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Liver cancer

Cancer begins when cell in the body start to divide and grow out of control. When this out of control growth occurs in the liver, it is called liver cancer. Liver cancer is also known as hepatic cancer. Liver cancer is the one that starts in the liver (primary cancer) and not the one that starts elsewhere and metastasize to the liver (secondary cancer).

Liver cancer
Liver is the largest internal organ in the body. It is located under the right ribs just beneath your right lung. Liver is mainly made of cells called hepatocytes. It is also made of other types of cells like cells that form its blood vessels and those forming bile duct.
Liver is divided into the right and left lobes. Nutrient-rich blood reaches the liver from the intestines through hepatic portal vein, while oxygen-rich blood reaches the liver through hepatic artery.
Among the main functions of liver include detoxification (removing toxins from our body through passing it to urine and feaces), production of proteins, breaking down fats and production of important biochemical essentials for digestion.

Types of liver cancer


There are different types of liver cancer depending on the type of cells from which the cancer originates. This include the following types;
• Hepatocellular carcinoma. This type of cancer originate from hepatocytes. It is the most common type of liver cancer.
• Cholangiocarcinoma. This is the type of liver cancer that originate from the Cells that form bile duct.
• Angiosarcoma. It is a type of liver cancer originating from the cells that form Blood vessels of the liver.

Risk factors of liver cancer
When it comes to cancer, anything that increases your probability of developing cancer is called a risk factor. Risk factors only influence development of cancer but it does not directly cause cancer. Sometimes people with risk factors do not develop the disease while those with no risk factors do develop the disease. Knowing risk factors will help you live your life making some better healthy choices to reduce the risk. Some of the factors that may increase your chance of developing liver cancer include the following;

> • Liver cirrhosis. Liver cirrhosis is a chronic liver disease marked by degeneration of cells, inflammation, and thickening of tissue. This occurs when healthy tissues are damaged and replaced by scar tissues. Sometimes this is caused by too much use of alcohol and hepatitis B and C.
> • Gender. Statistics shows men are more affected by liver cancer compared to women. The main reason behind that is thought to be their lifestyle which is more different to that of women. For example, men drink alcohol more that women do.
> • Viral hepatitis. Hepatitis B and C infections tend to increase your chances developing liver cancer. Liver cancer from hepatitis C is more common than that from hepatitis B. this is contributed by lack of hepatitis C vaccination. If you have been affected by hepatitis and then you receive treatment, your risk for developing the disease will be reduced.
> • Too much alcohol use. High consumption of alcohol can lead to liver cirrhosis which can then influence development of liver cancer.
> • Aflatoxins. Aflatoxin is a substance made by a fungus and may be found in moldy wheat, groundnuts, corn, nuts, soybeans and peanuts. For liver cancer risk to increase there needs to be long-term exposure.
> • Family history. Being in the family with one of the family members suffering or suffered from this type of cancer, increases your risk of developing this cancer.
> • Obesity. Obesity is linked to liver cancer because being obese increase your risk of developing liver fatty disease which in turn may lead to liver cancer.
> • Type 2 diabetes. People with this type of diabetes are linked liver cancer because these people are often obese (overweight) which in turn increase the risk of this cancer. The risk is much higher to those with other risk factors like heavy alcohol drinking and chronic hepatitis.
> • Anabolic steroids. These are steroids used by some athletes and weight lifters to increase their muscle strength and mass. Long term use of these hormones may lead to development of liver cancer.
> • Exposure to vinyl chloride and thorium dioxide (Thorotrast). Vinyl chloride is used in making some plastics and thorotrast is a chemical that was used in the past as type of x-ray test but it is now not used due to its link to liver cancer.
> • Tobacco use. Smokers increase their risk of developing this type of cancer compared to non-smokers.
> • Arsenic. Those who rely on water wells that contain arsenic, have slightly higher risk of developing liver cancer.

