Understanding Cancer in the Liver

Transcription

1 Understanding Cancer in the Liver A guide for people affected by primary liver cancer or secondary cancer in the liver Cancer information

2 Understanding Cancer in the Liver A guide for people affected by primary liver cancer or secondary cancer in the liver First published October This edition May Cancer Council Australia 2012 ISBN Understanding Cancer in the Liver is reviewed approximately every two years. Check the publication date above to ensure this copy of the booklet is up to date. To obtain a more recent copy phone Cancer Council Helpline Acknowledgements This edition has been developed by Cancer Council NSW on behalf of all other state and territory Cancer Councils as part of a National Publications Working Group initiative. We thank the reviewers of this booklet: Dr Benjamin Thomson, Hepato-pancreato-biliary Surgeon, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, VIC; Joyce Bonello, Cancer Care Coordinator GIT, Prince of Wales Hospital, NSW; Carol Cameron, Cancer Nurse Coordinator Upper GI, WA Cancer & Palliative Care Network; Karen Hall, Clinical Nurse Cancer Services Division, Flinders Medical Centre, and Cancer Council Helpline Nurse, SA; Robyn Hartley, Consumer; Mamta Porwal, Project Coordinator, B Positive Project, Cancer Council NSW; Chris Rivett, Clinical Nurse Oncology, Western Hospital, and Cancer Council Helpline Nurse, SA; and Dr Kellee Slater, Hepatobiliary, General and Liver Transplant Surgeon, Princess Alexandra Hospital, QLD. We would also like to thank the health professionals and consumers who have worked on previous editions of this title, as well as the original writer Jenny Mothoneos. Editor: Vivienne O Callaghan Designer: Paula Marchant Printer: SOS Print + Media Group Note to reader Always consult your doctor about matters that affect your health. This booklet is intended as a general introduction to the topic and should not be seen as a substitute for your doctor s or other health professional s advice. However, you may wish to discuss issues raised in this booklet with them. All care is taken to ensure that the information in this booklet is accurate at the time of publication. Cancer Council WA Cancer Council is the leading cancer charity in WA. It plays a unique and important role in the fight against cancer through undertaking high-quality research, advocating on cancer issues, providing information and services to the public and people with cancer, and raising funds for cancer programs. This booklet is funded through the generosity of the people of WA. To make a donation to help defeat cancer, visit Cancer Council s website at or phone Cancer Council Helpline for more information. Cancer Council WA 46 Ventnor Avenue, West Perth WA 6005 Cancer Council Helpline Telephone Facsimile questions@cancerwa.asn.au Website ABN

3 Introduction This booklet has been prepared to help you understand more about cancer that affects the liver. Many people feel understandably shocked and upset when told they have primary liver cancer or secondary cancer in the liver. We hope this booklet will help you understand how cancer in the liver is diagnosed and treated. We also include information about support services. We cannot give advice about the best treatment for you. You need to discuss this with your doctors. However, we hope this information will answer some of your questions and help you think about other questions to ask your treatment team. This booklet does not need to be read from cover to cover just read the parts that are useful to you. Some medical terms that may be unfamiliar are explained in the glossary. You may also like to pass this booklet to your family and friends for their information. How this booklet was developed This information was developed with help from a range of health professionals and people affected by primary liver cancer or secondary cancer in the liver. Some of information was sourced from Macmillan Cancer Care, UK. Cancer Council Helpline can arrange telephone support in different languages for non-english speakers. You can also call the Translating and Interpreting Service (TIS) direct on

4 Contents What is cancer?...4 The liver... 6 Key questions...8 What is primary liver cancer?... 8 What are the risk factors?... 8 Hepatitis B and liver cancer... 9 Can primary liver cancer spread? What is secondary cancer in the liver? Naming secondary cancers How common is cancer in the liver? What are the symptoms? Key points Diagnosis Blood tests...14 Scans (imaging tests)...15 Biopsy...18 Further tests...19 Staging cancer in the liver...20 Prognosis...21 Which health professionals will I see?...22 Key points...24 Treatment Surgery...25 Tumour ablation...30 Chemotherapy...31

5 Biological therapy...34 Selective internal radiation therapy...34 Endoscopic stent placement...35 Palliative treatment...36 Key points...37 Making treatment decisions Talking with doctors...39 A second opinion...39 Taking part in a clinical trial...40 Looking after yourself Healthy eating...41 Staying active...41 Complementary therapies...42 Relationships with others...43 Sexuality, intimacy and cancer...44 Changing body image...45 Dealing with your emotions...46 Seeking support Practical and financial help...50 Talk to someone who s been there...51 Caring for someone with cancer...52 Useful websites...53 Question checklist Glossary...55 How you can help... 60

