Types of Liver Cancer and Their Treatment

Types of Liver Cancer - Primary and Secondary

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, hemochromatosis (a 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.

Laboratory investigations

• Blood tests: complete blood count, LFT, RFT, Serum electrolytes, coagulation profile, HIV, HCV &HBV
• Radiological imaging: USG Abdomen, CT scan of the abdomen, MRI Abdomen, MRI Abdomen & pelvis
• Tumor marker: AFP

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

B) 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 (Tumour 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 resectable 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.

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Liver Cancer - FAQs

1) What is liver cancer?

Ans Cancer that starts in the cells of your liver is called liver cancer.

There are two types of liver cancer

A) Primary Liver Cancer  - hepatocellular carcinoma and cholangiocarcinoma

B) Secondary liver cancer - Cancer that spreads to the liver from other organs. Example colon cancer, stomach cancer, and pancreatic cancer.

2) Is cirrhosis of the liver the same thing as liver cancer?

Ans Cirrhosis is due to long-term injury to the liver. It can be alcoholic or non-alcoholic cirrhosis seen in patients with fatty liver. The most common causes are hepatitis and alcohol abuse. Cirrhosis by itself is not cancer but increases the risk of liver cancer.

3) Can liver cancer be prevented?

Ans Once cirrhosis (or scarring of the liver) has set in, it is generally not reversible. Therefore, the best way to prevent liver cancer is to avoid liver damage by treating any underlying hepatitis and avoiding excess alcohol use.

4) What is the survival rate after the surgery for HCC?

Ans In general, survival rates are higher for people who can have surgery to remove their cancer, regardless of the stage. Overall survival is over 50-70% in patients with small resectable tumors who do not have cirrhosis or other health issues. For early-stage HCC with cirrhosis and liver transplant, the 5-year survival rate is 60-70%.

5) What will be the follow-up duration after the treatment?

Ans You must consult your doctor every 3 to 6 months for the first 2 years, then every 6 to 12 months. Then, the longer you are cancer-free, the less often the visits are needed. After 5 years, they may be done once a year.

6) What are the side effects of chemotherapy and radiotherapy?

Ans Side effects of chemotherapy include nausea, vomiting, hair loss, infection, and loss of appetite. These symptoms will settle down once the patient has completed chemotherapy. Side effects of radiotherapy include skin changes where the radiation is given and fatigue.

7) What are the complications of major liver resection?

Ans Bile leak, wound infection, post-surgery hepatic insufficiency, and intra-abdominal collection. Most of the complications are managed conservatively. In case of complications, hospital stay, and expenses may increase.

8) What is the survival rate in colorectal metastasis after surgery?

Ans In solitary and resectable liver metastasis the survival rate is 60-70%, in multiple resectable liver metastases the survival rate is 25-30%.

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