Early Prevention
In order to prevent something you need first to know what causes it, but for liver cancer there is no known specific cause. Therefore the only way to prevent this cancer is by reducing exposure to known risk factors. This include taking the following measures;

>• Avoiding hepatitis infections. Hepatitis B virus infections can be stopped by the use of vaccines. Since there is no vaccine for hepatitis C, the only way to minimize the risk is by avoiding contacting the virus which can spread from person to person through sharing contaminated needles (such as in drug use) and through unprotected sex, so some of these cancers may be prevented by not sharing needles and by using safer sex practices such as consistent use of condoms.
>• Alcohol & smoking Limiting alcohol use and avoid smoking
>• Limiting exposure to cancer causing chemicals. This include avoiding exposure to aflatoxins, vinyl chloride, thorotrast and arsenic from drinking water.
>• Seeking for treatment of diseases that may lead to liver cancer. For example fatty liver disease.
>• Physical exercises. This will help reduce the risk of being obese which could lead to liver cancer.

Early detection
Early detection of cancer is very crucial as it mostly improve prognosis of the disease. When liver cancer is found early, chances for better treatment outcome are very high. For most cancers, early detection has been greatly contributed by the presence of screening process.

Screening is the process of running some tests to someone with no signs and symptoms of the disease with the intention of testing for presence or absence of the disease.

For liver cancer there are no widely recommended screening tests for people with average risk and this makes it very difficult for this cancer to be detected while it is still at an early stage. Signs and symptoms of this cancer normally start to show while the disease is at late stage.

For those at high risk of developing this disease including those with liver cirrhosis and chronic hepatitis infections, are recommended by to have alpha-fetoprotein (AFP) blood tests and ultrasound more often to see if there is any abnormality. Alpha-fetoprotein level tend to be high to someone with liver cancer.

Signs and symptoms of Liverr cancers
In most cases symptoms of liver cancer do not show up until the disease is at late stage. But in few cases symptoms may show up earlier. So when you go to see a doctor when you first notice the symptoms your disease may be diagnosed while at an early stage hence providing you with good chance of better prognosis. Among the symptoms and signs of liver cancer include the following;
• Jaundice. The skin, tongue and white part of the eyes becomes yellow. This is due to fact that liver is working properly so there is too much bilirubin in the body.
• Abdominal pain. Normally occurs on the right side and can sometimes go up to the shoulders.
• Fatigue
• Unexplained weight loss
• Loss of appetite
• Feeling full after small meal
• Itching
• Enlarged liver. This can be felt as abnormal enlargement under the ribs on the right side
• Nausea and vomiting
• Enlarged spleen. This is felt under the ribs of the left side


Sometimes tumors of liver can produce some hormones that may act on other organs in the body and lead to various effects including;

• Low level of sugar in the blood (hypoglycemia)
• Enlargement of breast (gynecomastia) or shrinkage of testicles in men
• High level of calcium in the blood (hypocalcaemia)
• High level of red blood cells (erythrocytosis) which can lead to someone look red and flushed

Diagnosis Medical diagnosis simply means identification of nature of an illness by elimination of the symptoms. Normally people don`t go to hospital knowing they have cancer but during diagnostic procedures is when doctors detect the disease.

Following suspicion of the disease, doctors normally run combination of tests to determine whether there are cancerous cells in the body or not and if there are cancer cells, how far have they spread. Along with thorough medical history and physical examination, doctors normally use combination of the following tests to diagnose cancer.

> Laboratory tests. Laboratory tests are important in ruling out other conditions and confirming diagnosis. For cancer diagnosis laboratory tests normally include blood tests, urine tests, tumor markers and other body fluids tests. • Blood tests. Blood tests help to reveal level of different substances in the blood which will help doctors to know if there is anything wrong in the body. From blood tests doctors can see complete blood count which indicates number, size and maturity of blood cells. Also from the blood tests doctors can analyze if kidney and liver are working properly.
• Urine tests. Urine tests (urinalysis) involve laboratory examination of urine to check presence of blood, proteins, and other substances such as drugs. For instance blood in the urine may be an indication of benign condition, infection or other health problem.
• Tumor markers. These are biomarkers (proteins) that can be produced by both cancer cells and normal body cells in response to cancer. Tumor markers are released into the blood or urine. Although studies are still conducted to determine role of these markers in diagnosing cancer because sometimes people with benign condition will have elevated level of these proteins. Also not all tumors have their markers and some markers are not specific to one type of tumor.
• Other body fluids. Despite being rarely used, sometimes body fluids can be tested in the lab during diagnosis of cancer. For instance the use of cerebral spinal fluid (CSF) and pleural fluid. CSF is used in diagnosis of brain tumors while pleural fluid for lung cancer.