6 What is cancer? Cancer is a disease of the cells, which are the body s basic building blocks. Our bodies constantly make new cells to help us grow, to replace worn-out cells and to heal damaged cells after an injury. Normally cells grow and multiply in an orderly way, but sometimes something goes wrong with this process and cells grow in an uncontrolled way. This uncontrolled growth may result in a lump called a tumour or may develop into abnormal blood cells. A tumour can be benign (not cancer) or malignant (cancer). A benign tumour does not spread to other parts of the body. However, a malignant tumour is made up of cancer cells, which are able to spread. The cancer that first develops in a tissue or organ is called the primary cancer. How cancer starts Normal cells Abnormal cells Cancer in-situ Angiogenesis Boundary Lymph vessel Blood vessel Normal cells Abnormal cells Abnormal cells multiply Malignant or invasive cancer 4 Cancer Council

7 When it first develops, a malignant tumour may not have invaded nearby tissue. This is known as a cancer in-situ, carcinoma in-situ or localised cancer. As the tumour grows, it may spread and become what is known as invasive cancer. Cancer cells can spread to other parts of the body by travelling through the bloodstream or the lymphatic system. They may continue to grow into another tumour at this new site. This is called a secondary cancer or metastasis. A metastasis keeps the name of the original cancer. Liver cancer that has spread to the bones is still called liver cancer, even though the person may be experiencing symptoms in the bones, while breast cancer that has spread to the liver is called breast cancer. How cancer spreads Primary cancer Local invasion Angiogenesis tumours grow their own blood vessels Lymph vessel Metastasis cells invade other parts of the body via blood vessels and lymph vessels What is cancer? 5

8 The liver The liver is the largest organ inside the body. It is on the right side of the tummy area (abdomen), next to the stomach. It is found under the ribs, just beneath the right lung and the diaphragm. The diaphragm is a sheet of muscle that separates the chest from the abdomen. The liver is made up of two sections, the right and left liver. Blood flows into the liver from the hepatic artery and the portal vein. Blood from the hepatic artery carries oxygen, while blood from the portal vein carries nutrients and waste products (toxins). The liver performs several important functions including: producing bile to help dissolve fat so it can be easily digested converting sugar and fat into energy storing nutrients making proteins for the blood helping the blood to clot making other chemicals the body needs breaking down harmful substances such as alcohol and drugs, and getting rid of waste products. Unlike other internal organs, the liver can usually repair itself. It can function normally even if only a small part of it is working. After surgery or injury it can grow back to normal size in 6 8 weeks. Bile is made in the liver and is stored in the gall bladder. When needed, bile is released into the bowel to help break down fats. 6 Cancer Council

9 The liver Lung Hepatic vein Liver (right) Diaphragm Liver (left) Stomach Gall bladder Hepatic artery Common bile duct Pancreas Portal vein The liver 7

10 Key questions Q: What is primary liver cancer? A: Primary liver cancer is cancer that starts in the liver. It is when a malignant tumour or tumours are found in the liver tissue. There are different types of primary liver cancer: Hepatocellular carcinoma (HCC) starts in the hepatocytes, the main cell type in the liver. HCC, also called hepatoma, is the most common type of primary liver cancer. Cholangiocarcinoma starts in the cells lining the bile ducts, which connect the liver to the bowel and gall bladder. It is also called bile duct cancer. Angiosarcoma a very rare type of liver cancer starting in the blood vessels. It usually occurs in people over 70. Q: What are the risk factors? A: The exact cause of primary liver cancer is not known, but the following factors may increase the risk: infection with hepatitis B liver scarring (cirrhosis) due to hepatitis B or C, inflammation, alcohol, or genetic disorders, such as haemochromatosis or alpha 1-antitrypsin deficiency diabetes drinking alcohol over a long period of time smoking high-fat diet being overweight or obese. 8 Cancer Council

11 Hepatitis B and liver cancer Infection with hepatitis B is the biggest known risk factor for developing primary liver cancer. The hepatits B virus affects the liver cells (hepatocytes). This stimulates the immune system to attack the virus. However, the immune response causes inflammation in the liver, which can lead to ongoing damage. It isn t the virus itself that causes damage. People with chronic hepatitis B often develop cirrhosis, which increases the risk of liver cancer. However, hepatitis B can also cause liver cancer before cirrhosis has occurred. Hepatitis B is spread through infected semen, blood, or other body fluids entering the body of someone who is not infected. Spread can occur through sex with an infected partner, direct contact with the blood of an infected person, or sharing items such as razors or toothbrushes with an infected person. People can spread hepatitis B without knowing they re infected. To reduce the spread of hepatitis B and the incidence of primary liver cancer, it is recommended that all at-risk people receive a vaccination against the virus. This includes: migrants from South-East Asia, Africa and the Pacific Islands sexually active partners of infected individuals people in the same household as someone with hepatitis B recipients of blood products all infants and children. If you are in one of these groups or are concerned about getting hepatitis B, contact your doctor or call Cancer Council Helpline for more information. Key questions 9

