Download Liver cancer

Hepatocellular carcinoma
The following organizations offer support to liver cancer patients.*
www.beatlivertumors.org
www.dailystrength.org/c/Liver-Cancer/support-group
www.cancer.gov/cancertopics/types/liver
www.cancer.gov/cancertopics/coping
www.bluefaery.org
Liver cancer
Information for patients
*BTG International group companies take no responsibility for the content or advice offered
by these organizations.
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every reasonable care has been taken to ensure accuracy in compiling the content of this
booklet, it is for information purposes only and is not intended to provide medical advice.
Always consult a doctor regarding the diagnosis and treatment of any medical condition.
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Provided as an educational service by
Biocompatibles, Inc., a BTG International group company
Liver cancer
Liver cancer is described as either primary, when
the cancer starts in the liver itself, or secondary,
when the cancer starts elsewhere in the body but
spreads (metastasizes) to the liver. This booklet
looks only at the most common type of primary
liver cancer which is called hepatocellular carcinoma
(HCC). Worldwide, the number of people getting
HCC is increasing – it is the fifth most common
cancer in men and the seventh most common
cancer in women.
1,2
Inferior vena cava
This booklet will answer some of your questions
about the liver, who may be at risk of HCC, its
diagnosis and treatment.
Gall bladder
Hepatic artery
Portal vein
Supplies a healthy
liver with 25% of
its total blood
Supplies a healthy
liver with 75% of
its total blood
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3
Where and what is the liver?
The liver is the second largest organ (after the skin)
in the body and makes up about 2–3% of our body
weight, that is 1.5–2.0kg in the average adult.
It lies under the right side of the diaphragm,
protected by the rib cage.
The blood entering the liver through the hepatic
artery carries oxygen and the blood entering the
liver through the portal vein carries nutrients from
food digested in the stomach.
3,4
3,4
A quarter of your body’s blood passes through the liver
with each heartbeat – more than any other organ.
The hepatic artery supplies about 25% of the blood
and the portal vein, the remaining 75%.
The liver has four lobes and the liver tissue is
made up of six-sided units called lobules.
The liver contains many blood vessels and
each lobule has its own blood supply.
3
3,4
Medical words about the liver often include ‘hepato’
or ‘hepatic’ from the Greek word for the liver,
‘hepar’. Liver tissue cells are called hepatocytes.
3
Caudate lobe
Left
lobe
Right
lobe
Lungs
Posterior (back)
view of liver lobes
Heart
Liver
Stomach
Right
lobe
Quadrate
lobe
Left
lobe
Pancreas
Kidneys
Colon
Lobule
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What does the liver do?
The liver makes many important
substances. These include:
5,6
•Cholesterol
•Bile
RES
STO
MAKES
The liver also stores:
•Carbohydrates and helps control
the level of sugar in the blood
5,6
•Fats and breaks them down
to produce energy
5,6
Makes
important
substances
including
cholesterol,
bile, hormones,
proteins, nucleic
acids (DNA
and RNA) and
amino acids
And cleans:
•Blood by removing alcohol, drugs
and normal body waste products
such as ammonia which would
otherwise build up and be harmful
5,6
Drains bile, which
is used to break down
fats and absorb waste
products from
the blood
DR
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AIN
Releases
substances
it stores into the
bloodstream as they
are required by
the body,
regulating
their levels
Cleans the blood,
removing alcohol,
drugs and waste
products such
as ammonia
NS
•Proteins needed to keep the body’s
fluid balance and for blood clotting,
immunity and to carry hormones
and iron round the body
R
S
SE
EA
EL
Stores the substances
it makes as well as
those it absorbs
from the blood
(e.g. carbohydrates)
•Nucleic acids – including DNA and RNA
EA
• Vitamin D
CL
•Hormones
S
7
Who may be at risk of HCC?
Cirrhosis is a major risk factor for HCC. Cirrhosis
describes a liver scarred by continual damage and
repair. The main causes of cirrhosis and HCC are:
1
Chronic hepatitis B or C
Prolonged alcohol abuse
Obesity, diabetes and nonalcoholic fatty liver disease
Aflatoxins
Hereditary conditions
Anabolic steroids
1,6,7
• Hepatitis B or C infection
• Prolonged alcohol abuse
•Non-alcoholic fatty liver disease
(commonly caused by obesity)
•Aflatoxins, which are poisonous chemicals
found in mold growing on cereals, nuts and
other crops in some parts of the world
•Inherited conditions, such as hemochromatosis,
which is when the body absorbs too much iron
from food and deposits it in the liver
Long-term use of anabolic steroids, used by some
athletes to improve their strength, may also increase
the risk of HCC.
