A913: Liver cancer. General facts of Liver cancer

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1 General facts of Liver cancer A913: Liver cancer There are two different types of primary liver cancer. The most common kind is called hepatoma or hepatocellular carcinoma (HCC), and arises from the main cells of the liver (the hepatocytes). This type is usually confined to the liver, although occasionally it spreads to other organs and occurs mostly in people with a liver disease called cirrhosis (see Causes section). There is also a rarer sub-type of hepatoma called Fibrolamellar hepatoma, which may occur in younger people and is not related to previous liver disease. The other type of primary liver cancer is called cholangiocarcinoma or bile duct cancer, because it starts in the cells lining the bile ducts. Some primary tumours in the liver are non-cancerous (benign) and do not spread to other parts of the body. They are usually small and may cause no symptoms, and are often discovered by chance during operations or investigations for other conditions. Unless they are causing symptoms they do not usually need to be removed. In the western world, most people who develop hepatoma usually also have a condition called cirrhosis of the liver. This is a fine scarring throughout the liver which is due to a variety of causes including infection and heavy alcohol drinking over a long period of time. However, only a small proportion of people who have cirrhosis of the liver develop primary liver cancer. Infection with either the hepatitis B or hepatitis C virus can lead to liver cancer, and can also be the cause of cirrhosis, which increases the risk of developing hepatoma. People who have a rare condition called haemochromatosis, which causes excess deposits of iron in the body, have a higher chance of developing hepatoma. In Africa and Asia a poison called aflatoxin, found in mouldy peanuts and grain, is an important cause of hepatoma. Bile duct cancers (cholangiocarcinomas) are less common than hepatomas. The cause of most bile duct cancers is unknown, but they are slightly more likely to occur in people with conditions which cause inflammation of the bowel, such as ulcerative colitis. In Africa and Asia, infection with a parasite known as the liver fluke is thought to cause many cholangiocarc In the western world, cancer of the liver usually occurs in middle-aged and elderly people, although rarely it can also affect children and young adults. In Africa and Asia it often occurs in young adults. It is three times as common in men as in women.

2 Treatment The doctors will plan the treatment taking into account a number of factors: whether the cancer is a primary or secondary liver cancer, patient age, general health, the type and size of the cancer, whether it has spread beyond the liver, whether the liver is affected by any other disease, such as cirrhosis. Surgery Surgery is the most effective treatment for primary liver cancer, but this is not always possible due to the size or position of the tumour. It is also not possible to operate if the cancer has spread beyond the liver. If only certain areas of the liver are affected by the cancer and the rest of the liver is healthy, it may be possible to have an operation to remove the affected part: this is called a liver resection. If the operation removes a whole lobe of the liver, it is called a lobectomy. If the liver is severely damaged by cirrhosis it may not be safe for the patient to have such surgery. The liver has an amazing ability to repair itself. Even if up to three-quarters of the liver is removed it will start to re-grow very quickly, and may be back to normal size within a few wee Removing the whole liver and replacing it with a liver from another person (a liver transplant) Tumour ablation This type of treatment is used for tumours less than 5cm in diameter. Liquids such as alcohol ( Laser or radiofrequency (thermal) ablation This treatment uses a laser or electrical generator to destroy the cancer cells. Under local anae Chemotherapy Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. Chemotherapy drugs are usually given by injection into a vein (intravenously) or by injecting t Chemotherapy is often given as a session of treatment, usually lasting a few days. This is follo Sometimes the chemotherapy drugs are given through a tube inserted through the skin of the A pump (similar in size to a Walkman) may be attached to the tube to give a continuous dose Radiotherapy Radiotherapy is not usually used to treat hepatomas, but it may be used to treat cholangiocarcinoma.