12 Q: Can primary liver cancer spread? A: If primary liver cancer is not found in its early stages, or if treatment is not successful, it can spread to other parts of the body. It typically spreads to the lungs and bones. The two most common ways that liver cancer spreads to other organs are: through the bloodstream through the lymphatic system. The lymphatic system is part of the body s defence system against infection and disease. It includes a network of thin tubes (lymph vessels). The vessels carry a clear fluid called lymph to and from tissues, before emptying it into the bloodstream. Q: What is secondary cancer in the liver? A: Secondary cancer in the liver is cancer that started in another part of the body but has spread (metastasised) to the liver. Most cancers can spread to the liver, but the most common ones start in the digestive system (large bowel, pancreas, oesophagus and stomach). Digestive cancers often spread to the liver because blood containing cancer cells from the digestive organs passes through the liver first and can lodge there. Melanoma and cancers of the breast, ovary, kidney and lung can also metastasise to the liver. 10 Cancer Council

13 Naming secondary cancers A secondary cancer is named after the primary site where it began. For example, bowel cancer that has spread to the liver is still called bowel cancer. To indicate that the cancer has spread, doctors may call it bowel cancer with liver secondaries, colorectal metastasis, metastatic bowel cancer or advanced bowel cancer. In this booklet we use the term secondary cancer in the liver to refer to any cancer type that has spread to the liver. Secondary cancer in the liver is sometimes found at the same time that the primary cancer is diagnosed. However, this is not always the case: It can be diagnosed soon after the primary cancer, or it may be diagnosed months or years after someone has been treated for primary cancer. It may be diagnosed before the primary cancer is found. If other tests don t show what the primary cancer is, this is called cancer of unknown primary (CUP). This is uncommon. If you have secondary cancer in the liver, it may be useful to read information about the related primary cancer, or about CUP if the primary cancer is unknown. Call Cancer Council Helpline or go to your local Cancer Council website to access relevant publications. Key questions 11

14 Q: How common is cancer in the liver? A: Primary liver cancer is one of the less common cancers in Australia. About 1400 people are diagnosed with it every year. It is more than twice as common in men, and in people aged over 65 years. Its incidence is increasing. Primary liver cancer particularly hepatocellular carcinoma (HCC) is common in Asia, Mediterranean countries and Africa due to the high rates of hepatitis B in people from those areas. In Australia, it is more common in migrants from Vietnam, Hong Kong and Korea due to the link with hepatitis. Secondary cancer in the liver is much more common than primary liver cancer. It occurs about 20 times more often, with about 28,000 people in Australia being diagnosed every year. Q: What are the symptoms? A: Primary liver cancer doesn t tend to cause symptoms in the early stages but they may appear as the cancer grows or becomes advanced. Secondary liver cancers may cause similar symptoms. These can include: weakness and tiredness (fatigue) pain in the upper right side of the abdomen severe abdominal pain if a primary liver tumour bleeds loss of appetite, feeling sick (nausea) and weight loss yellowing of the skin and eyes (jaundice) swelling of the abdomen (ascites) fever. 12 Cancer Council

15 Key points Cancer in the liver can occur as a primary cancer that started in the liver, or as a secondary cancer that started in another part of the body before spreading to the liver. Primary liver cancer can also spread throughout the body. It tends to spread to the lungs or bones. The main risk factors for primary liver cancer include infection with hepatitis B or C and liver scarring (cirrhosis) due to inflammation, genetic disorders or heavy drinking. Lifestyle factors such as smoking and a high-fat diet and being overweight can also increase the risk. more frequently in people from South-East Asia due to its link with hepatitis B, which is common in that region. Secondary cancer in the liver is much more common than primary liver cancer, occurring about 20 times more often. There are few symptoms that might suggest primary liver cancer or secondary cancer in the liver. The symptoms are vague and usually appear when the cancer has advanced. There may be fatigue, pain in the liver area, appetite and weight loss, jaundice, nausea, abdominal swelling and fever. Primary liver cancer is rare in Australia but its incidence is increasing. It is more common in men and in people over 65. It is also seen Key questions 13

16 Diagnosis Primary liver cancer and secondary cancer in the liver are diagnosed using a number of different tests. These include blood tests and scans. Tissue examination (biopsy) is only done rarely. Blood tests You will probably have a blood test to check how the liver is working (liver function) and how well your blood clots. You may also have liver function tests before, during and after treatment. If primary liver cancer is suspected, you will have blood tests to check for hepatitis B or C and various genetic problems. You may need a blood test to check the level of certain chemicals known as tumour markers, which are produced by cancer cells. Tumour markers can help diagnose some types of cancer. The tumour markers used to diagnose primary liver cancer include alpha-fetoprotein (AFP), cancer antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA). Carcinoembryonic antigen (CEA) can also be helpful in diagnosing secondary cancer that has spread from the large bowel. However, the tumour markers do not rise in all people with these cancers. Also, some conditions, such as pregnancy, hepatitis and jaundice, can increase tumour marker levels without cancer being present. If the markers are high due to cancer, they should fall when treatment ends. After blood tests, other tests will need to be done to confirm the diagnosis of primary liver cancer or secondary cancer in the liver. 14 Cancer Council