Diagnostic Imaging
Diagnostic imagings involve tests that create pictures of inside the body that help the doctor to see if there is tumor or not. There are several imaging tests used in cancer diagnosis depending on the type and location of cancer suspected. These imaging tests include;
• Computed tomography (CT) scan. CT scan machine is a donut-shaped scanner that uses x-rays to create series of pictures of body organs from different angles. This machine is linked to a computer where those series of pictures taken will be combined to create a 3D- image of inside the body. During the scanning process patient will lie still on the table which will slide into the scanner. In order to get a clear image, sometimes the doctor will inject the patient with a contrast material before scanning. From the images the doctor will be able to differentiate between healthy and unhealthy tissues.
• Magnetic resonance imaging (MRI). MRI is an imaging technique that uses powerful magnet and radio waves to take series of pictures of body organs and create a 3D image in a computer linked to a machine. Just like in CT, during MRI procedure the patient will lie on a table that will slide into a long round chamber. Also during this procedure the doctor may inject the patient with a contrast material for clear image view.
• X-ray. This is an imaging technique that is uses low dose of radiation to create pictures of inside your body. Technician will position the patient and direct the x-ray beam to the intended part of the body.
• Ultrasound. Ultrasound is a diagnostic imaging procedure that uses high energy sound waves to produce images of organs inside the body. During the examination, a patient will lie on the table while the technician will slowly move a device called transducer on the skin over the part of the body that is being examined.
• PET scan. Positron emission tomography (PET) scan is an imaging test that uses radioactive glucose to create 3-D images of areas inside the body. Radioactive glucose is used for this test because cancer cells tend to absorb more glucose than normal body cells, so the scan will show which areas of the body has more glucose than others. Before the scan, doctor will inject the patient with tracer called radioactive glucose then during imaging the patient will be asked to lie on the table that will be moving back and forth through the scanner.
• Bone scan. Bone scan is used to examine bones. When it comes to cancer, bone scan is used for diagnosis of bone cancer or cancer that has metastasized into the bones. Before the test, patient will be injected with small amount of radioactive material that tends to collect more on abnormal parts of the bones. Then pictures that will be taken by a scan will indicate the distribution of those radioactive materials in the bones throughout the body.

Biopsy
Biopsy is a diagnostic procedure that involves removing a tissue sample from the body and examines it under microscope in the laboratory. Examination in the laboratory is normally done by a pathologist who will check if the cells in the tissue are cancerous or not. In most cancer cases, biopsy is considered to be the confirmatory test. Depending on the location and type of cancer, biopsy can be obtained in different ways. Some of them include;
• Using needle. By using a thin needle, doctors can draw same tissue or fluid for examination under microscope. This method can be used to draw some fluid (spinal tap), bone marrow (bone marrow aspiration), blood or small amount of tumor from the suspected organ such as liver and breast (fine needle aspiration).
• Surgery. Abnormal tissue samples are obtained while the doctor is performing the surgery. Tissues are then sent to the lab for examination during the surgery. If the surgeon removes just a portion of abnormal area it is called incisional biopsy while when the entire tumor (abnormal site) is removed it is called excisional biopsy.
• Using endoscope. Endoscope is a thin, lighted tube with a camera (focusing telescope) at the end. It is used for viewing inside the body through natural openings like mouth and anus. During an examination if the doctor sees any abnormal tissue, then endoscope can also be used to take sample for that tissue. There are different kinds of endoscopy exams depending on the site of the body being examined. Some of the exams include colonoscopy (for rectum and colon), bronchoscopy (for trachea, bronchi and lungs) and esophagogastroduodenoscopy EGD (for esophagus, stomach and duodenum)

In addition to physical examination and medical history, diagnosis of liver cancer normally involves the use of blood tests, CT Scan, MRI Scan, Ultrasound, Biopsy and Angiogram which is an X-ray picture showing blood vessels.

