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| Cancer involving the liver |
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Reviewed by Professor Alastair J Munro, professor of radiation oncology
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How can cancer involve the liver?
There are two ways in which cancer can involve the liver. The
cancer can arise from the liver itself (primary liver cancer) or it can spread
to the liver from a primary tumour at another site (secondary, or metastatic,
cancer).
In the UK, secondary liver cancer is about 30 times more common
than primary liver cancer. Each year there are about 90,000 patients in the UK
with secondary liver cancer and about 3,100 with primary liver
cancer.
Primary liver cancer
Primary liver cancer can arise from the liver cells themselves
(hepatocellular carcinoma) or from the system of tubes that drains the bile
from the liver (cholangiocarcinoma, gall bladder cancer).
Most patients with primary liver cancer have suffered previously
from liver disease such as chronic
hepatitis,
cirrhosis or, in the
less developed world, have been exposed to poisons from plants
(aflatoxins).
Immunisation against
hepatitis B might,
particularly in the developing world, prevent many cases of primary liver
cancer.
Worldwide, primary liver cancer is the third most common cause
of death from cancer.
What are the symptoms of primary liver cancer?
People with chronic liver disease may develop liver cancer
without noticing any new symptoms. The typical symptoms are discomfort or pain
in the right side of the upper abdomen, weight loss and tiredness.
How is primary liver cancer diagnosed?
Primary liver cancer can be diagnosed using a combination of
blood tests,
diagnostic imaging and image-guided biopsy. The blood test that is most useful
is AFP (alpha-fetoprotein).
These tumours will often show on an
ultrasound scan, but
for full assessment both
CT and
MRI scans are
required.
A needle
biopsy using
ultrasound (or other imaging) guidance will usually confirm the diagnosis.
How is primary liver cancer treated?
Primary liver cancer is difficult to treat. Surgical removal is
the best option but these tumours are often too large and too extensive for
surgery.
For fit patients with limited tumours surgical removal may be
possible. Liver transplant may also be an option.
Some tumours can be treated by injecting them with alcohol (PEI
– percutaneous ethanol injection) or heating them with electrodes (RFA –
radiofrequency ablation). This can be done by using needles passed through the
skin or by using keyhole surgery.
A technique called TACE (transarterial chemoembolisation) can be
used for more advanced tumours.
An interventional radiologist can place a catheter into the
artery supplying the tumour and this can be used to deliver
chemotherapy drugs mixed with a syrupy fluid directly to
the tumour. This approach both delivers the cell-killing drug directly to the
tumour and cuts off its blood supply.
Standard intravenous chemotherapy is occasionally used for
inoperable tumours but any benefit is usually short lived.
Experimental treatments include biological agents such as
cetuximab (eg
Erbitux) and sorafenib or using catheters to deliver tiny radioactive
pellets to the tumour (SIRT – selective internal radiation
therapy).
Specialised techniques, involving the temporary placement of
radioactive wires, can be used to treat certain primary cancers of the ducts
within, or immediately adjacent to, the liver.
Unfortunately, survival rates for primary liver cancer are low
– the three-year survival rate is less than five per cent.
Secondary (metastatic) liver cancer
Secondary (metastatic) cancer reaches the liver by spreading
through the blood system from a primary tumour at a separate site.
In about 50 per cent of patients with metastatic liver cancer,
the primary tumour is in the
bowel (colon, rectum)
or
stomach. The other
common primary sites are the
breasts and
lungs.
What are the symptoms of secondary cancer involving the
liver?
The symptoms can include:
-
tiredness
-
loss of appetite
-
nausea
-
a dragging sensation or heaviness felt up under the lower ribs
on the right-hand side of the body
-
pain in the upper part of the belly, particularly on bending
forwards.
In the later stages, the skin can develop a yellowish tinge
(jaundice) together
with fevers and drenching sweats, particularly at night.
How is secondary liver cancer diagnosed?
The diagnosis is usually made with a combination of imaging
tests (ultrasound, CT scan, MRI) and image-guided biopsy. Sometimes blood
tests, for example a CEA (carcinoembryonic antigen) test, in someone with a
history of bowel cancer may also be useful.
How is secondary liver cancer treated?
The treatment of secondary (metastatic) liver cancer is
determined by the site of origin of the original (primary) tumour.
It’s important to realise that the tumour, even though it has
spread to the liver, will still behave according to its origin. A leopard does
not change its spots: breast cancer involving the liver behaves like breast
cancer, not like primary liver cancer. Consequently the outlook can be rather
better for patients with secondary, as opposed to primary, liver
cancer.
Surgery is increasingly being used for patients with secondary
liver cancer. This can sometimes involve removing a segment of
liver.
Alternatively, keyhole techniques can be used to apply extreme
cold (cryosurgery) or heat (radiofrequency ablation – RFA) to localised areas
of the liver.
Selective internal radiation therapy (SIRT) is an experimental
technique that involves delivering microscopic radioactive spheres directly to
the tumours via their blood supply.
The presence of secondary cancer within the liver implies that
the primary tumour has spread via the bloodstream and as a result other organs
may be at risk.
It is sensible, therefore, to consider using a treatment such as
chemotherapy, which acts all over the body. The type of chemotherapy used will
depend on the type of primary cancer.
Hormone treatment is
an additional option for patients with cancers of the breast or
prostate that have
spread to the liver.
References
http://info.cancerresearchuk.org/cancerstats/types/liver/incidence/
El-Serag HB, Marrero JA, Rudolph L, Reddy KR: Diagnosis and
treatment of hepatocellular carcinoma. Gastroenterology 2008,
134(6):1752-1763
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Based on a text by Dr Per Grinsted
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Last updated 04.09.2008
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