17 Scans (imaging tests) You will have at least one of these scans, but you may have more than one if the doctor needs further information about the cancer. CT scan A CT (computerised tomography) scan is a type of x-ray that takes three-dimensional pictures of several organs at the same time. It helps doctors make a diagnosis and see if the cancer has spread. It can also help doctors plan surgery if this is appropriate. The test usually takes minutes. You will need to drink a liquid dye (contrast) or have an injection of contrast into a vein beforehand to make the pictures clearer. The injection may be uncomfortable and the dye may briefly make you feel hot and sweaty. Some people can t have this scan because of poorly functioning kidneys or allergy to the contrast. In this case, a different scan will be arranged. You will lie on a table while the CT scanner, which is large and round like a doughnut, takes the pictures. The scan itself is painless. The contrast used in a CT or MRI scan (see the next page) may contain iodine. If you are allergic to iodine, fish or dyes, let your doctor know in advance so other arrangements can be made. If you have the contrast, drink a lot of water afterwards to flush it out of your system. If you develop a rash or have difficulty breathing, go to the emergency department as you may be having an allergic reaction. Diagnosis 15

18 MRI scan An MRI (magnetic resonance imaging) scan uses both magnetism and radio waves to take detailed cross-sectional pictures of the body. These show the extent of the tumour and whether it is affecting the main blood vessels around the liver. The pictures are taken while you lie on a table that slides into a metal cylinder a large magnet that is open at both ends. You may be given an injection of contrast into your veins to make the pictures clearer. An MRI is painless but some people find that lying in the cylinder is too confined (claustrophobic) and noisy. If you feel uncomfortable, let your doctor or nurse know. They can give you medication to ease this feeling or earplugs to reduce the noise level. You can also usually take someone into the room with you for company. I had various scans when I was diagnosed with primary liver cancer. I found the MRI was frightening, going in to the cylinder head first and having to hold my breath. But now when I have this scan during check-ups, I count to myself. This helps me feel more in control. Robyn PET-CT scan A positron emission tomography (PET) scan combined with a CT scan (see page 15) is a type of imaging test available at some major metropolitan hospitals. It produces a three-dimensional colour image that shows where some cancers are in the body. 16 Cancer Council

19 For the PET scan, you will be injected in the arm with a glucose solution containing a small amount of radioactive material. It takes minutes for the solution to go through your body. During this time you will be asked to sit quietly. Your whole body will then be scanned for high levels of radioactive glucose. Cancer cells show up brighter on the scan pictures because they are more active and take up more of the glucose solution than normal cells. It s advisable to drink plenty of water after the scan to flush out the radioactive material from your body. Ultrasound An ultrasound uses soundwaves to create a picture of a part of your body. It can show the size and location of abnormal tissue in your liver. The test takes about 15 minutes and is painless. You will be asked to not eat or drink for about four hours before the test. During the scan, you will lie down and a gel will be spread over your tummy area (abdomen) to help conduct the soundwaves. A small paddle-shaped device called a transducer is then moved over your abdomen. It creates soundwaves that echo when they meet something dense, like an organ or tumour. The soundwaves are sent to a computer and turned into a picture. If a solid lump is found, the scan will help show whether it is cancer. Non-cancerous (benign) tumours in the liver can also be found during an ultrasound. These occur in about four out of 10 people. Diagnosis 17

20 Biopsy A biopsy means removing a small amount of tissue to examine under a microscope. Tissue samples are taken from the liver in either a fine needle aspiration or a laparoscopy. The biopsy can sometimes show if the cancer in your liver is a primary or secondary cancer. A biopsy is usually only done to make a diagnosis if no surgery is planned. Before a biopsy, you may have a test to check how well your blood clots (your bleeding time) because the liver has many blood vessels. Fine needle aspiration You will have a local anaesthetic to numb the area where a fine needle is passed through the skin into the tumour. An ultrasound or CT scan will be done at the same time to help the doctor guide the needle to the right place. The cancer cells are drawn into the needle and removed. Afterwards, you will stay in hospital for a few hours. You may need to stay overnight if there is a high risk of bleeding. It is possible to do a biopsy and not get a diagnosis when the results come back. In some cases the biopsy will need to be repeated. If the cancer hasn t spread and is able to be surgically removed, you won t have a biopsy. This is because there is a small risk that the cancer will spread along the pathway where the fine needle has been inserted and removed. A biopsy may also not be needed if you are able to have a transplant (see page 29). 18 Cancer Council