3 Cryosurgery or cryotherapy In cryotherapy treatment a device called a cryoprobe is inserted into the centre of the tumour during an operation. Liquid nitrogen is then passed through the probe. This freezes the surrounding area and destroys the cancer cells. Chemoembolisation This treatment involves mixing chemotherapy drugs with an oily substance called lipiodol. Under local anaesthetic the mixture is then injected into the liver through a tube inserted into the hepatic artery (the main blood vessel carrying blood to the liver). It is thought that adding lipiodol to the chemotherapy drugs helps them to remain in the liver for longer, and makes the treatment more effective. This treatment can be repeated several times. It is carried out in the x-ray department and usually needs a stay in hospital of hours. Follow-up After your treatment has been completed, regular check ュ ups and x-rays or scans. References Oxford Textbook of Oncology (2nd edition). Souhami et al. Oxford University Press, Gastrointestinal Oncology: Principles and Practice. Kelsen et al. Lippincott Williams and Wilkins, The Textbook of Uncommon Cancers (2nd edition). Raghavan et al. Wiley, 1999 For further references, please see the general bibliography.

4 Primary tumor (T) Staging of Liver cancer TX: Primary tumor cannot be assessed T0: No evidence of primary tumor : Solitary tumor without vascular invasion T2: Solitary tumor with vascular invasion or multiple tumors none more than 5 cm T3: Multiple tumors more than 5 cm or tumor involving a major branch of the portal or hepatic vein(s) T4: Tumor(s) with direct invasion of adjacent organs other than the gallbladder or with perforation of the visceral peritoneum Regional lymph nodes (N) NX: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis : Regional lymph node metastasis Distant metastasis (M) Stage Stage Stage Stage I, N0, M0 II T2, N0, M0 IIIA T3, N0, M0 IIIB T4, N0, M0 IIIC Any T,, M0 IV Any T, any N, M1 MX: Distant metastasis cannot be assessed M0: No distant metastasis M1: Distant metastasis References 1. Liver (including intrahepatic bile ducts). In: American Joint Committee on Cancer.: AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer, 2002, pp

5 A913: liver: hepatocellualar carcinoma Lot. No : Fig3. RT-PCR for GAP3DH Sample : Serial 10 sections of / AGE: 53 Sex: Male Stage: T2N0M0 1.Liver, right lobe, lobectomy: Hepatocellular carcinoma 1) size: 8x8x6.8cm 2) Edmondson-Steiner grade III 3) clear cell (majority) and trabecular histologic type 4) single nodular type with perinodal spreading growth 5) necrosis: less than 10% of total volume 6) microvascular invasion 7) intact intrahepatic resection margin 8) nonneoplastic liver showing: Chronic hepatitis, B viral, with mild inflammatory activity (Grade II) and early cirrhosis (Stage III). * Post operation:preoperative trans arterial chemo embolisation (50mg)

6 A913: liver: hepatocellular carcinoma Lot. No : Fig 2. Scanned images Fig3. RT-PCR for GAP3DH Sample : Serial 10 sections of / AGE: 54 Sex: Female Stage: N0M0 1.Liver, central lobe, lobectomy: Hepatocellular carcinoma 1) size: 5x4.5x3cm 2) compact histologic type with fatty change 3) Edmondsion-Steiner grade III 4) single nodular type with marked stromal fibrosis and no capsular formation 5) chronic hepatitis, clinically B viral, with minimal inflammatory activity(grade I) and septal fibrosis (stage III) 2.Gallbladder, cholecystectomy, separately submitted: Autolysis. * Post operation: Trans arterial chemo embolisation (ADR50mg)

7 A913: liver: hepatocellular carcinoma Lot. No : Fig3. RT-PCR for GAP3DH Sample : Serial 10 sections of / AGE: 55 Sex: Male Stage: N0M0 1.Liver, left lateral segment, segmentectomy: Hepatocellular carcinoma 1) size: 3x2.5x2.3cm 2) single nodular type with expanding growth 3) Edmondson-Steiner grade I 4) trabecular histologic type 5) no coagulative necrosis 6) intact intrahepatic resection margin (safety margin: about 0.5mm) 7) nonneoplastic liver showing: Chronic hepatitis, B viral, with mild inflammatory activity (Grade II) and macronodular cirrhosis (Stage IV).

