessive amounts of alcohol. It is contagious (virus can be passed on by sharing contaminated needles, having unprotected sex, or during birth).
The infection is considered chronic when the hepatitis virus remains in the blood for more than 6 months and causes a reduction in liver function.
- Use of anabolics (the most famous being steroids, they accelerate tissue growth)
- Excessive alcohol consumption (at least 6 alcoholic drinks a day)
- Obesity: accumulation of fat in the hepatic ducts preventing the proper drainage of bile, which can lead to cirrhosis.
- Exposure to aflatoxins (poisons produced by the mold of certain crops such as corn, soy, rice and peanuts)
- Schistosomiasis (parasitic disease)
- Tobacco consumption
Liver cancer can be prevented by:
- Avoiding and getting timely treatment for hepatitis
- Limiting alcohol and tobacco consumption
- Maintaining a healthy weight
- Limiting your exposure to chemicals like aflatoxins and arsenic
- Seeing your doctor regularly, seeing a specialist for follow-ups if you have been diagnosed with a preexisting disease
- Getting vaccinated to prevent chronic hepatitis B (HBV) infections
- Not sharing needles
- Treating hepatitis B and C
Testing and diagnosis
The tests used by doctors to diagnose liver cancer include:
- Physical exam: take special care when examining the abdomen to detect any masses or increased liver size. Check if there is liquid in the abdomen or any yellowing of the skin and eyes.
- Analysis of patient’s medical and family history
- Blood test: a liver function test is carried out (to check for bilirubins, transaminases, alkaline phosphatase and others). Additionally, an alpha-fetoprotein blood (AFP) test is requested, which is a specific tumor marker for the liver. It is important to note that a negative blood test result does not rule out the possibility of cancer and a positive result does not definitely confirm it.
- Ultrasound to detect nodules, if a nodule smaller than 1 cm is found, it will be monitored with regular ultrasounds every 6 months. If it is between 1 and 2 cm across, it should be corroborated with a contrast-enhanced tomography or nuclear magnetic resonance imaging.
- Contrast-enhanced computerized tomography (CT) scan, shows the extent and number of nodules and identifies whether blood vessels are feeding the tumor.
- Contrast-enhanced magnetic resonance imaging (MRI), captures a more precise image of the surrounding soft tissue and any possible damage.
- Angiography, a contrast dye is injected into the veins to examine the blood vessels and see whether they are feeding the tumor, or whether there is some abnormality in the blood vessels in the liver.
- Gammagraphy, specifically used to see whether the tumor has metastasized to the bones.
Some other tests that are also used to detect cancer in the liver are:
- Biopsy, an incision is made in the nodule using a fine needle and a tissue sample is taken. The sample is then examined under a microscope to determine the type of tumor.
- Laparoscopy, a thin tube is inserted to examine the abdomen and take a small tissue sample.
The 5 stages of liver cancer
People suffering from this disease are in one of the five following categories:
BCLC 0 (very early stage): patients with one tumor measuring less than 2 cm who exhibit normal liver function (Child-Pugh A).
BCLC A (early stage): patients with one tumor of any size or multiple tumors measuring less than 3 cm, with preserved liver function. Includes patients that have had a liver transplant and have good liver function.
BCLC B (intermediate stage): patients with large tumors or more than 3 tumors that measure less than 3 cm, with preserved liver function.
BCLC C (advanced stage): patients with relatively preserved liver function (Child-Pugh A-B) who are not in the terminal stage, but the cancer has spread to the blood vessels, lymph nodes or other body organs.
BCLC D (terminal stage) : this group includes those patients with severe liver damage (Child-Pugh C) who are not liver transplant candidates and who are generally not well.
Conventional treatments for liver cancer
Treatment for liver cancer depends on the patient’s stage, as well as other factors such as age and general physical condition.
Surgery can be a suitable treatment for patients in the very early or early stages. Patients in the intermediate stage may undergo trans-arterial chemoembolization. Sorafenib is a drug that is commonly administered in the advanced stages of the disease. For terminal patients, there are treatments available to help manage symptoms.
Treatment for patients in stage BCLC 0-A
Depending on the stage of the disease and if there is only one tumor and it is large enough to be removed, surgery will be performed. In this procedure, the entire area affected by cancer is removed. When it comes to multiple cancerous nodules, it is best to perform a partial liver transplant (partial hepatectomy), removing the area where there is liver is damaged.
In cases where the liver cancer has metastasized (when the cancer cells have spread to other organs), radiotherapy and chemotherapy are also used following surgery.
If the entire liver is damaged, the patient will undergo a liver transplant.
A liver transplant is considered when there is one tumor measuring less than 5 cm or there are 2 or 3 tumors measuring less than 3 cm. Usually, livers are donated by patients who have just died, but in some cases they may also be donated by a living donor.
