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Q&A About Liver Cancer

02 SEPTEMBER 2017

Q&A About Liver Cancer

The American Liver Foundation reached out to top doctors Ghassan K. Abou-Alfa, MD, and Ronald P. DeMatteo, MD., to get answers to the most commonly asked liver cancer questions.

Below are experts from their book, 100 Questions and Answers About Liver Cancer, now in its third edition, which provides clear, concise and timely information.

The Basics

A. Two broad categories of liver cancer exist: primary and secondary. Primary liver cancer means that the tumor originated in the liver. A tumor can start from any of the different types of cells that normally exist in the liver. Hepatocellular cancer is the most common type of primary liver cancer. It is also known as hepatocellular carcinoma or hepatoma for short, and is often abbreviated HCC.

There is a subtype of HCC called fibrolamellar hepatocellular carcinoma. It makes up less than 1 percent of all HCCs. It tends to occur in young adults and is typically not associated with an underlying liver disease. In general, it carries a better prognosis.

The other types of primary liver cancer are rare. Cholangiocarcinoma is a cancer that arises from the bile ducts within the liver. Mixed hepatocellar and cholangiocarcinoma is a tumor that contains elements of both HCC and cholangiocarcinoma. Hepatoblastoma is a primary liver cancer that occurs in children. Cancer can also arise in the gallbladder. A variety of other very rare primary liver tumors exist.

A secondary liver cancer is a spread of any cancer in the body to the liver. Examples of secondary liver cancer include colon, breast, pancreas, or other cancers.

A. About 15,000 new cases of HCC are seen in the United States per year, making it relatively uncommon compared with many other tumors. However, the frequency has increased by 75% in this country over the last decade. While HCC is less common in the United States, it is one of the most common tumors in the world, with nearly a million people affected per year.

Risk Factors and Screening

A. Liver cancer rarely occurs spontaneously and for no apparent reason; in most instances, it starts because of an existing abnormality in the liver. Six main reasons exist for having an abnormal liver: 1) viral hepatitis B; 2) viral hepatitis C; 3) alcohol use; 4) obesity and diabetes; and 5) other inherited metabolic diseases that affect the liver.

A. About 15,000 new cases of HCC are seen in the United States per year, making it relatively uncommon compared with many other tumors. However, the frequency has increased by 75% in this country over the last decade. While HCC is less common in the United States, it is one of the most common tumors in the world, with nearly a million people affected per year.

Several rare inherited metabolic diseases can cause liver damage and may lead to cirrhosis and/or liver cancer. One of these diseases is called hemochromatosis. It leads to the accumulation of a mineral in the liver and cirrohosis, which increase the risk of liver cancer. Hemochromatosisis is an illness of increased iron absorption and deposition in many organs of the body, including the liver. The disease is inherited and is most commonly seen among northern Europeans or their descendants. People who are affected can lead a normal life, but many (especially men) start to have symptoms around the age of 40 years. Affected individuals may start to feel tired and weak and may acquire a shiny tan to their skin in the absence of sun exposure because of iron deposition in the skin.

There are multiple other genetic diseases that might cause inflammation in the liver (hepatitis) and cirrhosis and therefore can lead to the development of liver cancer. Some of these diseases are listed below:

  • Hemochromatosis
  • Wilson’s Disease
  • Alpha-1 antitrypisin deficiency
  • Primary biliary cirrhosis
  • Porphyria cutanea tarda
  • Types 1 and 3 glycogen storage disease
  • Galactosemia
  • Citrullinemia
  • Hereditary tyrosinemia
  • Familial cholestatic cirrohosis
  • Familial polyposis coli
  • Ataxia telangiectasia
  • Biliary artesia
  • Congenital hepatic fibrosis
  • Neurofibromatosis
  • Situs inversus
  • Fetal alcohol syndrome
  • Budd-Chiari syndrome

A. From a practical standpoint, a person who carries any of the previously discussed risk factors should be screened for liver cancer. For example, individuals with chronic hepatitis B or C infection should be regularly evaluated by a physician for the development of liver cirrhosis and liver cancer. This also applies to individuals with a history of excess alcohol ingestion, especially if they have liver problems; patients with a family history for any genetic disease that carries a risk of developing liver cancer; and patients with an environmental risk, especially if they already have liver problems. Although there are no clear recommendations for screening, if you happen to be diabetic and morbidly obese, many physicians believe that you should be very closely followed.

