Treatment for Liver Cancer

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1 Treatment for Liver Cancer Surgical Services Directorate Information for Patients Liver Stomach Pancreas University Hospitals of Leicester NHS Trust

2 Contents Page Introduction...3 Where is my liver and what does it do?...3 What is cancer?...3 What is liver cancer?...3 What is primary liver cancer?...4 What is secondary liver cancer?... 5 What are the symptoms of liver cancer?...5 How is liver cancer diagnosed?...6 The multi-disciplinary team...6 What treatments are available?...7 Consenting to surgery...8 What are the risks of surgery?...8 What are the risks of liver surgery?...9 After your operation...9 How long will I be in hospital?...10 Going home...11 Follow up after surgery...11 Other sources of help and information...12 Glossary...13 Contact details

3 Introduction The aim of this booklet is to help you understand more about the treatments that are available to you. There is a glossary at the end of the booklet where words that you may be unfamiliar with are explained. Words in bold type can be found in the glossary. Where is my liver, and what does it do? Your liver is situated on the right hand side of your body, tucked under the lower ribs and is your body s largest organ. Its functions include: producing bile a fluid passed into the gut to help with fat digestion and make cholesterol soluble. Bile contains bile salts and bilirubin. converting food into energy. fighting infections within the body. inactivating and destroying harmful substances, such as toxins and drugs. producing proteins and enzymes, which play a major role in blood clotting. removing waste products from the body. What is cancer? The body normally works on the principle that as one cell dies, it is replaced. However, cancer cells are cells that grow and do not die. These cells then form new abnormal cells, which form a tumour. These cells can spread to nearby tissues and other organs. 3

4 What is liver cancer? Liver cancer can start from the cells in the liver, and this is known as primary liver cancer. More commonly though, the cancer cells spread from elsewhere. This is known as secondary liver cancer. What is primary liver cancer? There are two main types of cells that may form liver cancer: Hepatocytes, which carry out the liver s important jobs, can become hepatocellular carcinoma (HCC) or hepatomas. People with a history of liver disease, such as liver cirrhosis or liver infections (Hepatitis B and Hepatitis C) have an increased chance of getting a hepatoma. 4 There are several treatment options. If the liver cirrhosis is not too advanced, then surgery is advisable to remove the cancerous cells. If the cirrhosis is more advanced, but the cancer is still small, then a liver transplant may be an option. However, when considering a transplant operation other issues have to be taken into account, and these may make the transplant option unsuitable. Other treatments for hepatomas involve drugs, to slow the cancer cells down, or microwave ablation. The cells that make up the bile duct s lining may produce cancer cells known as cholangiocarcinomas. This form of cancer remains hard to treat. Blockages within the bile duct can happen when the cancer cells increase and the flow of bile that normally drains from the liver down to the duodenum becomes trapped. The bile is then forced back up into the liver and bilirubin is excreted out of the body in your urine instead of taking its normal route through the digestive system in your stools. This results in dark urine and pale stools.

5 What is primary liver cancer? (continued) When these blockages happen, obstructive jaundice occurs, causing a yellowing of the eyes and skin. Due to the presence of bile salts, itching is also common. Recommended treatments may include an endoscopy to insert a small plastic tube, known as a stent, through the blockage. This procedure is known as an E.R.C.P. (Endoscopic retrograde cholangio-pancreatography). If it becomes blocked, the stent may require changing at a later stage. Alternatively a metal stent can be used. This is usually put in place by a Radiologist, within the X-ray department, and is less likely to require changing. Separate leaflets about these procedures are available - please ask a member of staff. There is an increased risk of cholangiocarcinoma in people with a rare condition that causes gradual damage to the bile ducts, known as sclerosing cholangitis. What is secondary liver cancer? This is also known as metastatic carcinoma and accounts for 95% of all tumours in the liver. The commonest areas within the body for the cancer to spread from are the colon, pancreas and stomach. The liver becomes a secondary site for cancer due to the blood supply from these primary areas going via the liver. Treatment for secondary liver cancer often involves surgery as well as chemotherapy. However if the disease is not diagnosed early enough, surgery will be of little benefit. 5