8 A913: liver: hepatocellular carcinoma Lot. No : Fig2. RT-PCR for GAP3DH Sample : Serial 10 sections of / AGE: 55 Sex: Male Stage: T2N0M0 1.Liver, segmentectomy: Hepatocellular carcinoma 1) size: 3.5x3.2x2.3cm. 2) histologic type: trabecular type. 3) Edmondson-Steiner grade III with perinodal spread. 4) single nodular type. 5) vascular invasion. 6) necrosis: approximately 60% of total volume. 7) intact hepatic resection margin. 8) chronic hepatitis, B-viral, with moderate inflammatory activity (grade III) early cirrhosis (stage III) showing multiple dysplastic nodules. 2.Gallbladder, cholecystectomy: No pathological diagnosis. 3.Soft tissue, separately submitted: Fat necrosis with calcification. * comment : Diabefes mellitus Tbc

9 A913: liver: hepatocellular carcinoma Lot. No : Fig2. RT-PCR for GAP3DH Sample : Serial 10 sections of / AGE: 54 Sex: Male Stage: T2N0M0 1.Liver, subsegmentectomy: Hepatocellular carcinoma, 1) size: 4.5x3.8x3cm 2) Edmondson-Steiner grade I 3) trabecular histologic type 4) multinodular gross type 5) microvascular invasion 6) no necrosis 7) intact intrahepatic resection margin 8) multiple, dysplastic nodules showing high to low grade dysplasia and transformation to hepatocellular carcinoma (early hepatocellular carcinoma) 9) chronic hepatitis, probably B viral, with minimal inflammatory activity (Grade I) and macronodular cirrhosis (Stage IV). 2.Gallbladder, cholecystectomy, separately submitted: Free from tumor extension. * comments: Reccurent, familly history (father hepatocellular carainoma)

10 A913: Liver : adenoma Lot. No : N N N2 Fig2. RT-PCR for GAP3DH Sample : Serial 10 sections of N / AGE: 21 Sex: Female Stage: -(benign) 1.Liver, segment III, segmentectomy: Hepatocellular(liver cell) adenoma with 1) multifocal fatty change and 2) mild congestion, 3) completely resected. 4) nonneoplastic liver showing reactive hepatitis with portal fibrosis. * Comments: Smoking,Diabetes mellitus

11 A913: Liver : hepatocellular carcinoma Lot. No : Fig2. RT-PCR for GAP3DH Sample : Serial 10 sections of / AGE: 67 Sex: Male Stage: T2N0M0 1.Liver, VII segment, segmentectomy: Hepatocellular carcinoma, 1) size: 5x4.5x4.5cm. 2) Edmondson-Steiner grade I to II. 3) single nodular type with expanding growth. 4) no necrosis (less than 5% of total volume). 5) microvessel invasion. 6) intact resection margin (safety margin: less than 0.2cm). 7) non-neoplastic liver showing chronic hepatitis, B-viral, with mild inflammatory activity (grade II) and cirrhosis (stage IV). 2.Gallbladder, cholecystectomy: Free from tumor extension. * Comments: Diabefes mellitus, HTN, smoking

12 A913: liver: hepatocellular carcinoma Lot. No : for H&E stained slides N2 N T2 Fig2. RT-PCR for GAP3DH Sample : Serial 10 sections of T2 N / AGE: 75 Sex: Female Stage: T3N2M1 1.Liver, right lobe, lobectomy: Metastatic adenocarcinoma, originated from colon 1) extensive necrosis, and lymphovascular and capsular invasions. 2) Intact hepatic resection margin. 3) Surrounding liver showing reactive hepatitis. 2.Gallbladder, cholecystectomy, separately submitted: Autolysis without tumor extension.

13 A913: liver: hepatocellular carcinoma Lot. No : for H&E stained slides Fig2. RT-PCR for GAP3DH Sample : Serial 10 sections of / AGE: 62 Sex: Female Stage: N0M0 1.Liver, segment IV, segmentectomy: Hepatocellular carcinoma 1) size: 5.3x4.5x3.5cm 2) Edmondson-Steiner grade I(in majority) to III 3) trabecular(in majority) and compact histologic type 4) single nodular type with encapsulation 5) capsular invasion but not vascular invasion 6) non-neoplastic liver showing chronic hepatitis, B viral, with moderate inflammatory activity(grade III) and early cirrhosis (stage III) by Ludwing classification 2.Gallbladder, cholecystectomy: Free from tumor extension. *Pre operation : Trans arterial chemo embolisation ( Adriamycin,Lipiodal )