8
People who smoke, have diabetes or a family history
of HCC are all at higher risk of developing this type
of cancer than those who do not.
1,7
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How HCC develops and spreads
HCC occurs when the normal liver cells
(hepatocytes) have to keep reproducing
to repair damage to the liver. As they do this,
they build up genetic mistakes. Eventually,
they can turn into cancer cells which carry on
growing and increasing in number because
the normal controls don’t work properly.
1
The cells become small tumors (lumps). Growing HCC
tumors produce special chemicals to create their
own blood vessels. This is to try to ensure they have
a good supply of nutrients and oxygen and c­ an
continue to grow and spread.
1
2
1
3
Liver with cirrhosis
Damaged liver cells
build up genetic
mistakes and become
cancerous (HCC)
Liver with cirrhosis and HCC
If the cancer is not contained
and the tumor(s) get larger,
cancer cells are likely to
get into the blood vessels.
This allows the cancer cells
to spread (metastasize) to
other parts of the liver and
elsewhere in the body.
1,9
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Signs and symptoms of HCC
All the symptoms mentioned here may have
other causes, including other liver disease. If you
have any of these symptoms, please don’t assume
you have liver cancer but do see your doctor.
Unexplained weight loss
!!!
Jaundice
Bilirubin is a yellow waste product
from dead red blood cells. A healthy
liver uses some bilirubin to make
bile and sends the rest to the
intestines to be excreted.
6
You may unexpectedly
lose a large amount of
weight (more than 10% of
your normal body weight).
1,6,11
If the liver is not working properly,
the bilirubin builds up in the
bloodstream and the skin and the
whites of the eyes become yellow.
This is known as jaundice.
6
Jaundice can also cause itchy
skin, pale-colored stools and dark-colored urine.
Loss of appetite
6
You may not feel like
eating or may feel full
or bloated after only
a small meal.
Other symptoms
1,6
•
Nausea and/or vomiting (feeling and/or being sick)
6,11
•High temperature/sweating
•Extreme tiredness
Abdominal problems
6,10
6,11
Your liver may get bigger,
causing a swelling on the right
side of your abdomen. Swelling
may also appear all over your
abdomen due to build-up of
fluid, known as ascites. Enlarged
veins may show through your
skin where the abdomen has
stretched.
1,6
You may have abdominal
pain or feel a lump below the
ribcage on the right-hand side
where your liver has swollen.
1,6,11
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Always see your doctor if you previously have had
a condition affecting the liver, such as cirrhosis or
hepatitis C, and your health suddenly worsens.
13
Tests for HCC
If you are at risk of HCC, your doctor will examine
you and do blood tests at regular intervals to see
if there are any changes in your condition.
•
A physical examination to check for any signs and
symptoms which give cause for concern
• A
n ultrasound scan, which uses high-frequency
sound waves to create images of organs and
internal structures. A doctor or nurse will move
a probe (sensor) gently over your abdomen.
The probe sends images of your liver to a screen
to check for any tumors or other abnormalities
•
Blood tests:
-A
liver function test will check the blood for
proteins, enzymes and other substances that
the liver makes or regulates to see if the levels
are abnormally high or low
6,10
- A test for a substance in the blood called
alpha-fetoprotein (AFP) which is an indicator
that HCC may be present
6,10
Ultrasound scan
Blood tests
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You are also likely to be given an ultrasound scan
and blood tests if you have no obvious risk factors
for HCC or history of liver problems, but are
showing symptoms of liver disease or liver cancer.
While ultrasound scans can detect tumors in the
liver, they cannot tell doctors if they are cancerous
(malignant) or not. In the same way, blood tests can
indicate if something is wrong with the liver, but not
whether it is definitely HCC. So, if these first tests
show that HCC may be present, more thorough
scans will be obtained using CT (computerized
tomography) or MRI (magnetic resonance imaging).
These provide a series of detailed images of the liver
and any tumors that are present.
7,10
Occasionally, if the CT or MRI does not give a clear
result, a biopsy may be required. This is when a small
sample of tissue is removed from the tumor through
the skin so that it can be tested in a laboratory.