6 What are the symptoms of liver cancer? During the early stages of liver cancer the disease is often symptom-free, which makes early diagnosis more difficult. If the tumour causes a blockage, resulting in a reduction in bile flow, then obstructive jaundice will occur. This causes dark urine to be passed, stools to become pale and the eyes and skin to become yellow. Itching may also occur. Weight loss may occur. There may be pain over the liver. This pain happens when the tumour causes the coating that surrounds the liver to stretch. Vomiting can occur as the growth expands and presses on the stomach, constricting the flow of food and drink. How is liver cancer diagnosed? In order for a diagnosis of liver cancer to be made, you will have had several tests done. Blood tests may have detected an abnormality. Although there is no one blood test that can detect liver cancer, the blood test to check your liver function may have shown high levels of a substance called alpha-fetoprotein, which can point to a hepatoma. A more accurate diagnosis can be made by viewing images of your body. These are done by ultrasound scan, Magnetic Resonance Imaging (MRI) scan and/or Computed Tomography (CT) scan. Occasionally a Positron Emission Tomography (PET) scan may be recommended. Separate leaflets about these tests are available - please ask a member of staff. 6

7 The multi disciplinary team (MDT) While planning your care, your doctor will wish to discuss your medical problem at a weekly meeting, where different specialists meet. This means that your planned treatment is a joint decision by your doctor and several other specialists. Members of the MDT include: other hepatobiliary surgeons (doctors who specialise in operations involving the liver, pancreas and biliary tree) a radiologist (a specialised X-ray doctor) a pathologist (a doctor who studies body tissues) an oncologist (a specialist cancer doctor) doctors and nurses from the palliative care team medical consultants clinical nurse specialists (CNS) What treatments are available? Liver cancer may be treated by surgery, chemotherapy or microwave ablation. The treatment you will receive will depend on: exactly where the cancer is in your liver, and whether there is more than one tumour the size of the tumour(s) the health of the rest of your liver your general health 7

8 Surgery During the operation, the surgeon removes the cancerous cells With the affected segments of the liver. This is known as a liver resection. The liver is constructed of eight segments and it may be possible for up to 80% of the liver to be safely removed. The liver is able to regenerate itself within about six weeks of surgery, as the part left behind enlarges (the part removed does not grow back). During this surgery, it is common for your gall bladder to also be removed. This may be done if your gall bladder is attached to the part of liver that you have had removed and will also prevent you from having gall stone problems in the future. You can lead a perfectly normal life without a gallbladder. Chemotherapy This is the use of anti-cancer drugs to destroy cancer cells. Your consultant may prescribe chemotherapy for you, and you may receive this either before or after your operation, or both. Microwave ablation Liver resection may not be possible if the functioning capacity of the liver is already damaged, as this makes the risk of liver failure too great. In this case, microwave ablation may be suitable. This procedure can be done during your surgery, and uses heat to destroy the tumours. A small probe is placed on the diseased area under ultrasound guidance. Microwave energy is then delivered to destroy the abnormal cells. 8

9 Consenting to surgery Before any operation is performed, your doctor will need to have your consent. This is a written form that you and your doctor will sign together. Your doctor will tell you how much of your liver will need to be removed, and how many probable segments the cancer has grown in. However you also need to be aware that sometimes it is only during the operation that the spread of the disease is fully apparent. This may mean that the cancer has become fixed to important blood vessels making a complete removal of the growth too dangerous. You need to be fully aware of the operation that you are going to have done. If you have any doubts or questions, you should speak to your doctor. What are the risks of surgery? With any operation there are risks. Your anaesthetist will see you prior to surgery, to assess that you are fit enough to undergo the procedure. Your anaesthetist will review your breathing ability and also any cardiac (heart) history you may have. A routine chest x-ray and a tracing of your heart (ECG) will be done. With liver surgery, the operating time can be long, at least several hours, so you will be advised in the time leading up to your operation to concentrate on getting yourself as fit as you can and building yourself up. If you smoke, try to cut down (giving up altogether is preferable). 9

10 What are the risks of surgery? (continued) With long operations, there is a risk of clots forming in your legs deep vein thrombosis (DVT). During your stay in hospital, you will be measured for and given a pair of support stockings to wear. Your doctor will also prescribe you regular Heparin injections. While on the operating table, you will have a pair of compression boots put on your legs, to aid blood flow. You will have blood specimens taken before you go to theatre to check your blood group and your blood s ability to clot. We will also carry out routine liver function tests, blood sugar levels and check that you are not anaemic. Many of the above tests will be carried out at your pre-assessment appointment before you are admitted for your operation. You will also be screened for MRSA at this appointment. What are the risks of liver surgery? Although this is complex surgery most people leave hospital well and pain free. However, 1 in 25 patients can have severe complications that may prove fatal. Problems which could occur after surgery are: Bile duct leakage, which could require further surgery to rectify the problem. Heart problems. Chest infection, which could lead to pneumonia. Large amounts of blood loss, which may mean that you need a blood transfusion. Infections from wounds and drains. Liver failure. 10

