ON LIVER CANCER (HEPATOCELLULAR CARCINOMA)

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1 ON LIVER CANCER (HEPATOCELLULAR CARCINOMA)

2 What is a liver and what does it do? The liver is the largest organ in the body. It is situated in the right side in the abdomen below the right lung and lies behind the lowest ribcage. It lies close to the colon, intestines, and right kidney. The liver is essential for survival. It is required for digestion, stores nutrients, helps in detoxification, and produces portions required for body clouting among many other vital functions. What is liver cancer? Both benign (non-cancerous) and malignant (cancerous) tumours can develop in the liver. The most common cancer that originates in the liver is hepatocellular carcinoma (HCC). Cancer can also spread to the liver from other organs such as the colon, pancreases, or breast. This type of cancer is common to HCC, but it is not considered to be primary liver cancer but it is more of a secondary or metastatic cancer. Is there a reason I have developed liver cancer? The cause for liver cancer varies from person to person and, in some patients, may never be found. The most common cause is cirrhosis (a progressive disorder that leads to scarring of the liver). Cirrhosis is caused by chronic viral hepatitis B and C, alcohol abuse, and certain genetic disorders. Food contaminants, long term use of steroids, and exposure to certain chemicals have also been linked with liver cancer. What are the symptoms of liver cancer? Most symptoms of liver cancer are non-specific and overlap with other cancers as well as less serious conditions. The sooner a person seeks medical treatment and confirms the diagnosis, the sooner effective treatment can be started. These symptoms include unexplained weight loss, persistent lack of appetite, abdominal pain, increase in abdominal girth, and jaundice. For people with hepatitis or cirrhosis, a dramatic change in the general condition may point to the development of liver cancer. What test will I be required to undergo? Specific blood tests that are important for treatment are liver function test, test for hepatitis, as well as tumour markers

3 such as alpha-fetoprotein (AFP) and CA Specialised imaging for the liver in the form of ultrasound, CT scan and / or MRI scan helps in accurately defining the tumour. A liver biopsy is sometimes performed to rule out cirrhosis. If hepatitis or cirrhosis is suspected, an endoscopy, hepatitis viral load, and other tests may be needed. How will the course of my treatment be decided? The treatment planning is complex and involves a multi-disciplinary team which includes doctors who are specialised in the treatment of liver cancer. The team includes a liver surgeon, a hepatologist (physician), a radiologist, and a pathologist. The team takes into consideration various aspects including the stage of the diseases, the presence or absence of cirrhosis, if present, and the general condition of the patient. The severity of cirrhosis is determined by a scoring system called the Child Pugh scoring system. By this system, points are allotted based on serum bilirubin levels, albumin levels, prothrombin time, ascites and encephalopathy. These points are then added, based on which a patient is determined to have Child s A, B or C cirrhosis with A indicating early disease and C advanced disease. Should I undergo an operation for liver cancer? The only chance for a cure is an expert surgery. This may not always be possible and depends on the size and location of the tumour. The operation entails removing the part of the liver which is involved by the tumour. Complete removal of the tumour is essential for favourable and long-term results. The general condition of the patient for surgery depends on the amount of functioning liver that is expected to remain after the surgery, and also, the quality of the liver itself. In an otherwise normal liver, a remnant liver volume around 25% is sufficient to carry out the required function of the body. If the liver is cirrhotic, a minimum expected remnant of 40% is necessary. These assessments are made prior to the operation. In the event that resection (removal of part of the liver) is not feasible, or even when used as an alternative to resection, liver transplantation is a viable option in a highly selected group of patients. Unfortunately, all the patients are not eligible for surgery and alternative treatment modalities which are best suited under the circumstances will be offered in order to

4 control the disease. What are the other treatment options? When surgery is not feasible, several other suitable treatment options are available: Detailed information on each of these modalities is available separately. Radiofrequency Ablation (RFA) is appropriate for smaller tumours (<3cm) as an alternative to surgery or as a bridge to resection or transplantation. This method uses a needle which is placed into the tumour and delivers rapidly alternating current to kill tumour cells. Transarteria Chemoembolization (TACE) is the best method of treatment for larger or multiple tumours which have not spread beyond the liver and in which the blood vessels supplying the liver are not blocked. It can also be used to shrink the tumour to allow for an operation, or even as a bridge to surgery or transplantation. In this technique, chemotherapy is injected directly into the blood vessel supplying the tumour. Transarteria Radioembolization (TARE) uses a radioisotope (Y90) to deliver radiotherapy to the tumour employing a similar method as is used in TACE. This method is used when a blood vessel supplying the liver is blocked and TACE is not possible. Chemotherapy is sometimes used. Commonly used drugs are doxorubicin, cisplatin, 5-fluorouracil and gemcitabine. This is not suitable for everyone and can only be given if the liver function is reasonable. Targeted therapy (sorafenib) is used when the above options are not possible and the liver function is moderate. The dose of this table may have to be adjusted according to any side-effects that may be experienced. Chemotherapy and targeted therapy will not cure the cancer. Many other treatment options are being studied such as interferon therapy and alternate forms of radiotherapy with encouraging results. They may benefit selected patients.

5 If I have to undergo surgery how do I prepare myself for it? Preparation for liver surgery is similar to preparation for any major surgery. From the perspective of the patient, breathing exercises should be practiced as instructed and smoking should be stopped. A nutritious diet should be implemented. Follow the anaesthiologist s instructions regarding your regular medications. Necessary arrangements regarding the logistics of hospital stay for Days after the operation, or even longer in the event of any complication, should be made. What are the risks involved if I get operated? As the case with all major operations no matter how well done, there is a minimal but definite risk of complications associated with the surgery. Liver surgery is considered to be one of the most major operations in the domain of the abdomen. There is almost a 10% chance that the recovery after the operation may be affected due to complications adequate and timely intervention will solve such problems in the majority of cases. Up to 2% of patients are at risk of death during or immediately after surgery. These risks are significant but are acceptable even in the best centres world-wide. How long can I expect to live after treatment? Some patients may want to know the survival statistics of people in similar situations. Other may not find the numbers helpful, or even might not want to know. It is up to you whether you want to read about the survival statistics for patient with liver cancer. These figures are a rough estimate of your life-span after treatment. Studies have shown that small tumours can be removed, patients who do not have cirrhosis or other serious health problems, are likely to do well if the tumours are removed. There exists a 5 year survival over 50% (the percentage of patients that will live at least 5 years after the cancer is diagnosed). For all stages combined, the relative 5 year survival rate is about 10%. Part of the reason for the low survival is that many patients have cirrhosis, which can be fatal in itself. Keeping in mind that every person s situation is unique & statistics cannot predict exactly what will happen in your case.

6 Is there any chance of cancer coming back? Despite optimal treatment, the risk of cancer appearing back exists. After completion of treatment, one needs to go for a THE MEDICAL & SURGICAL CENTRE LTD HEAD OFFICE: Georges Guibert Street, Floréal 74111, Mauritius Tel: (230) Fax: (230) (Administration) / (230) (Medical) FCD NORTH: Office C, C0 05A & C2 204, La Croisette Mall, Grand Bay, Mauritius Tel: (230) Fax: (230) /7 Emergency and Ambulance Services: Dial 118

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