21 Laparoscopy This operation is also called keyhole surgery. It allows the doctor to look at the liver and surrounding organs using a thin tube containing a light and a camera (a laparoscope). It is often done if your doctor thinks the cancer is in other areas besides the liver. A laparoscopy is done under general anaesthetic. A small cut is made in your lower abdomen for the laparoscope to be inserted. During the procedure, carbon dioxide gas is used to increase the size of your abdomen to make space for the surgeon to see. If necessary, the surgeon will take tissue samples. The small cut in the abdomen will then be closed with a couple of stitches. The most common risks of laparoscopy are wound infection and bruising. Because the liver has many blood vessels, there is a slight risk of bleeding, but this is rare. The carbon dioxide can also cause shoulder pain and wind for a few days. Usually you will need to stay in hospital overnight for monitoring. Some people need to stay in hospital for a few days. Further tests If you have not previously been diagnosed with cancer and the tests described on pages show you have secondary cancer in the liver, you may need further tests to find out where the primary cancer started. These will probably include an examination of the bowel (colonoscopy), the stomach (endoscopy) and, for women, the breasts (mammogram). Diagnosis 19

22 In other cases, it will be clear where the primary cancer began, as you may have been diagnosed and treated for that cancer in the past. This is common if you have had cancer of the large bowel. You may need blood tests to look for different tumour markers, a urine test to see if there are problems with organs such as the kidney or bladder, or other imaging tests, such as a PET-CT scan, to see different parts of the body. ICG test An indocyanine green (ICG) test is done in some hospitals for people with primary liver cancer and cirrhosis to help surgeons determine their fitness for surgery. This may be done because it can be dangerous to remove part of the liver in people with cirrhosis. A green dye is injected into the blood and 15 minutes later, a reading is taken using a machine attached to the patient s finger. The machine measures the amount of dye left in the blood. If there is a high reading, this means the liver is not working well and any operation will be risky. Staging cancer in the liver The tests described in this chapter will show whether you have: primary liver cancer primary liver cancer that has spread secondary cancer that has spread to the liver from elsewhere. 20 Cancer Council

23 Working out whether the cancer has spread from the primary cancer site and if so, how far is called staging. This helps your doctor recommend the best treatment for you. The different stages of cancer are based on how far away from the original tumour site the cancer is found. Different types of cancer have different staging systems. In primary liver cancer, generally stage 1 and stage 2 tumours are confined to the liver. Usually stage 3 and stage 4 describes cancer that has spread away from liver. If you have primary liver cancer or secondary cancer in the liver, your doctor can explain more about the stage of the cancer and how it relates to your diagnosis and treatment. Prognosis Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis and treatment options with your doctor, but it is not possible for any doctor to predict the exact course of your disease. Factors used to assess your prognosis include: test results the type of cancer, where it is in the body, and the rate of growth how well you respond to treatment your age and fitness your medical history. Diagnosis 21

24 Doctors often use numbers (statistics) when considering someone s prognosis. Statistics show the typical outcome of disease in large numbers of people. While statistics give doctors a general idea about a disease, they don t necessarily show what will happen in your situation. If surgery or transplant is an option for primary liver cancer, these treatments usually offer a good chance of cure. Other treatments for primary liver cancer and secondary cancer in the liver may enable you to live for much longer than if you were to have no treatment. Which health professionals will I see? Your general practitioner (GP) will arrange the first tests to assess your symptoms. If these tests do not rule out cancer, you will probably be referred to a gastroenterologist who will organise further tests for you and advise you about treatment options. You may need to see other specialists such as a surgeon or a medical oncologist to discuss the different types of treatment. You will be cared for by a range of health professionals who specialise in different aspects of your treatment. This is called a multidisciplinary team, and includes doctors, nurses and allied health professionals such as a physiotherapist and dietitian. Some people in non-metropolitan areas will have to travel to appointments with specialists. Your GP can be kept informed of all your test results and treatment. They can answer questions you have in-between appointments with specialists. 22 Cancer Council

25 Health professionals hepatobiliary surgeon Role a doctor who specialises in surgery of the liver and its surrounding organs gastroenterologist a specialist in diseases of the digestive system hepatologist a gastroenterologist who has further specialised in diseases of the liver and gall bladder medical oncologist prescribes and coordinates the course of chemotherapy cancer nurse coordinators and nurses social worker, physiotherapist, occupational therapist dietitian help administer drugs, including chemotherapy, and provide care, information and support throughout your treatment link you to support services and help you to resume your activities recommends an eating plan for you to follow while you are in treatment and recovery palliative care team assists you with symptom management and emotional support for you and your family Diagnosis 23

