Primary Liver Cancer Includes A) Hepatocellular carcinoma (HCC) B) Cholangiocarcinoma (intrahepatic)
A) Hepatocellular carcinoma It usually occurs in livers that are damaged by birth defects, alcohol abuse, or chronic infection with diseases such as hepatitis B and Hepatitis C, (a hemochromatosis hereditary disease associated with too much iron in the liver), nonalcoholic steatohepatitis (NASH) and cirrhosis. The male: female ratio for HCC in India is 4:1. The age of presentation varies from 40 to 70 years.
What are the Risk Factors of HCC? Secondary liver cancer or metastasis is the most common cancerous condition of the liver. It depends on the location of original cancer. Primary cancers that are most likely to spread to the liver are cancers of the: – Colon – Rectum – Stomach – Esophagus – Lung – Pancreas
Even if the primary cancer is removed, liver metastasis can still occur years later. If you’ve had cancer, it’s important to learn the signs of liver metastasis and get regular checkups. Liver cancer signs and symptoms may include: – Jaundice – Yellowish discoloration of skin and eyes – Abdominal pain – often in the right upper abdomen – Loss of weight and appetite – Hepatomegaly – enlarged liver, the abdomen may appear swollen – Fatigue – Nausea and vomiting – Back pain – General itching – Fever
How is HCC diagnosed? Physical examination: Your doctor will examine your abdomen to look for any pain and swelling in the upper abdomen. He also examines your eyes and skin to look for evidence of jaundice.
What are the treatment options for HCC? – Treatment options depend on the stage of the disease, the general condition of the patient, and associated comorbidities. – Treatment modalities include – Surgical resection of the diseased liver, liver transplantation, and loco-regional ablative techniques like TACE, RFA, MWA, and chemotherapy. Loco-regional ablative techniques are considered in patients who are not candidates for surgery (patients with portal hypertension, poor liver functions, functional liver remnant (FLR) less than 40%, poor general condition, metastasis). – In advanced metastatic and unresectable disease, patients will be referred to a medical oncologist for chemotherapy-targeted therapy.
B) Cholangiocarcinoma
Cholangiocarcinoma is a cancer of the bile ducts. The bile duct connects the liver to the gall bladder and intestine. There are three types of cholangiocarcinoma: A) Intrahepatic cholangiocarcinoma B) Hilar cholangiocarcinoma C) Distal cholangiocarcinoma
How is intrahepatic cholangiocarcinoma diagnosed? Physical examination: Your doctor will examine your abdomen to look for any pain or swelling in the upper abdomen. He also examines your eyes and skin to look for evidence of jaundice.
Laboratory investigations
Blood tests: complete blood count, LFT, RFT, Serum electrolytes, coagulation profile, HIV, HCV &HBV testing, CEA, and CA19-9 (Tumor marker). Radiological imaging: USG Abdomen, Triple phase CT scan of the abdomen, MRCP, PET CT scan. Biopsy: if a biopsy is required, then you might be referred to a radiologist to get a CT-guided biopsy done.
What are the treatment options for intrahepatic cholangiocarcinoma?
Surgery: If the tumor can be resected, then the patient will be offered liver resection or bile duct resection depending on the location of the tumor in the bile duct. Based on the histopathology report patient may require chemotherapy or radiotherapy.
Chemotherapy/radiotherapy: Unresectable intrahepatic cholangiocarcinoma with a widespread disease in an advanced stage you will be referred to a medical oncologist for chemotherapy or a radiation oncologist for radiotherapy.
Ablative techniques: Unresectable intrahepatic cholangiocarcinoma, not spread to other regions, can be treated with TACE or TARE.
Palliative Care: patients who are in the terminal stage of illness are offered palliative care. The aim of palliative care is symptomatic relief. The patient may be referred to a pain management team for pain relief. If the patient is having obstructive jaundice features, then he/she will be referred to an interventional radiologist for PTBD.
Secondary Liver Cancer It is the most common cancerous condition of the liver. It depends on the location of original cancer. Primary cancers that are most likely to spread to the liver are cancers of the colon, rectum, stomach, esophagus, lungs, and pancreas.
How are liver secondaries managed?
– The liver is the most involved organ in patients with metastatic colorectal cancer. Approximately 20% of the patients have clinically recognizable liver metastases at the time of their primary diagnosis. – After resection of primary colorectal cancer in the absence of apparent metastatic disease, approximately 50% of the patients will subsequently manifest metastatic liver disease. – Primary gastrointestinal malignancies, such as those of the pancreas, stomach, or gallbladder, although frequently metastasizing to the liver, rapidly develop disseminated disease. Few of these patients present with the respectable disease remain limited to the liver.
How are patients with liver secondaries evaluated?
Physical examination: Your surgeon will examine your abdomen to look for any swelling in the abdomen. Blood investigations: CBC, LFT, RFT, Serum electrolytes, coagulation profile, CA 19-9, CEA, HIV, HCV, and HBV testing. Radiological imaging: USG, Triphasic CT Scan of Abdomen & Pelvis, MRI, Whole body PET-Scan.
What are the treatment options for liver metastasis?
Surgery Liver resection, open surgery as well as minimally invasive surgery (Robotic or Laparoscopic).
Ablative techniques for liver metastasis – TACE, Radiofrequency Ablation (RFA), and Microwave Ablation (MWA). – Ablative techniques may be combined with liver surgery. For example, liver metastasis in both lobes of the liver. Ablation may also reduce the risk of cancer coming back for people with liver metastases that can’t be completely removed. It may prolong survival for people with recurrent metastases whom the doctors previously treated with surgery and chemotherapy.
Chemotherapy Chemotherapy shrinks the tumor by slowing or stopping the growth of cancer cells and relieving the symptoms. It may be given after the surgery to lower the risk of recurrence.
Targeted therapy Targeted therapy is used to control the growth of liver metastases. They are given intravenously or orally. It is most often used along with chemotherapy.
If you think you might be at risk of liver cancer, contact a Liver Specialist at Dr. Aswin Krishna Liver doctor-hepatologist and transplant physician www.draswinliverexpert.com
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