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Liver cancer



Primary liver cancer is a rare form of cancer, but recently there has been an increasing prevalence.


The most common disease is in Africa and parts of Asia.


Prof. Dan AderkaChairman of the Gastrointestinal Cancer Service. Head of GI Biology and Immunotherapy Program Sheba Medical Center. Consultant at Cell Regulation Department, Weizmann Institute. Head of the Gastrointestinal Cancer Unit at the Assuta Hospital.


Prof. Menahem Ben Chaim – Head of the Department of Hepatobiliary Surgery, Shaare Zedek Medical Center. Hepatologist, gastroenterologist, general surgery.



There are two types of primary liver cancer:
The more common type is called hepatoma (hepatocellular carcinoma) is formed of the main liver cells – hepatocytes. This type of cancer develops in the liver, but often spreads to other organs. It is particularly common in people with cirrhosis. There is a rare subtype of hepatoma, which affects young people and is not associated with previous liver disease.


A second type of primary liver cancer is called cholangiocarcinoma, which is formed in the cells lining the bile ducts.


Some of the primary liver tumors are benign (not applicable). These tumors are, by and large, does not cause symptoms. Thus, they are mainly found by chance during operation or diagnosing other diseases.


There are several factors that increase the risk of developing this cancer type:
Cirrhosis of the liver – in the Western world, many cancer patients also suffer from hepatitis, cirrhosis of the liver. Cirrhosis is scarring of the liver tissue, which may be due to various reasons (infection, alcohol). Nevertheless, only a small percentage of patients with cirrhosis develop primary liver cancer.


Hepatitis B and C may lead to liver cancer and are an important risk factor for the development of cirrhosis that can later also lead to liver cancer. Such a higher risk of infection in smokers.


Heredity – people with a rare disease as hemochromatosis, which causes an overload of iron in the body, or alpha 1 antitrypsin deficiency, a protein produced in the liver (glycoprotein AATN), more likely to develop liver cancer.


Liver cancer usually affects middle-aged and older people. But in rare cases it may occur in young people or children.


Primary liver cancer is twice more common in men than in women.


In most cases, primary liver cancer does not cause symptoms in the early stages. Sometimes patients complain of a vague feeling of discomfort and/or pain in the upper abdomen, due to the enlargement of the liver. Sometimes the pain extends to the right shoulder, because of the pressure from the enlarged liver nerves below the diaphragm (breathing muscle that separates the lungs from the abdomen). These nerves connected to the nerves of the right hand.


In the later stages of disease the most common symptoms are loss of appetite, weight gain, nausea, weakness and fatigue. Some patients also suffer from high fever and chills.


Later stages of the disease is also characterized by the appearance of jaundice and/or ascites. This clinical condition requires surgical intervention.


Jaundice. Enlargement of the liver can cause pressure and partial blockage of bile ducts. Therefore bile produced in the liver and contained in the gallbladder is fed back into the bloodstream, and cause jaundice. As a result, the skin and the whites of the eyes may turn yellow, darken urine. Additionally, itching may occur.


Ascites is formed when fluid accumulates in the stomach and causing its increase. Get rid of liquids possible with the medical procedure is inserted gastric tube and thus merges excess fluid. Several factors which may cause ascites: the spread of cancer cells through the stomach can cause irritation and accumulation of fluid, damage to the liver can lead to a reduction of protein production. The result is a decrease in albumin, which maintains the pressure in the blood vessels, whereby a balance can be eroded by body fluids, a condition that leads to an accumulation of fluid in the body tissues, particularly in the abdomen. Blockage of the lymphatic system cancer cells. The lymphatic system is a network of tiny tubes, distributed throughout the body. One feature of this system is to drain the excess fluid to be secreted from the body via the urine. If drainage system is not effective, the fluid accumulates in the body.


Diagnosis usually begins with a medical examination, as well as the following tests:
Ultrasound, CT (computed tomography) abdominal MRI (magnetic resonance imaging), testing of donated blood to the liver (liver arthrography) and blood: the level of alpha-feto protein, which can be very high in some cases of hepatoma. The final diagnosis may be done by biopsy of the liver, which helps determine the typical hepatoma cells under a microscope. The procedure is performed under CT or ultrasound to ensure the taking of proper tissue site. After the biopsy the patient tends to remain in the hospital for several hours or overnight.