26 Key points There are several different tests to diagnose primary liver cancer or secondary cancer in the liver. Blood tests show how the liver is working and whether there are tumour markers in the blood that might indicate cancer in the liver. Imaging tests include a range of scans that allow doctors to see your organs and whether they have any abnormal tissue or tumours in them. Sometimes non-cancerous (benign) lumps are found. A biopsy is when tissue is removed for examination under a microscope. This is not done very often. If you have secondary cancer in the liver, you may need tests such as a colonoscopy or endoscopy to find out where the primary cancer started. All of these tests will help your doctor work out the best treatment options for you and whether it may be possible to try and cure your cancer. Your doctor may tell you what stage the cancer is at. This describes how far the cancer has spread in the body. You may wonder about the likely outcome of the disease (your prognosis). There are many factors in considering your prognosis, such as test results, the type of cancer you have and your medical history. You will see many health professionals when you have tests and treatment. These include specialists, nurses, and allied health professionals such as a social worker. 24 Cancer Council

27 Treatment Your treatment will depend on whether you have primary liver cancer or secondary cancer in the liver; the size and spread of the cancer; and whether any other disease, such as cirrhosis, affects your liver. Your doctor will also consider your age and general health, as well as the options available at your hospital. Primary liver cancer Surgery, including a transplant, is used where possible but it isn t always an option. The most common treatments are tumour ablation using heat (radiofrequency ablation) and chemotherapy delivered directly into the cancer, known as transarterial chemoembolisation (TACE). Secondary cancer in the liver The main treatments are chemotherapy or a combination of surgery and chemotherapy. Surgery Surgery for liver cancer is called a liver resection. It removes the part of the liver that contains the cancer. Usually only part of the liver is removed, but occasionally the whole liver can be replaced in a transplant. Primary liver cancer Only a small number of people are suitable for surgery. This depends on the size, number and position of the tumours, how much of the liver is affected and whether cirrhosis is present. Operating on patients with cirrhosis is complicated because the liver may not function well afterwards. Some people with a small hepatocellular carcinoma may be considered for a transplant. This depends on their age and health, and the availability of a donor. Treatment 25

28 Secondary cancer in the liver Surgery may be possible if there is enough healthy liver and the cancer hasn t spread to other parts of the body where it can t be removed (such as the bones). Some people need surgery for both the secondary cancer in the liver and the primary cancer. These operations may be done separately or at the same time. Partial hepatectomy Surgery to remove part of the liver is called a partial hepatectomy. How much of the liver is removed depends on your circumstances. In some cases, the surgeons will remove one side of your liver. In other cases they will only need to cut out a small section (segmentectomy). The gall bladder is also taken out during a partial hepatectomy, as it is attached to the liver. Occasionally, part of the diaphragm located above the liver may be removed. The liver can repair itself easily if it is not damaged. It will start to re-grow quickly, even if up to three-quarters of it is removed. It will usually grow back to normal size within a few months. Two-stage surgery (two-stage hepatectomy) People with tumours in both sides of the liver may have two operations. The surgery is done in two stages. After the tumours are removed from one side of the liver, the patient is given time to recover and the liver time to re-grow. Sometimes the first partial hepatectomy is combined with tumour ablation (see page 30) or removal of the primary tumour. 26 Cancer Council

29 Before the second operation, the size of the liver will be checked. If enough of the liver has regrown, the tumours in the second side will be removed in another partial hepatectomy. These operations occur about two months apart. After surgery You will spend 5 10 days in hospital after a partial hepatectomy, and up to 3 weeks in hospital following a transplant. Drips and drains Different tubes will be in place to drain post-operative fluids, urine and bile. You will also have a drip (intravenous tube) giving you fluids and nourishment, as you may not be able to eat or drink for a few days. When you are able to eat, you will be given clear fluids at first, and then solid foods. Pain relief In most liver operations, a large cut is made in the upper abdomen. This means that after surgery you may experience pain, as well as breathing difficulties and nausea. The hospital staff will try to make you comfortable by giving you pain relief. You may have a tube called an epidural catheter placed in your back, or you may be given what is known as an intravenous patientcontrolled analgesic (PCA) system. The PCA system allows you to control the pain by pressing a button to give yourself a dose of pain relief when you need it. It is not possible to give yourself an overdose of medication. Let your doctor or nurse know if the pain control is not working. Fatigue You will probably feel quite tired and weak after the operation, but this should improve within a few weeks. Treatment 27

30 Mobility A physiotherapist can help with your recovery by giving you exercises to improve your breathing, strength and ability to walk (mobility). Check-ups After you return home, you will need frequent check-ups to monitor your health and the success of the surgery. Your doctor will tell you how often check-ups will occur. Don t lift anything heavy for about six weeks after surgery. Avoid driving if you are taking strong (opioid) pain-killers. Avoid alcohol for at least two months and only drink alcohol in moderation after this time. Start light exercise as soon as you are able to, and continue any physiotherapy exercises if appropriate. Wait at least four weeks before swimming, and six weeks before starting heavy exercise. Laparoscopic liver surgery If tumours are small and near the surface of the liver, the surgeon may do a laparoscopy (see page 19) to remove or destroy (ablate) the tumour. Your surgeon will make small cuts in your abdomen and use a camera to view your organs. While recovery is faster after this type of surgery, you will still be in hospital for at least one night and you will need pain medication. You should give yourself a week to recover before returning to work or usual activities. You should avoid heavy lifting for about six weeks. 28 Cancer Council