Patients suffering from alcoholic liver cirrhosis and who are still drinking, or patients with a poor prognosis due to certain aspects of their cancer or other simultaneous diseases, are not considered for transplants. Transplants are usually considered for people in stage BCLC A.
This procedure seeks to destroy cancer cells by attacking them using physical or chemical means. Local ablation is effective for destroying small tumors, but does not prevent new tumors from forming.
- Radiofrequency ablation: uses high-energy radio waves to destroy cancer cells. A tube similar to a fine needle is inserted through the abdomen into the tumor, subsequently destroying cancer cells, sealing off the small blood vessels.
This method is suitable for patients with no more than 5 tumors, which measure less than 5 cm. It should not be performed in masses near blood vessels due to the risk of bleeding.
- Percutaneous ethanol injection: ethanol (concentrated alcohol) is injected directly into the tumor to damage cancer cells. This method is less effective than ablation in tumors measuring more than 2 cm.
Treatment for patients in stage BCLC B
Trans-arterial chemoembolization (TACE)
A drug is injected directly into the artery that supplies blood to the liver, preventing cancer cells from growing and spreading.
In general, the most common chemotherapy drug used is Gelfoam. Small degradable particles of this drug are injected through a catheter to block the small arteries that supply blood to the tumor in the liver and, thus, prevent the supply of nutrients and oxygen to the tumor.
Treatment for patients in stage BCLC C
Systemic treatment with sorafenib, a drug that is administered orally and is known as targeted therapy, which seeks to attack the tumor specifically.
Radiotherapy uses high-energy radiation to destroy cancer cells. The procedure is similar to a common radiograph, it can be carried out before surgical intervention to reduce the size of tumors or afterwards, to destroy remaining lesions from a distance.
Consists of injecting drugs into the bloodstream, which flow throughout the whole body and attack cancerous cells. This treatment can be used before surgery to reduce the size of the tumor, or afterwards to destroy small quantities of remaining cancer cells.
Treatment for patients in stage BCLC D
The only treatment for this stage is managing symptoms that occur during the normal development of the disease. Patients in this stage are not considered candidates for invasive interventions.
These are therapies that go hand-in-hand with conventional treatments:
Adopting healthy habits is essential for controlling any disease:
Follow a balanced diet, eating at least 2 ½ cups of fruit and vegetables a day, as well as several portions of plant-based whole grains, such as grains, cereals, rice, pasta or pulses. Limit your consumption of red and processed meat.
You should also try to avoid saturated or trans-fats. After treatment, your tastes may change and you may experience a loss of appetite. Although this can be difficult, there are complementary treatments available for managing these symptoms, which you should discuss with your doctor.
Regular exercise is recommended for your general health, but especially when you have cancer. Exercise improves blood flow and helps your metabolism work more efficiently.
During treatment, you may experience a decline in your physical condition, strength and muscle tone. A regular exercise routine will make you feel better physically and emotionally.
Meditate, reflect, remember that you are the person who knows you and your body best. Get to know yourself and your body; sometimes, a bit of self-awareness can help you better understand your disease and how to combat it.
Cannabinoids reduce general discomfort, since they contribute to the improvement of nausea and vomiting, to the stimulation of appetite and to the pain relief that some chemotherapy and radiotherapy treatments produce. It can promote the death of tumor cells, reducing their ability to spread and metastasize.
A study on the cannabinoids CB65 ( connects with the CB2 receptor) and ACEA (connects with the CB1 receptor), revealed that they are a viable option for a new treatment for liver cancer, since they reduce cell viability and cellular invasion of cancer cells. Better efficacy was found at higher concentrations.
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Coping strategies and support
We know that a cancer diagnosis can be a huge emotional challenge, so it is important that you keep your friends and family close by and that you share your thoughts and feelings with them. Letting your loved ones know how you are coping and being open to their support will help you feel stronger.
Look for support groups for people with similar diagnoses to yours. Usually, these groups will be offered to you during treatment. These networks can be very useful for answering any questions you may have regarding what to expect and tips to help you cope along the way.
Want to find out more about cancer and how to combat it? At Livee, we are here to support and guide you.
¿Qué es cáncer de hígado? [American Cancer Society, 2016]
Neoplasias hepáticas malignas: 1.a parte. Hepatocarcinoma: papel de la biopsia hepática, estudios de inmunohistoquímica y otros aspectos importantes [Rocío del Pilar López Panqueva, 2015]
Cáncer de hígado: una guía para pacientes [Fundación contra el cáncer y ESMO (European Society for Medical Oncology), 2014]
Factores de riesgo del cáncer de hígado [American Cancer Society, 2016]
Carcinoma hepatocelular [Carlos Rodríguez de Lope, Alejandro Forner, María Reig y Jordi Bruix]