A. The reason to screen patients who are considered to be at high risk of developing liver cancer is that if a liver cancer does occur, the tumor will more likely be detected when it is small and before it has spread to other parts of the liver or elsewhere in the body. In other words, screening may allow detection of a cancer in an early stage. Otherwise, many patients with liver cancer may have advanced disease by the time they have symptoms and seek medical attention. First, the liver does not sense pain very well. Only the outside lining of the liver (called the liver capsule) has nerve fibers. Second, the liver has an enormous functional reserve. As a result, even an advanced tumor may not alter the normal function of the liver and may not cause any abnormalities in blood work.

A. This is a controversial issue. However, most physicians recommend an ultrasound of the liver and a blood test to measure an alpha-fetoprotein, known as AFP. Typically the test is easy and painless and does not involve any injections of radiation exposure. You may feel some pressure at the site being evaluated as the probe is pushed close to your body. Some doctors prefer to use a different type of radiologic test such as a computed tomography (CT scan) or magnetic resonance imaging (MRI).

Treatment Options

A. In contrast to many other cancers, liver cancer is often two diseases in one. Cirrhosis by itself contributes to the development of cancer and directly affects the level of function of the liver. A cirrhotic liver will be unable to synthesize or make the essential proteins and bile. It also will fail to metabolize or break down the different compounds that go through the liver. A badly cirrhotic liver might affect survival and can actually be a worse problem than the cancer it harbors. Even therapeutic decisions regarding the cancer might be influenced by the degree of cirrhosis. Although a cancer specialist may treat a patient primarily for liver cancer, often a liver specialist may need to be involved. Cirrhosis is graded using different criteria. One of the more commonly used grading systems is the Child-Pugh score, as discussed previously. This score assesses the synthetic and metabolic functions of the liver.

ASeveral treatment options are available for patient with HCC. In general, the most effective therapy is to remove the tumor. This can be done in two ways. One method is to remove the part of the liver that contains the tumor. This is caller liver resection or partial hepatectomy. The other option is to remove your entire liver and replace it with a new liver. This is called liver transplantation.

Treatments for Hepatocellular Cancer

    • Liver resection
    • Liver transplantation
    • Hepatic artery embolization
    • Radiofrequency ablation
    • Alcohol injection
    • Cryotherapy
    • Chemotherapy
    • Investigational chemotherapy
    • Biologic and targeted therapy
    • Supportive care
    • Investigational biologic or targeted therapy

A. Patients should ask their doctors about clinical trials. Many doctors, both at academic centers and in private offices in the community, run or are part of a group of doctors running a clinical trial. Thus, the answer might be at the doorsteps of where a patient lives. Nonetheless, patients might consider commuting a reasonable distance to get to a center that runs a pertinent clinical trial. Patients might know about those through either their doctors, the center’s website, or the government’s National Cancer Institute: www.cancer.gov and www.clinicaltrials.gov. The National Cancer Institute offers not only a listing of all clinical trials that are registered with them, but also several web pages with information about clinical trials. Other sites that offer similar services include the Coalition of National Cancer Cooperative Groups, www.cancertrialshelp.org, and Centerwatch, www.centerwatch.com.

If a patient identifies a clinical trial that is relevant to his or her medical condition, he or she should discuss the trial further with his or her doctor. The doctor might call the investigation and discover more about the trial. This can ensure that patients will seek only trials that they might be eligible for and save a deemed ineligible for a certain trial, he or she should not be disappointed or have feelings of hopelessness. It is important that certain clinical trials answer only a specific question in a specific subset of patients with a given disease. For example, a new drug for primary liver cancer may be tested in only patients who have a specific level of liver function. The list of clinical trials is very dynamic and changes all the time.

For more information on liver cancer, you can purchase 100 Questions and Answers About Liver Cancer Third Edition by Ghassan K. Abou-Alfa, MD, and Ronald P. DeMatteo, MD. It is published by Jones & Bartlett Learning, Burlington, MA. (www.jblearning.com) The book is sold at Barnes and Noble, Amazon.com and other bookstores.

Reprinted with permission.


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