What Is Cancer?

[Guest guest]

Liver Cancer

Article Date: 3/5/2004

What Is Cancer?

Cancer is a group of many related diseases that begins with abnormal

growth in the cells of the body.

Normally, cells grow and divide to form new cells as the body needs

them, but sometimes, this process goes wrong.

New cells form when the body does not need them, or old cells do not

die when they should. These extra cells can form a mass of tissue

called a growth or tumor. Tumors can be benign or malignant.

Benign tumors. These tumors are not cancer. Usually, doctors can

remove them and in most cases, they do not return. Benign tumors do

not spread to other parts of the body and are rarely a threat to life.

Malignant tumors. These tumors are cancer. Cells from cancerous

tumors can invade and damage nearby tissues.

Cells from cancerous tumors can also break away and enter the

bloodstream or the lymphatic system, spreading to form new tumors in

other organs. This process is called metastasis. Different types of

cancer tend to metastasize to different parts of the body.

What is Liver Cancer?

Liver cancer, also called hepatocellular carcinoma or malignant

hepatoma, is a primary liver cancer that originates in the

hepatocytes (liver cells).

" Primary' means that is begins in the liver, as opposed to cancers

that begin elsewhere in the body and metastasize to the liver.

When liver cancer metastasizes, the cancer cells tend to spread to

nearby lymph nodes and to the bones and lungs. When this happens, the

new tumor has the same kind of abnormal cells as the primary tumor in

the liver.

For example, if liver cancer spreads to the bones, the cancer cells

in the bones are actually liver cancer cells. The disease is

metastatic liver cancer, not bone cancer.

It is treated as liver cancer, not bone cancer. Doctors sometimes

call the new tumor " distant " disease.

Similarly, cancer that spreads to the liver from another part of the

body is different from primary liver cancer. When cancer cells

spread to the liver from another organ (such as the colon, lung, or

breast), doctors may call the tumor in the liver a secondary tumor.

In the United States, secondary tumors in the liver are far more

common than primary tumors.

Hepatocellular carcinoma is a tumor that is relatively uncommon in

the United States, although its incidence is rising, principally in

relation to the spread of hepatitis C infection.

It is the most common cancer in some parts of the world, with more

than one million new cases diagnosed each year.

What Causes Liver Cancer?

Currently, no one knows the exact cause of liver cancer, but

scientists have found that people with certain risk factors are more

likely than others to develop liver cancer.

Studies have identified the following risk factors for developing

liver cancer:

Chronic liver infection (hepatitis). Hepatitis B and hepatitis C

infection appear to be the most significant causes of hepatocellular

carcinoma worldwide.

Studies have found that male patients older than 50 years who have

both hepatitis B and hepatitis C infection may be at particularly

high risk for hepatocellular cancers.

In people who are not already infected with hepatitis B virus,

hepatitis B vaccine can prevent chronic hepatitis B infection and can

protect against liver cancer.

Cirrhosis. Cirrhosis develops when liver cells are damaged and

replaced with scar tissue. Cirrhosis may be caused by alcohol abuse,

certain drugs and other chemicals, and certain viruses or parasites.

Hepatocellular carcinoma is associated with cirrhosis in 50% to 80%

of patients; about 5% of cirrhotic patients eventually develop

hepatocellular cancer.

Alcohol Use and Viral Hepatitis. There is evidence that patients with

both hepatitis B and hepatitis C infection who consume more than 80

grams of alcohol per day have an increased risk of developing cancer

as compared to patients who abstain from alcohol.

Aflatoxin. Liver cancer can be caused by aflatoxin, a toxic substance

made by certain types of mold found in peanuts, corn, and other nuts

and grains.

Aflatoxin has also been associated with the development of primary

liver cancer in Asia and Africa where aflatoxin is found in high

levels in ingested food.

In the United States, the Food and Drug Administration (FDA) does not

allow the sale of foods that have high levels of aflatoxin.

Gender. Men are twice as likely as women to get liver cancer.

Family history. People who have family members with liver cancer may

be more likely to get the disease.

Age. In the United States, liver cancer occurs more often in people

over age 60 than in younger people.

The more risk factors a person has, the greater the chance that liver

cancer will develop. However, many people with known risk factors for

liver cancer do not develop the disease.

Liver Cancer Symptoms

Liver cancer is sometimes called a " silent disease " because in an

early stage it often does not cause clinical symptoms.

Abnormal laboratory results may include:

Increasing alpha-fetoprotein (AFP)

Increasing alanine aminotransferase (ALT)

Increasing aspartate aminotransferase (AST)

Increasing alkaline phosphatase

Polycythemia (an abnormal increase in red blood cells)

Hypoglycemia (low blood sugar)

Hypercalcemia (elevated serum calcium)

Dysfibrinogenemia (abnormal production of fibrin, a clotting

component).

As the size of the tumor increases, symptoms may include:

Pain in the upper abdomen on the right side, extending to the back

and shoulder

Swollen abdomen (bloating)

Weight loss

Loss of appetite and feelings of fullness

Weakness or feeling very tired

Nausea and vomiting

Jaundice (yellow skin and eyes, and dark urine)

Fever.