Staging

Staging is a standard way cancer care team use to explain how far the cancer has grown or spread. Staging has enabled oncology team to understand each other worldwide. In this process of staging doctors use systems in order to give their information about the extent of cancer. For liver cancer there are various systems including TNM system (tumor, node and metastasis), BCLC system (Barcelona clinic of liver cancer), Japan integrated staging system and cancer of liver Italian program (CLIP).

In Tanzania, TNM system is the most used staging system so even in this page, the discussion will be on TNM staging system. As explained before TNM is the combination of three worlds, tumor, node and metastasis.
>>> Tumor. Tumor explains size (how large is the tumor?) and its location.
>>> Node. This explain lymph nodes involved.
>>> Metastasis. Metastasis explains how far has disease spread.

For liver cancer, there are four stages under this system (I –IV). More discerption on this TNM system is as follows;

Tumor
• TX. Primary tumor cannot be evaluated.
• T0. There is no evidence of primary tumor.
• T1. Tumor is 2cm or smaller and doesn`t involve nearby blood vessels.
• T2. There may be more than one tumor but none is larger than 5 cm. There is nearby blood vessels involvement.
• T3a. There is more than one tumor and at least one of them is larger than 5cm.
• T3b. Tumor is of any size and has invaded major liver veins (hepatic vein or portal vein).
• T4. Tumor has spread to the nearby organs excluding gallbladder or the tumor has invaded visceral peritoneum that lines the abdomen.

Node
• NX. Node involvement cannot be evaluated
• NO. No reginal lymph node involvement.
• N1. Reginal lymph nodes are involved.

Metastasis
• MX. Distant metastasis cannot be evaluated.
• M0. No evidence of distant metastasis.
• M1. The disease has spread to other parts of the body.
In order to provide the specific stage of liver cancer stage, doctors will combine all those there in terms tumor, node and metastasis to complete TNM system. The stages of liver cancer are as follows;

• Stage I(T1,N0,M0) : Tumor is of 2cm or smaller with no blood vessels involvement. There is no lymph node involvement or distant metastasis.
• Stage II (T2, N0, M0): There may be more than one tumor but none is larger than 5 cm. There is nearby blood vessels involvement. There is no lymph node involvement or distant metastasis.
• Stage IIIA (T3a,N0, M0): There is more than one tumor, and at least one is larger than 5 cm. There is no lymph node involvement or distant metastasis.
• Stage IIIB (T3b,N0, M0): Tumor is of any size and has invaded major liver vein. There is no lymph node involvement or distant metastasis.
• Stage IIIC (T4, N0, M0): Tumor has spread to the nearby organs excluding gallbladder or it may have invaded visceral peritoneum that lines the abdomen. There is no lymph node involvement or distant metastasis
• Stage IVA (any T, N1, M0): Tumor is of any size with reginal lymph node involvement but there is no distant metastasis.
• Stage IVB (any T, any N, M1): Tumor is of any size that may or may not have reginal lymph node involvement but there is distant metastasis.

Treatment Following cancer diagnosis, the doctor will break the news and it is normally not very easy to accept that it is cancer. The doctor will be there to help the patient process the news and to help the patient in taking the next steps.
After the patient receives and processes the news that he/she has cancer, one of the most important steps that will follow is decision making. The doctor will present to the patient (relatives/parents/guardians) with all the possible treatment options and explain what they mean. Then with the help of the doctor, the patient (relatives/parents/guardian) will have to choose which treatment option is good depending on benefits of such option.

Despite all the information given by the doctor, sometimes the patient may still be unsatisfied with what he/she has been told. In such situation, the patient is free and advised to seek a second opinion. Second opinion is the opinion that the patient may seek from another specialist (doctor) regarding his/her health problem and in this case it is cancer. Second opinion may include confirmation of the diagnosis, more clarification on your primary doctor recommendations or even reassurances that all the options have been explored.

