• Liver Cancer


    "Recent advances in liver cancer treatment have significantly expanded options for patients. At Lahey, our multidisciplinary teams provide patients with the most innovative liver cancer therapies developed at the nation's leading research centers, as well as the opportunity to participate in groundbreaking clinical studies."

    -Keith E. Stuart, MD, Lahey liver cancer specialist and chair of Hematology/Oncology 

    The liver is one of the body's largest, most important organs. This hard-working organ not only filters toxic materials out of the blood, but also produces chemicals essential for digestion and blood clotting.

    The term "liver cancer" actually refers to two different types of tumors. The more common are secondary, or metastatic tumors-malignant cells that have spread to the liver from cancers in other parts of the body such as the colon, lung or breast. Primary liver cancer consists of tumors that originate in the cells of the liver (hepatocellular carcinoma or hepatoma) or bile duct (cholangiocarcinoma). In the United States, primary liver cancer is relatively rare, although that may be changing. Recent statistics suggest it has actually doubled over the past 10 years, possibly associated with the rise in chronic hepatitis C infections during the 1970s. Bile duct cancer is uncommon, accounting for only 10 percent of primary liver cancer cases.

    Lahey physicians have significant experience employing traditional and newer treatments for liver cancer, including chemoembolization and transplantation. Since 1999, the Liver Transplant Team has performed nearly 400 transplants-more than any other liver transplant center in New England. Lahey radiologists are specialized in applying state-of-the-art noninvasive imaging techniques, including computed tomographic angiography (CTA), to produce 3-D models of liver arteries prior to surgery. This technology delivers exceptional images of the liver and its vasculature, allowing radiologists and surgeons to customize scans that increase the effectiveness of pre-surgery planning.

    Given the link between hepatitis and liver cancer, both diseases are highly active areas of research at Lahey Clinic. Our clinicians work on the front lines of medical research with the goal of improving outcomes for liver cancer patients. See our clinical trials, and learn how to participate in them.  

    Risk Factors

    Approximately 25 percent of liver tumors have no known cause. In the remaining 75 percent of cases, the following risk factors increase the likelihood of developing primary liver cancer:

    • Male gender
    • Age: 40+ years
    • Heavy alcohol consumption
    • Existing liver disease such as cirrhosis or chronic infection with hepatitis B or C virus, which can lead to cirrhosis
    • Hereditary conditions including hemochromatosis (abnormal amount of iron in the body) and certain metabolic disorders
    • Chronic exposure to chemicals and toxic substances. These include aflatoxins-byproducts of various fungi that infect wheat, peanuts, soybeans and other foods in tropical parts of the world-as well as anabolic steroids, arsenic and other harmful materials
    • Obesity and smoking, particularly among heavy drinkers, may also be risk factors, according to the American Liver Foundation. 

    What many of the above risk factors have in common is that they all can lead to cirrhosis-severe, irreversible scarring of the liver caused by a continuous cycle of repeated cell injury, death, and regeneration. The cirrhotic process itself may eventually trigger the formation of cancer cells.

    Cholangiocarcinoma, or cancer of the bile duct, has various causes, ranging from ulcerative colitis to bile duct damage. Few cases are due to cirrhosis, and many people with this type of cancer have no obvious risk factors.

    Prevention

    To lower the risk of developing liver cancer: 

    • Drink alcohol in moderation (no more than two drinks per day for men, and one for women)
    • Get prompt treatment of hepatitis B or C if you contract it 
    • Avoid the risk of contracting hepatitis B or C by 
      • Getting immunized against hepatitis B
      • Using clean needles, and not sharing needles, if you use them to inject medication 
      • Using latex condoms when having sexual intercourse if you don't know if your partner has hepatitis  

    Symptoms

    Liver cancer is hard to detect because symptoms often don't appear until the disease is in its later stages. Further complicating diagnosis, the signs and symptoms of liver cancer can be vague and associated with many other digestive disorders.

    When symptoms do occur, they include: 

    • Fatigue and weakness
    • Nausea, poor appetite and weight loss
    • A feeling of fullness after small meals
    • Pain on the right side of the upper abdomen
    • Jaundice (yellowing of the eyes and skin, accompanied by dark urine)
    • Diagnosis may occur by chance; for example, a doctor may note an abnormal result on a liver function blood test. Liver tumors can also be found during a routine physical exam if the clinician feels hard lumps in the abdomen or sees something suspicious on an imaging study.

    If a physician suspects liver cancer, he or she will order high-resolution studies. These include CT (computerized tomography) and PET/CT (position-emission-tomography) scans, ultrasound and MRI (magnetic resonance imaging). Sometimes additional tests are needed, such as specialized angiograms or laparoscopy-procedures that allow more precise visualization of the liver and its major arteries and blood vessels.