As CT and MRI scanning become more advanced
and provide increasingly detailed information,
biopsies become less common.
7
1,7,10
MRI and CT scans
15
Treatment of HCC: resection and transplantion
Many different treatments are possible for the
treatment of HCC. The choice depends on:
Surgery
12
•How big the tumor is
Surgery to remove the part of the liver containing
the cancer is known as a resection or partial
hepatectomy and can provide a cure for HCC.
Resection may be possible if liver function is
good and the HCC is at an early stage.
1,7,10
•Whether there is more than one tumor
•The ‘stage’ of the tumor (how advanced it is)
•Whether HCC is only in the liver or has spread
to other parts of the body
•Liver function (how well the liver is working)
9
A liver transplant may be the right treatment if the
HCC is too advanced for resection. Receiving a
transplant depends on a suitable donor liver
becoming available.
1,7,10
•General health
Surgical resection
Transplantation
Donor liver
Diseased liver
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Treatment of HCC: ablation
Patients with HCC who are not suitable for surgery
or who are awaiting transplant may be offered other
therapies to reduce the size of their tumor(s)
and/or prevent the HCC from progressing.
7
Ablation therapies
Ablation therapies avoid the need for open surgery
and are usually carried out by an interventional
radiologist (IR) who uses special imaging equipment
to see inside the body and to gain access to the
tumor(s) through small incisions.
• P
ercutaneous ethanol injection (PEI) uses ethanol
(a type of concentrated alcohol) injected through
the skin to destroy tumor tissue
Radiofrequency
Microwave
ablation
PEI is less commonly used today than other
ablation techniques:
•
Radiofrequency and microwave ablation use
high temperatures to destroy the tumor
• C
ryoablation uses freezing temperatures to
kill the cancer cells
•
Irreversible electroporation (IRE) uses high-energy
pulses of electricity (without heat) to destroy tissue
Cryoablation
Irreversible
electroporation (IRE)
+
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Treatment of HCC: embolization and systemic therapies
Embolization therapies
mbolization therapies are also carried out by an
E
interventional radiologist using catheters (thin flexible
hollow tubes) to reach vessels feeding the tumor(s).
Particles (embolic agents) are injected to block the
vessels, starving the cancer cells of oxygen and
nutrients. Embolization therapies are used when the
tumor size is too large for ablation or to prevent the
HCC from progressing in patients awaiting transplant.
• Transarterial chemoembolization (TACE)
combines embolization with a chemotherapy
drug (usually doxorubicin)
7,9,10
• Transarterial radioembolization (TARE) targets
the cancer by delivering tiny beads loaded with
radioactive Yttrium-90 directly to the tumor(s)
7
7,12
Liver
Embolic agents are injected
into vessels feeding tumor
Tumor shrinks in size
HCC tumor
Hepatic
artery
Catheter
Catheter
entry site
Systemic therapies
•Biological drug
therapies, such as
sorafenib offer the
potential for prolonged
survival in patients with
advanced HCC
7,11
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21
Glossary
Ablation
Destruction of tissue (eg cancer cells).
Aflatoxin A poisonous chemical found in mold growing
on crops in some parts of the world.
Alpha-fetoproteinA substance produced by some types of cancer
cell but also found in non-cancerous conditions.
Anabolic steroidA substance sometimes used by athletes to
improve muscle strength.
Ascites
A build-up of fluid in the abdomen.
Benign
Non-malignant or not cancerous.
BileA substance produced by the liver and stored in the gall
bladder. Helps to digest fats in the intestine.
Contains bilirubin.
Bile ductA tube carrying bile. The common bile duct releases bile
into the intestine to help digest fats.
BilirubinA yellow pigment that is a waste product from dead
red blood cells. Gives bruises their yellow color and
discolors skin and whites of the eyes when
someone has jaundice.
Biological drugsDrugs which boost the body’s immune system to
target cancer cells while not affecting healthy cells.
BiopsyRemoval of a small tissue sample for examination under
a microscope.
ChemoembolizationEmbolization (blocking) of arteries combined with
chemotherapy. The aim is to trap the drug in the
tumor and block the blood supply to the tumor.
ChemotherapyDrugs aimed at killing cancer cells or slowing
their growth. May also impact healthy liver cells.