31 I had an 11-cm long hepatocellular carcinoma, but I was lucky that the tumour was operable. After surgery, the physiotherapy exercises helped my recovery. Robyn Liver transplant People with primary liver cancer are occasionally suitable to have a liver transplant. This involves removing the entire liver and replacing it with a liver from another person (a donor). There are many factors to take into account before someone is eligible for a liver transplant. Their overall health must be good, they cannot smoke or take illegal drugs, and they must have stopped drinking alcohol. Waiting for a donor liver may take many months or years. During this time, the cancer may continue to grow. Some people may not be able to wait for a transplant due to the way the cancer is progressing. Others may be able to have treatment to control the cancer while they wait for a donor. If you have a transplant, it may take 3 6 months to recover. You will probably find it takes a while to regain your former energy. You will also be given medications to reduce the chance of infection and stop the body rejecting the new liver (immunosuppressants). You will need to take immunosuppressants for the rest of your life. After you return home, you will need frequent check-ups to monitor your health and the success of the transplant. There is no cost involved for having a liver transplant in Australia. Treatment 29

32 Tumour ablation Tumour ablation is treatment that destroys a tumour without removing it from the body. Ablation works best when there are only one or two small tumours (less than 3 cm in size) but surgery isn t possible. It is used most commonly for primary liver cancer. It is rarely used for secondary cancer in the liver. The most common ablation treatments use radio waves or microwaves to heat and destroy cancer cells. This can be done with a needle inserted through the skin (percutaneously) or with a surgical cut. Less common types of tumour ablation include alcohol injection and cryotherapy (see the next page). Percutaneous ablation The procedure is done in the x-ray department or operating theatre while you are under local or general anaesthetic. It takes 1 3 hours. A CT or ultrasound scan is used to guide a fine needle through the skin and into the tumour. Radio waves or microwaves are then passed through the needle and into the tumour to destroy it. Afterwards you will probably feel quite drowsy. Side effects, which include pain, nausea or fever, can be managed with medication. You will usually stay in hospital overnight. Ablation with surgery If the tumours are close to the surface of the liver, you may have an operation to avoid damage to the diaphragm or nearby organs. A cut is made in the skin to access the liver, and probes are inserted to do the ablation. You can expect your recovery to be similar to the recovery for liver surgery (see page 27). 30 Cancer Council

33 Alcohol injection Alcohol injection is a procedure that injects pure alcohol directly into a tumour to destroy the cancer cells. It is not available at all hospitals, but it is occasionally used if other forms of ablation aren t possible. The treatment is given under local anaesthetic, and an ultrasound is used to guide the needle into the tumour. You may be given more than one injection over several treatment sessions. You may have some pain or a fever afterwards but these side effects can be managed with medication. Cryotherapy Cryotherapy (or cryosurgery) is a procedure to freeze and kill cancer cells, but it is not widely available. If you have cryotherapy, you will have a general anaesthetic and a cut will be made in your abdomen. A probe is inserted into the centre of the tumour through the cut. The probe releases liquid nitrogen which freezes and kills the cancer cells. Cryotherapy takes about 60 minutes and recovery is similar to having surgery. Chemotherapy Chemotherapy is the use of drugs to kill, shrink or slow the growth of tumours. Depending on the type of cancer you have, you will have chemotherapy that either spreads throughout your body (systemically) or goes directly into the tumour (locally). If given systemically, you may have intravenous chemotherapy (through a drip) or tablets over weeks or months. If given locally, this is called transarterial chemoembolisation (TACE). Treatment 31

34 Whether or not you have chemotherapy depends on factors such as your overall health, liver function, and if you have advanced cirrhosis. Systemic chemotherapy This is used by itself or in conjunction with surgery for secondary cancer in the liver. If surgery is not possible, chemotherapy can help slow down cancer growth and reduce pain. Occasionally the chemotherapy is able to shrink a secondary cancer enough so that it can be operated on later. Systemic chemotherapy is not used in primary liver cancer unless it has spread. In this case, it is used to reduce pain and discomfort. Chemotherapy may also be given following other treatment, such as cryotherapy or surgery, to get rid of any remaining cancer cells. This is called adjuvant chemotherapy. Systemic chemotherapy can cause side effects because the drugs circulate through the whole body and affect normal, healthy cells. These side effects are usually temporary. Transarterial chemoembolisation (TACE) Chemoembolisation is a way of delivering chemotherapy directly into a primary cancer. It is rarely used for secondary cancers. By targeting the tumour directly, stronger drugs can be used without causing many of the side effects of systemic chemotherapy. Usually treatment is given only once, or once every few months. It is done in the x-ray department of a hospital. 32 Cancer Council