Liver Cancer Diagnosis

If a patient has symptoms that suggest liver cancer, the doctor may

perform one or more of the following procedures:

Physical exam. The doctor palpates (feels) the abdomen to check the

liver, spleen, and nearby organs for any lumps or changes in their

shape or size, checks for ascites, and examine the skin and eyes for

signs of jaundice.

Blood tests. As mentioned above, laboratory abnormalities may be

present in liver cancer, especially elevated alpha-fetoprotein

(AFP). Between 50 and 70 percent of patients in the United States

who have liver cancer have elevated levels of AFP.

AFP levels can be used to indicate the prognosis for liver cancer

patients; the median survival of AFP-negative patients is

significantly longer than that of AFP-positive patients.

However, patients with other cancers may also have elevated AFP

levels. Other blood tests (alanine aminotransferase, aspartate

aminotransferase) can assess how well the liver is functioning.

CT scan. Computerized tomography (CT) is used to take a series of

highly detailed x-rays of the liver and other organs and blood

vessels in the abdomen. CT scanning allows the doctor to identify

tumors in the liver or elsewhere in the abdomen.

Ultrasonography. An ultrasound device uses very high-frequency sound

waves to produce a pattern of echoes as they bounce off internal

organs.

Computerized interpretation of the echoes create a picture of the

liver and other organs in the abdomen, allowing for the

identification of tumors or other abnormalities.

Magnetic Resonance Imaging. In an MRI scan, a powerful magnet linked

to a computer is used to create detailed pictures of areas inside the

body, identifying tumors or other masses.

Angiogram. In this procedure, a physician injects a special dye into

an artery that shows up on x-ray. This permits the physician to

identify areas of abnormal blood flow through an organ, such as in an

area of tumor.

Biopsy. A biopsy is the removal of a small sample of tissue for

microscopic examination. A pathologist examines the biopsy specimen

to identify abnormal cells, characteristic of cancerous growths.

Classification of Liver Cancer

For purposes of treatment, patients with liver cancer are grouped

into 1 of 3 groups: localized resectable, localized unrespectable, or

advanced disease.

Localized resectable primary liver cancer. This type of liver cancer

is confined to a solitary mass in a portion of the liver that allows

the possibility of complete surgical resection (removal) of the tumor

along with a margin of normal liver.

In the small group of patients that fall into this category, liver

function tests are usually normal or minimally abnormal.

Cirrhosis, if present, should be mild, and there should be no

evidence of chronic hepatitis, because patients with chronic

hepatitis and cirrhosis are at high risk for complications when

surgical resection is performed.

Locally advanced unresectable primary liver cancer. This type of

liver cancer is confined to the liver, but surgical removal of the

entire tumor is not possible.

This may be due to cirrhosis or other conditions that cause poor

liver function, the location of the tumor within the liver, or other

health problems.

These patients may be candidates for liver transplantation. In other

cases, chemoembolization, percutaneous ethanol injection, or

radiofrequency ablation may be options (these treatment options are

discussed below).

Advanced primary liver cancer. In these patients, advanced liver

cancer is present in both lobes of the liver or has metastasized to

distant sites, such as lung or bone.

The prognosis for these patients is very poor, with a median survival

of 2 to 4 months. Chemoembolization has been beneficial in some

patients who have no cancer lesions outside of the liver.

Talking to the Doctor

Many people with liver cancer want to learn all they can about their

disease and their treatment choices. However, the shock and stress

that people often feel after a diagnosis of cancer can make it hard

for them to think of everything they want to ask the doctor.

These are some examples of questions a person may want to ask the

doctor before treatment begins:

Is there any evidence the cancer has spread? What is the stage of the

disease?

Do I need any more tests to determine whether I can have surgery?

What are my treatment choices? Which do you recommend for me? Why?

What are the expected benefits of each kind of treatment?

What are the risks and possible side effects of each treatment?

Will I need to stay in the hospital?

How will you treat my pain?

What is the treatment likely to cost? Is this treatment covered by my

insurance plan?

How will treatment affect my normal activities?

Would a clinical trial (research study) be appropriate for me?

People do not need to ask all of their questions or understand all of

the answers at once. They will have other chances to ask the health

care team to explain things that are not clear and to ask for more

information.

Options for Treating Liver Cancer

At present, liver cancer can be cured only when it is found at an

early stage (before it has spread) and only if the patient is healthy

enough to have an operation.

However, non-surgical interventions may help control the disease,

extend life, and ease suffering.

Treatment options for liver cancer depend on many factors, including:

The condition of the liver

The number, size, and location of tumors

The presence of cancer has spread outside the liver

The patient's age and general health

Concerns about treatment and possible side effects

The patient's personal values.

Surgical resection of the tumor is an option in a small number of

cases. For these patients, options include partial and total

hepatectomy with liver transplant.

Partial hepatectomy. Surgery to remove part of the liver is called

partial hepatectomy. This option is only available to small

percentage or patients with localized resectable liver cancer.