    Once there is definite evidence of liver cancer, your physician may want to order further tests such as the following to help clarify certain aspects of the diagnosis: 

    • Specialized blood tests that measure tumor protein levels, a potential indicator of the cancer's aggressiveness
    • A needle biopsy to extract liver tissue for examination under a microscope to determine what type of cancer cells are present; this procedure is performed in the operating room

    Treatments

    Although some cancers are treated mainly on the basis of tumor size, liver cancer is usually more complex, requiring more individualized therapy. This is particularly important when cancer occurs in people who already have diseased or damaged livers, as is often the case. Whatever form of treatment doctors prescribe for liver cancer, it is important for patients to remember that all treatments have limitations, as well as potential benefits. Because every therapy involves side effects, any decision about treatment will depend on a careful evaluation of the patient's liver function, blood vessels, degree of disease and overall health. The reality is many patients find themselves ineligible for surgery or transplantation. For these patients, physicians often find the best treatment results from using multiple techniques or drugs, trying one, seeing what helps, and moving along to the next therapy as needed. Lahey oncologists will work closely with other specialists on the cancer care team to determine the best treatment approach for each patient.

    When developing a treatment plan, physicians consider:

    • How well the liver is functioning
    • The size, number, and location of the liver tumors
    • The presence of coexisting medical conditions that may affect the patient's ability to tolerate therapy

    Surgery

    The best treatment for primary liver cancer is also the only truly curative one-cutting and removing the malignant tissues and possibly surrounding lymph nodes. The formal medical term for this is liver resection, but unfortunately, it is not often possible for a number of reasons. First, if a patient's liver is cirrhotic or poorly functioning, it might not be safe to perform the operation. Second, the tumors may be so small or widespread that surgery will not be effective in preventing the cancer from returning. 

    Transplantation

    Transplantation involves replacing the diseased organ with healthy liver tissue from a donor. It is interesting to note that 

    • Liver transplants can be performed using organs from deceased or live donors
    • In the case of live donors, only part of the healthy liver is transplanted to the patient; this type of transplant is possible because liver tissue regenerates so rapidly
    • Since 1999, the Lahey Liver Transplant Team has carried out nearly 400 transplants-58 in 2006, more than any other liver transplant center in the New England region (UNOS Region 1)
    • The Lahey live adult donor liver transplant (LDLT) program is the 3rd largest in the country, with nearly 140 surgeries performed to date 

    Chemotherapy

    Chemotherapy is the term for specialized anticancer drugs given by mouth or intravenously. Chemotherapy medications work against tumors anywhere in the body, not just in the liver. Although highly effective for many types of tumors, chemotherapy does not always work well against primary liver cancer. This is because the liver's primary job is to filter out all toxic chemicals from the body-including the chemotherapy. 

    Radiation

    Radiation, which applies high-dose energy such as X-rays directly on small areas of the body, is used to destroy many forms of cancer cells. In liver cancer, radiation is particularly challenging because it may be more damaging to healthy liver tissue than to cancerous cells. For this reason, standard radiation is seldom used in treating patients with liver cancer unless it involves one of the newer techniques such as radiofrequency ablation and stereotactic radiation, described below.

    Tumor-directed therapies

    The following treatments target only the liver tumor, not the entire organ: 

    • Chemoembolization, also called hepatic artery chemoembolization, is a promising new procedure that involves injecting high doses of chemotherapy directly into the blood vessels that feed the malignancy. Also injected are special oils and proteins that form a dam, which closes off blood vessels and isolates the tumor. Chemoembolization attacks liver cancer two ways: it destroys the existing tumor, and then chokes off its blood supply, preventing further growth. Please refer to our chemoembolization brochure [link to PDF] to learn more.
    • Cryoablation is another form of liver-directed therapy that uses liquid nitrogen to isolate and kill the cancer. Specialists inject super-cold nitrogen right inside the tumor, freezing and ultimately destroying the cancer cells. An alternative form of this treatment is ethanol ablation, where liquid alcohol is injected directly into the tumor.
    • Radiofrequency ablation [RFA] uses heat energy in the form of radio waves to kill the liver tumor. Using ultrasound or CT scan equipment as a guide, the physician inserts a metal probe into the tumor. Radio waves emitted at the tip of the probe deliver thermal energy right to the center of the tumor. This heat energy destroys the surrounding tissue, killing the tumor.
    • Advanced stereotactic radiation uses specialized equipment called the Trilogy System, physicians are able to target the tumor site with high-dose beams of precisely focused external radiation, achieving a much greater degree of accuracy than with traditional radiation techniques. Lahey was one of the first hospitals in New England to offer this advanced technology.  

    Emerging treatments

    Researchers are constantly exploring new approaches to improve treatment of liver cancer. On the horizon for patients with liver cancer are several emerging therapies: 

    • Biological therapy, or biological response modifier therapy, is used to "switch on" certain bodily substances that can restore or mobilize the patient's own natural defenses against cancer.
    • Lahey physicians have joined researchers in Israel in studying MRI-guided, focused ultrasound, a bloodless technique that destroys tumors affecting the liver and other organs. The entire procedure, which uses an FDA-approved device already in use at Lahey to treat uterine fibroids, is performed without cutting or puncturing the skin. Physicians use MRI as a visual guide to help them target the tumor and aim a highly focused ultrasound beam at the liver tumor under, or between, the ribs. For more information about the device and the procedure, please visit these websites: http://www.insightec.com and http://www.lahey.org/Medical/Radiology/ThermalAblation.asp.
       
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