Current Management of Liver Cancer

Hepatocellular carcinoma (the most common form of primary liver cancer, abbreviated “HCC”) has historically carried a very serious prognosis with few treatment options and generally only a short-term survival. In a small percentage of patients, the liver function is normal and surgical removal of the tumor is possible with good long-term results, and this is always the first choice for treatment.  Unfortunately, however, most patients have associated liver disease (that is, cirrhosis) from a long-term condition like hepatitis C or fatty liver disease, and this damage is known to lead to liver cancer.

For patients with both early-stage hepatocellular carcinoma and cirrhosis who cannot undergo resection (removal), the latest advancement in treatment is liver transplantation. A multidisciplinary clinic at the Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine makes this option available to patients through the expertise of the largest liver program in Missouri and one of the largest in our region. In addition, patients with other benign and malignant tumors, including metastatic colorectal cancer, can be evaluated for the latest treatment options.

Most patients with both HCC and cirrhosis are not candidates for surgical resection of their tumors for several reasons. First, when liver resection is performed, the remaining liver must be able to regenerate and function for the part that was removed. For patients with HCC and cirrhosis, that regeneration is not possible. Second, the factors that led to cancer development remain and will cause recurrent cancers. Finally, it is not always possible to detect sites of small cellular implants within the remnant liver. Even for the small number of patients who can have their livers resected, about 80% will have tumor recurrence.

In recent years, two factors played a role in making transplantation a viable option for patients with HCC and cirrhosis: Significant advances in transplantation techniques were made, and the criteria for allocating organs were changed to give priority to cirrhotic patients with early-stage liver cancer. At Siteman Cancer Center, the results with liver transplantation in these patients have been excellent. In patients with the standard accepted transplant criteria for stage II cancer, the recurrence risk is less than 10% with long-term follow-up. This statistic also holds true for patients with stage III cancers when their tumors are first downstaged and observed for a period of time to ensure they are under control and have not metastasized (that is, spread to another site in the body).

One of the challenges of treating these patients is that they have two diseases: cancer and cirrhosis. The multidisciplinary team at the Siteman Cancer Center includes not only liver surgeons, but also experienced hepatologists who help manage liver disease. In addition, medical oncologists and interventional radiologists provide care while patients await surgical resection or transplantation. Available treatments include chemoembolization, which involves injecting chemotherapy drugs and embolic material into the tumor in order to control and shrink it. Other complex procedures performed by specialists at the clinic are transjugular intrahepatic portosystemic shunts (TIPS), used to treat portal hypertension due to cirrhosis, and percutaneous ablation of tumors.

The Liver and HCC
The liver is the largest organ in the body. It lies under the right ribs, just below the right lung. It filters harmful substances from the blood, digests fats from food and converts sugars into glycogen, which it stores until required.

HCC is the most common form of liver cancer and accounts for about 75 percent of primary liver cancers (cancers that start in the liver). Liver cancer is a leading cause of cancer-related deaths in the United States and throughout the world. According to the American Cancer Society, it was estimated that 20,550 deaths would occur from cancer of the liver and intrahepatic bile duct in the United States during 2012.

Chronic infection with hepatitis B virus (HBV) or hepatitis C virus (HCV) is a very important liver cancer risk. Cirrhosis, which results from scar tissue in the liver (major causes of liver cirrhosis are alcohol abuse and hepatitis B and C; another cause is too much iron in the liver), also often leads to cancer.

In the United States, almost two percent of Americans have hepatitis C. In large part, this occurred before 1991, when approximately 200,000 people a year were infected because there was not an effective blood-screening system in place. Although the rate of infection has fallen since that time, there are still numerous ways to contract the disease, from substance abuse and other high-risk behaviors to unclean tattoo needles.

The insidious nature of hepatitis C means most people remain without symptoms for 15 to 20 years after first becoming infected. Only in the late stages of the disease do they develop cirrhosis, HCC or both of these complications.

Symptoms
Liver cancer usually doesn’t cause symptoms in the early stages of the disease. In addition, many of its symptoms could also be caused by other cancers or conditions. Nevertheless, the following symptoms may be present with liver cancer:

  • Abdominal pain or tenderness, especially in the right-upper quadrant
  • Swollen stomach
  • Easy bruising or bleeding
  • Jaundice (yellow color in the skin, mucous membranes or eyes)
  • Weight loss
  • Continuous lack of appetite
  • Itchy skin
  • Swollen veins that can be seen through the skin
  • Becoming sicker if you have chronic hepatitis or cirrhosis

Other resources on liver cancer/HCC:

For a patient appointment with a liver transplant surgeon, call (314) 747-9889.