The doctor may remove a wedge of tissue that contains the liver

tumor, an entire lobe, or an even larger portion of the liver.

In this procedure, the surgeon leaves a margin of normal liver

tissue. This remaining healthy tissue takes over the functions of the

liver.

Total hepatectomy with liver transplantation. In this procedure, the

transplant surgeon removes the patient's entire liver (total

hepatectomy) and replaces it with a healthy liver from a donor.

A liver transplant is an option only if the disease has not spread

outside the liver and only if a suitable donated liver can be found.

Patients with localized unresectable cancer may receive other

treatments to control the disease and extend life.

Radiofrequency ablation. In this procedure, a probe is used to kill

tumor cells with heat. Laser and microwave techniques also destroy

tumor cells with heat.

Percutaneous ethanol injection. In this procedure, alcohol (ethanol)

is injected directly into the liver tumor to kill cancer cells.

Cryosurgery. In this procedure, a probe is inserted into the tumor

that freezes and kills cancer cells.

Hepatic arterial infusion. In hepatic arterial infusion, anticancer

medications are injected in to the hepatic artery, sending the

medication directly to the tumor.

This minimizes the effect of the drug on other organs. In some

cases, the medication is delivered continuously to the tumor by way

of a small, surgically implanted pump.

Chemoembolization. Similar to hepatic arterial infusion,

chemoembolization involves injecting an anticancer drug into the

hepatic artery.

After the drug is injected, tiny particle are infused that block the

flow of blood through the artery. Without blood flow, the drug stays

in the liver longer.

Currently there is no cure for advanced liver cancer. Some patients

choose to receive anticancer therapy to try to slow the progress of

the disease, reduce their pain and control other symptoms.

Because there is no standard therapy for patients with advanced

metastatic liver cancer, patients should be considered for clinical

trials of new medications or combinations of existing drugs and other

therapies.

Current standard treatment for advanced liver cancer may involve

chemotherapy, radiation therapy, or both.

Chemotherapy. Chemotherapy uses drugs to kill cancer cells. The

therapy may involve chemoembolization, hepatic arterial infusion or

systemic therapy, in which the drugs are injected into a vein and

flow to nearly every part of the body. The physician may administer

one drug or a combination of medications.

Radiation therapy. Also called radiotherapy, this treatment uses

high-energy rays, similar to x-rays, to kill cancer cells.

Radiation therapy is local therapy, meaning that it affects cancer

cells only in the treated area. A large machine outside the body

directs radiation to the tumor area.

Support for People with Liver Cancer

Coping with a serious disease such as liver cancer is difficult.

Often, people find they need help coping with the emotional and

practical aspects of their disease.

Patients may worry about caring for their families, holding on to

their jobs, or keeping up with daily activities. Concerns about

treatments and managing side effects, hospital stays, and medical

bills are also common.

Doctors, nurses, and other members of the health care team will

answer questions about treatment, working, or other activities.

Meetings with social workers, counselors, or members of the clergy

can be helpful to those who want to talk about their feelings or

discuss their concerns.

Often, social workers can suggest resources for emotional support,

financial aid, transportation, or home care.

Many find that support groups can help. In these groups, patients or

their family members get together to share what they have learned

about coping with the disease and the effects of treatment.

Patients may want to talk with a member of their health care team

about finding a support group. Groups may offer support in person,

over the telephone, or on the Internet.

More Information

U.S. residents may call the National Cancer Institute's (NCI's)

Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-

6237) Monday through Friday from 9:00 a.m. to 4:30 p.m.

Deaf and hard-of-hearing callers with TTY equipment may call 1-800-

332-8615. The call is free and a trained Cancer Information

Specialist is available to answer your questions.

The NCI's Cancer.gov Web site provides online access to information

on cancer, clinical trials, and other Web sites and organizations

that offer support and resources for cancer patients and their

families.

There are also many other places where people can get materials and

information about cancer treatment and services.

Local hospitals may have information on local and regional agencies

that offer information about finances, getting to and from treatment,

receiving care at home, and dealing with problems associated with

cancer treatment.

The NCI has booklets and other materials for patients, health

professionals, and the public. These publications discuss types of

cancer, methods of cancer treatment, coping with cancer, and clinical

trials.

Some publications provide information on tests for cancer, cancer

causes and prevention, cancer statistics, and NCI research

activities. NCI materials on these and other topics may be ordered

online or printed directly from the NCI Publications Locator.

These materials can also be ordered by telephone from the Cancer

Information Service toll-free at 1-800-4-CANCER (1-800-422-6237), TTY

at 1-800-332-8615.

The NCI's LiveHelp service, a program available on several of the

Institute's Web sites, provides Internet users with the ability to

chat online with an Information Specialist.

The service is available from 9:00 a.m. to 10:00 p.m. Eastern time,

Monday through Friday. Information Specialists can help Internet

users find information on NCI Web sites and answer questions about

cancer.

For more information from the NCI, please write to this address:

NCI Public Inquiries Office

Suite 3036A

6116 Executive Boulevard, MSC8322

Bethesda, MD 20892-8322