Laparoscopy. This is an invasive test, during which doctors are able to examine the liver and other organs in this area. Examination is carried out under general anesthetic and involves a short period of hospitalization. Under general anesthesia the surgeon performs a small incision on the front of the lower abdomen and inserts a small tube with a flashlight and a camera (laparoscope) through which the doctor will be able to watch the liver and take a small sample of cells to perform a biopsy under a microscope.

Angiography of the liver. This test helps doctors study the effect of growth in the major blood vessels around the liver. A thin tube is inserted through an artery in the groin and through a special dye is injected. The material passes through the blood vessels and arteries and allows physicians to examine them with X-ray examination. Sometimes, such a study can be performed using MRI, in which case there is no need for angiography.


Staging of liver cancer
Stage Cancer is a term which describes the size and the degree of tumor spread.
Stage 1: the tumor is less than 2 cm and has not spread so far.
Stage 2: there is more than one tumor in the liver.
Stage 3A: a tumor larger than 5 cm or has spread to nearby blood vessels.
Stage 3B: the tumor has spread to nearby organs in the liver, such as the intestine or stomach, but has not yet spread to the lymph nodes.
Stage 3C: the tumor has spread to nearby lymph nodes (regardless of size).
Stage 4: The tumor has spread to other organs in the body that are not adjacent (eg, light).


Liver cancer management
When choosing a method of treatment for the doctor are important factors such as: primary/secondary cancer, age and general health of the patient, the type and size of the cancer, whether the tumor has spread beyond the liver, and other diseases (eg, cirrhosis).


Surgery. Surgery is the most effective treatment for primary liver cancer. Nevertheless, there are cases where the operation can not be performed because the stage of the cancer, its localization in the liver or cirrhosis of the liver. Another reason is the spread of cancer beyond the liver.


Partial hepatectomy. When the disease affects certain areas of the liver, can be performed partial hepatectomy, which removes only the infected part.


Lobectomy. Surgery to remove a large part possible because the liver has an ability to regenerate (recovery). The organ can return to its normal size within a few weeks, even after the removal of three-quarters of it.


Liver transplantation. Replacing the liver from another person is another treatment option for patients with primary liver cancer. Nevertheless, this can be accomplished in only a small proportion of cases, where the tumor less than 5 cm, or when there are less than three tumors less than 3 cm.
After surgery, the patient may be hospitalized in intensive care, at least until the effects of anesthesia not scattering (about 1 day). Pain or discomfort in the liver after surgery is no exception. To facilitate the patient continuously injected an anesthetic.


Ablation. This method is used for the removal of tumors with a diameter of not more than 5 cm. Alcohol (ethanol) or acetic acid is injected into the tumor, that destroys the cancer cells. The procedure performed in the radiology department under ultrasound guidance. In case of recurrence of the disease (when the tumor appear again), the procedure can be repeated.


Thermal ablation (laser or radio waves). Destruction of cancer cells is achieved using a laser or an electric generator. Under this procedure, a needle is inserted into the center of the tumor under local anesthesia and under ultrasound guidance. Through this needle is introduced radio waves or laser waves that heat and kill cancer cells directly locally without damaging healthy tissue nearby.


Chemotherapy. Chemotherapy is used in the treatment of most tumors which can not be surgically removed. Drugs are usually administered by injection into a vein in the arm or directly into the artery that leads to the liver blood flow.
Chemotherapy can often cause undesirable side effects, but symptoms can be alleviated. Any side effect often is temporary and treatable with medication. Common symptoms of this decrease in resistance to infection, nausea, sensitivity, mouth sores and hair loss.


Radiotherapy. This method is not generally used in the treatment of hepatitis, but can be applied in the case of cholangiocarcinoma. Radiation therapy uses high-energy rays to kill cancer cells, while causing little damage as possible, to normal cells.
Selective internal radiation therapy (SIRT). Was recently approved a new method of treatment of hepatic tumors that can not be surgically removed. This treatment is a topical treatment, at which the direct injection of plastic pellets containing minor dose of radioactive material called yttrium-90. These pellets are transported directly into the blood stream to the liver and block blood vessels that feed the tumor, and irradiated from the inside. This procedure is performed on the target tumor cells. Treatment helps to focus regulatory activity and maintain healthy liver tissue.


Targeted therapy. Biological treatment and immunotherapy. For the development of cancer cells requires “chemical signals” that cause them to divide and form new cells. Preparations – growth inhibitors and block these signals affect the ability to grow and develop cancer in the body.


More detailed about targeted, biological and imminotherapy for liver cancer in Israel.


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