In addition to standard care treatment options, sometimes there are those new treatments or drugs or combination of treatments that have not been approved yet to be used as standard care treatments for a particular cancer (disease) but have shown some promising results that they may help. These type of treatments are called clinical trials.

If there are some clinical trials for your case, the doctor may present to the patient or the patient may ask if there are any clinical trials for the particular cancer case. Over the years, have improved treatments and led to better outcomes to people diagnosed with various diseases including cancer. If you have decided to take part in clinical trial, you can also withdraw at any time
Treatment options Following cancer diagnosis, the doctor will break the news and it is normally not very easy to accept that it is cancer. The doctor will be there to help the patient process the news and to help the patient in taking the next steps.

After the patient receives and processes the news that he/she has cancer, one of the most important steps that will follow is decision making. The doctor will present to the patient (relatives/parents/guardians) with all the possible treatment options and explain what they mean. Then with the help of the doctor, the patient (relatives/parents/guardian) will have to choose which treatment option is good depending on benefits of such option.

Despite all the information given by the doctor, sometimes the patient may still be unsatisfied with what he/she has been told. In such situation, the patient is free and advised to seek a second opinion. Second opinion is the opinion that the patient may seek from another specialist (doctor) regarding his/her health problem and in this case it is cancer. Second opinion may include confirmation of the diagnosis, more clarification on your primary doctor recommendations or even reassurances that all the options have been explored.

In addition to standard care treatment options, sometimes there are those new treatments or drugs or combination of treatments that have not been approved yet to be used as standard care treatments for a particular cancer (disease) but have shown some promising results that they may help. These type of treatments are called clinical trials.

If there are some clinical trials for your case, the doctor may present to the patient or the patient may ask if there are any clinical trials for the particular cancer case. Over the years, have improved treatments and led to better outcomes to people diagnosed with various diseases including cancer. If you have decided to take part in clinical trial, you can also withdraw at any time

Treatment Option
Treatment of liver cancer requires a team of doctors and other health care professionals. This team work together and it is called multidisciplinary team. Team may vary depending on the treatment option for a particular case. But normally multidisciplinary team for treatment of liver cancer includes hepatologist, transplant and hepatobiliary surgeons, medical oncologist, interventional radiologist, and palliative care specialists. Depending on stage and type of liver cancer, treatment options include the following;

Surgery
Surgery is the treatment option that involves removing the tumor and surrounding healthy tissues by operation. This is done by surgeons. Surgery for liver cancer can be done in two ways depending on your disease state and your medical condition.

• Partial hepatectomy. Partial hepactectomy is as surgical removal of a small portion of liver. This type of operation is done when small part of liver is affected while the remaining part is functioning well. Liver may grow back to its size within few weeks. This type of surgery is not recommended to someone with advanced liver cirrhosis despite having small tumor.

Side effects of this
After this type of surgery, patient may experience fatigue, pain, weakness, bleeding, infection and temporally liver failure. Some of these symptoms will disappear soon after completion of treatment but some will be relieved by medication. Your care team will be there to watch you and relieve some of the side effects that you may experience.

• Liver transplantation. This is the surgery that involves removing the diseased liver and replacing it with some or all of a healthy liver from another person. This is treatment option when tumor cannot be removed completely through partial hepatectomy or liver is too diseased to withstand hepatectomy. For a person to meet criteria for liver transplantation, tumor should be of 5cm or smaller, should not have more than 3 tumors in the liver and cancer should not have spread to other structures of the body. ...Donors of liver are few so until donor is found, patient has to be in close care of doctors. Most livers used for transplants come from people who have just died. But some patients receive part of a liver from a living donor (usually a close relative) for transplant.