CholesterolA substance found in animal fat. An essential part
of the diet; a building block of all cell membranes
and used to make hormones.
CirrhosisDescribes a liver badly scarred by continual
damage and repair.
Contrast mediumA substance to help show up blood vessels and
flow during radiography and CT- and MRI- scans.
CT-scanComputerized tomography, in which a computer builds
up many X-rays to make a detailed 3-dimensional
picture of internal organs and tissues.
DiabetesA condition where a person’s blood sugar levels
are too high. Treated with diet, tablets and/or
insulin injections.
DiaphragmA sheet of muscle separating the heart and lungs
of the abdomen. Assists breathing by helping to
move air in and out of the lungs.
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DoxorubicinA chemotherapy drug that works by damaging DNA.
Used to treat many kinds of cancer.
Embolization therapyTherapy that deliberately blocks the blood supply
to the tumor.
Gall bladder A small, pear-shaped organ, 7-10cm long, found
just beneath the liver. Stores and releases bile.
Genetic Relating to the genes, the material in each cell that
holds the information that controls everything about
the cell. Passed to the next generation (inherited)
through reproduction.
HCC See hepatocellular carcinoma.
Hemochromatosis A rare inherited condition where the body absorbs too
much iron from the food and deposits it in the liver.
Hepatectomy
Surgical removal of all or part of the liver.
Hepatic
Relating to the liver.
Hepatitis Inflammation of the liver, usually due to infection by
one a group of viruses. Infections caused by hepatitis B
virus and hepatitis C viruses increase the risk of HCC.
Hepatocellular carcinoma Primary liver cancer.
Hepatocyte The name given to the type of cells which make up
most of the liver.
Hormone A chemical made by cells in one part of the body that
sends messages to cells in another part of the body.
Examples are oestrogen, testosterone and adrenaline.
Invasive tumor A tumor that gets into blood vessels.
Jaundice A yellow coloration of the skin and whites of the eyes
caused by build-up of bilirubin. Caused by liver disease
or conditions affecting the red blood cells or bile duct.
Liver function test A blood test to find out how well the liver is working.
Malignant Another word for cancerous.
Metastasis Spread of a primary cancer to other tissues.
Microwave Energy source used for tissue ablation.
MRI scan Magnetic resonance imaging, which uses a
magnetic field rather than X-rays to look more
closely at internal organs and tissues.
Non-alcoholic fatty A build-up of fat in the liver cause by something
liver diseaseother than drinking too much alcohol. Seen in people who are overweight or obese.
Nucleic acids DNA and RNA, the chemicals that contain and
pass on genetic information.
23
Glossary
Notes
PercutaneousThrough the skin.
Portal vein The vein that carries blood containing nutrients
to the liver from food digested in the stomach.
Primary liver cancer Cancer that starts in the liver.
Radioembolization Embolization therapy which uses radioactive
embolic beads to target the tumor with radiation.
Radiofrequency ablation Treatment that uses high-frequency radio waves to heat
and destroy tumor cells.
Radiography The use of X-rays to examine the inside of the body.
Recurrence The return of a cancer after treatment has appeared
to have removed it.
Red blood cellThe most numerous type of blood cell that give blood
its red color. Contains a pigment (haemoglobin)
that carries oxygen round the body.
Risk factorAnything that increases the chance of developing
a disease.
Secondary liver cancer Cancer that starts elsewhere in the body but
spreads (metastasizes) to the liver.
Sorafenib A biological drug that targets several types of
cancer cell, including HCC.
Systemic therapy Treatment that uses medicines delivered into the
bloodstream and so can affect any cell in the body.
TACE Transarterial chemoembolization.
TARE Transarterial radioembolization.
Transarterial
Performed through the arteries.
Tumor staging A way to describe how advanced the tumor
is and whether it has spread.
TumorA lump that forms when cells reproduce faster
than they die. Not necessarily cancerous.
Ultrasound scanThe use of sound-wave echoes to build a picture
of internal organs and tissues.
Vitamin DA group of essential substances vital to make healthy
bones. Some forms of vitamin D are made in the liver;
others are made in skin when exposed to sunlight.
X-rays
A type of radiation used to examine the inside of the body.
Y-90
Radioactive material.
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Notes
References
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Accessed 19 March 2013.
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9.Hussain HK, Francis IR (eds). Primary carcinomas of the liver. Cambridge:
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