11 After your operation Following your operation, you will be transferred to the high dependency ward or intensive care unit. This is usual following any major operation. Tubes and drains When you wake up from your operation you may be aware of a tube helping you to breathe. You will have a tube in a vein in your neck, allowing the doctors and nurses looking after you to give you fluids and other medications that you might require to help with your recovery, such as antibiotics. A further tube for giving medication may have been put in a vein in your arm. You will also have tubes in place to help drain fluid from the wound. Urinary catheter A catheter tube will have been placed in your bladder to drain your urine into a bag. The catheter will also help those planning your care to assess how much fluid your body is passing. Pain control It is very important that your pain is well controlled so that you are not frightened to move and cough to help keep your chest clear. You will probably have an epidural that delivers strong pain killers through a fine tube that goes into your back (the same thing that is sometimes used for women giving birth). The nurses will monitor you regularly and ask you if you have pain or you feel sick or drowsy. A specialist nurse from the pain team will see you every day to check on your progress. Wound You will have a wound going across the top of your abdomen, beneath your ribs. The nurses looking after you will change the dressing on this as necessary, and will give you further information before you are discharged. 11

12 After your operation (continued) Mobility As you begin to recover following your operation, the drains and tubes will be removed, enabling you to move more freely and helping you to avoid complications that could arise from staying in bed too long. How long will I be in hospital? When the team looking after your care feels that you are recovering adequately, you will be transferred back to the general surgical ward until you are ready to be discharged home. The amount of time that you can expect to stay in hospital is approximately two weeks, however this can vary. During your operation your surgeon will have sent pieces from the removed liver for examination in the laboratory. Your consultant will inform you of the results of these when they are available. Going home Once you go home, you will find that you will feel tired: this is quite normal following this sort of surgery. You may find that you cannot eat the same amount of food that you did before surgery. Try eating small amounts often. For the first few weeks your body will be concentrating on regenerating your liver, so try to eat food with plenty of protein in it to aid your body s repair. 12

13 Follow up after surgery If you require further treatment your doctors will discuss this with you before you leave hospital. You will be given an appointment to come back to see a doctor from your surgical team a few weeks after your discharge from hospital. You will then have a scan (usually a CT scan) and clinic appointment every six months, to check for further problems. This will continue for two years after your operation. Following this you will be seen every year. If you experience no further problems for five years after your treatment, then you will be discharged from our care. Other sources of help and information Cancer Patient Information Centre Osborne Building Leicester Royal Infirmary LE1 5WW The Centre is staffed by Patient Information Officers who will provide you with the information you need, or signpost you to help and support available locally and nationally. Internet facilities and assistance are available. Opening hours: Monday to Friday from 9.30 am to 4.30 pm Telephone: cancerinfo@uhl-tr.nhs.uk Macmillan Cancer Support For information and support from cancer support specialists. Freephone: Website: Cancerhelp Ask specialist nurses about anything to do with cancer. Freephone: Website: cancerhelp.org.uk 13

14 Other sources of help and information British Liver Trust The national charity for adult liver disease. Website: CORE The charity for research and information on gut and liver disease. Also known as the Digestive Disorders Foundation. Website: Glossary alpha-fetoprotein: substance found in high levels in the bloodstream of some people who have primary liver cancer. bile: fluid produced by the liver and stored in the gall bladder, which flows down the bile duct and helps the body to digest fat. bilirubin: the end product of the breakdown of worn out red blood cells. Gives bile its dark green colour. cholangiocarcinoma: cancer of the bile duct. endoscopy: insertion of a small illuminated flexible telescope down the gullet in order to investigate or treat disorders. hepatocytes: the main cells of the liver. hepatocellular carcinoma (HCC): also sometimes called hepatoma. Hepatocellular means liver cells. Carcinoma means cancer. MRSA: (Methicillin Resistant Staphylococcus Aureus) A type of bacteria that is resistant to some antibiotics. 14

15 Glossary (continued) protein: meat, poultry, fish, beans, lentils, nuts, eggs, milk and cheese are protein sources. sclerosing cholangitis: a disease in which the bile ducts become narrow due to inflammation and scarring. Questions I would like to ask 15

16 Contact details: Your Specialist nurse is: Sophie Noble Pager number: (Monday to Friday - 8am to 4pm) If you would like this information in another language or format, please contact the service equality manager on LRI HPB Information Group Treatment for Liver Cancer Edition 4: June 2014 Review: June 2016 (Moody) KR CAN