Side effects
Most of side effects are the same as those of partial hepatectomy, but after liver transplantation, those who receive liver (recipients) are normally given some drugs so as to suppress body immunity in order to prevent their body from rejecting the new organ. These drugs have their own possible side effects including the following;

• Increasing blood pressure • Puffiness of face
• By suppressing immunity, they increase infection possibility
• Suppressing immunity can allow other liver cancer that has spread outside the liver to grow even faster than before
• Risk of diabetes

Ablative Therapy
Ablation therapy is an option of liver cancer treatment that destroy tumor without removing it. This is used when tumor is not very large (mostly less than 3cm) and tumors are few in number in the liver. This is often used when surgery is not very good treatment choice due to the condition of disease as it might bring more harm than benefit. For example patient is in poor condition. This option may also be used to those patients waiting for liver transplantation. This treatment can be done in the following ways;

Percutaneous ethanol injection. In this option, concentrated alcohol is directly injected into the tumor so as to destroy it (kill cancer cells). Side effects of this procedure may include pain and fever. But these will disappear soon after treatment and can also be relieved by medication.

Thermal ablation. This involves both radiofrequency ablation and microwave ablation. A thin needle like probe is inserted into the tumor through skin or laparoscopy or through surgical operation. Heat from the probe due either high frequency current or microwaves passed will kill cancer cells. During the procedure, patient is normally sedated.

Chemoembolization
This is also known as trans-arterial chemoembolization as it combines chemotherapy and embolization. Chemotherapy is the treatment option that involves using drugs to destroy cancer cells or stop its growth while embolization is simply obstructing blood vessel. During this procedure, the hepatic artery is blocked by drugs so as chemotherapy drugs can stay in a tumor a little bit longer. In addition to that, blocking blood supply to the tumor also destroys tumor cells. This treatment option can be used as but sometimes it can be used to slow tumor growth for those waiting for liver transplantation.

Radiation therapy
Radiation therapy is the treatment option that uses high energy x-rays or other radiation particles to destroy or kill cancer cells. For liver cancer treatment, radiotherapy may be given in two ways.

• External beam radiation therapy. This is the treatment that involves directing radiation beam from machine that is outside the body. For liver cancer this is normally not preferred treatment choice due to the damage it will bring to the normal tissues of the liver and surrounding organs. This is mostly used for those at very advanced stage. It will help shrink the tumor and relieve some symptoms of the disease such as pain. With nowadays advancement, stereotactic body radiation therapy (SBRT) is used. This allows completion of treatment in short time as high dose of radiation is precisely aimed at tumor from multiple angles with minimum effect to surrounding tissues. This can be done with the help of special designed body frame that will immobilize the patient during treatment.

• Radioembolization. This involve blocking artery that supply tumor with radioactive beads. Beads deliver radiation directly to the tumor when they become trapped in these arteries supplying the tumor.

Side effects of radiotherapy
• Skin reactions at the site of treatment
• Fatigue
• Nausea and vomiting
• Low blood count
• Damage to stomach and lung due to radioembolization.

These side effects normally disappear soon after completion of treatment but can also be relieved if they become severe.

Trgeted therapy
Targeted therapy is an option that involves targeting specific molecules in the cancer cells using drugs. The drug will stop the growth and spread of cancer cells and at the same time limit harm to normal cells. Drugs for this kind of treatment work differently to that of normal chemotherapy drugs. The drugs for this option can sometimes help even when chemo isn’t, but they can also be used along with normal chemotherapy to help it work better.

Side effects of targeted therapy
Some of the possible side effects of targeted therapy include the following;
• Nausea and/or vomiting
• Mouth sores
• Increased risk of infection
• High blood sugar level
• Loss of appetite
• Diarrhea
• Bruising

Chemotherapy
Chemotherapy involve the use of drugs to kill cancer cells. Chemotherapy is given by a specialized doctor known as medical oncologist. For liver cancer normal chemotherapy has proven not to be very effective as liver cancer resist most of chemo drugs, hence it is not one of the most preferred treatment option. Among the drugs that have proven to be helpful for liver cancer include cisplatin and 5-fluorouracil.

Normally side effects of chemotherapy don`t last for long but always disappear after completion of treatment. But when side effects become too severe, there is always ways to relieve them and your treatment team will be available to help. Some of the possible side effects include the following,

• Loss of appetite
• Loss of hairs
• Mouth sores
• Nausea and vomiting
• Diarrhea

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