35 TACE involves injecting chemotherapy drugs through a thin tube (catheter) that has been inserted into the hepatic artery. Tiny plastic beads or soft gelatine sponges are then placed in the smaller arteries that lead to the tumour. This blocks the arteries, keeping the chemotherapy in the tumour and starving the cancer of oxygen. Beforehand you will be given a local anaesthetic and possibly some medication to relax. Afterwards you will need to remain lying down for about four hours. Depending on your recovery, you may also need to stay in hospital overnight or for a few days. Side effects of chemotherapy The side effects of systemic chemotherapy vary according to the drugs used. They include: nausea and loss of appetite tiredness hair loss and skin changes tingling or numbness in fingers and toes mouth sores increased risk of developing infections. There are many ways to cope with side effects. After treatment most gradually go away. Following chemoembolisation, it is common to develop a fever the next day but this usually passes quickly. Other side effects such as pain are less common but sometimes more severe. You will be given medication to help control any side effects. For ways to manage side effects, read Cancer Council s booklet about chemotherapy, which is available from Cancer Council Helpline or the website. Treatment 33

36 Biological therapy Biological therapies (also called biotherapies) may be used after or in conjunction with other treatments for primary liver cancer or secondary cancer in the liver. They are a range of treatments derived from natural substances in the body, which are concentrated and purified for use as drugs. The therapies work against cancer cells by either stopping their growth and the way they function, or by helping the body s immune system destroy them. Side effects of biological therapies depend on the types used. Your doctor will discuss any possible side effects with you. Selective internal radiation therapy Selective internal radiation therapy (SIRT) is a type of treatment that targets liver tumours directly with high doses of internal radiation placed in tiny radioactive pellets. SIRT is used for both primary and secondary cancers in the liver when the tumours can t be removed with surgery. Typically there may be many small tumours spread throughout the liver. Before treatment If SIRT is an option, you will have a number of tests, including an angiogram and a simulation of the treatment. An angiogram shows up the blood vessels in the liver and helps to map where the radioactive pellets need to go. The tests take about 90 minutes and you will be observed for 3 4 hours afterwards. If the results are good, you will have treatment about a week later. 34 Cancer Council

37 During treatment For the treatment, you will need another angiogram. Afterwards, the tiny radioactive pellets, which are known as SIR-Spheres, are inserted through a catheter that leads from your groin to your liver. The procedure takes about 60 minutes and you will be monitored closely for 3 4 hours before being taken to a general ward where you will recover overnight. Side effects can include flu-like symptoms, nausea, pain and fever. These can be treated with medication, and you usually can go home within 24 hours. SIRT is not available at all hospitals, and in most states you will need to fund the treatment yourself if you don t have private health insurance. Talk to your doctor about this option and the costs involved. Endoscopic stent placement Sometimes cancer in the liver can obstruct the bile ducts, particularly if it started in the ducts. If this happens, bile builds up in the liver and can cause symptoms of jaundice, such as yellowish skin, itchiness, pale stools or dark urine. Your doctor may recommend that a thin tube (stent) is placed in your liver to drain the bile and ease your symptoms. The earlier the stent is inserted, the less severe the symptoms. Endoscopic stent placement is done as a day procedure. You will have a local anaesthetic and possibly a sedative to reduce any discomfort. Treatment 35

38 A gastroenterologist or a surgeon inserts a long, flexible tube with a camera and light on the end (endoscope) through your mouth, stomach and small bowel into the bile duct. Pictures of the area show up on a screen so that the doctor can see where to place the stent. The stent is put in via the endoscope, which is then removed. Recovery is fairly fast. Your throat may feel slightly sore for a short time and you may be kept in hospital overnight. Infection of the bile duct and inflammation of the pancreas can also occur after this procedure your doctor will talk to you about these risks. Palliative treatment Palliative treatment helps to improve people s quality of life by reducing symptoms of cancer without trying to cure the disease. It is particularly important for people with secondary cancer. However, it is not just for end-of-life care and it can be used at different stages of cancer. Often treatment is concerned with pain relief and stopping the spread of cancer, but it also involves the management of other physical and emotional symptoms. Treatment may include chemotherapy, endoscopic stent placement or medications. Call for resources about palliative care and advanced cancer. The chemotherapy has stopped the secondary cancer from spreading further, but it makes me very tired. Barbara 36 Cancer Council

39 Key points The most common treatments for primary liver cancer are radiofrequency tumour ablation and transarterial chemoembolisation. The most common treatments for secondary cancer in the liver are chemotherapy or a combination of surgery and chemotherapy. Where possible, surgery is used to remove tumours, but tumours need to be small, accessible and not spread widely throughout the liver. Some people with primary liver cancer are able to have a liver transplant but it can take many months or years before a donor becomes available. After surgery, you will need a number of days in hospital to recover. You will be monitored closely and then will gradually return to normal activities. Tumour ablation is localised treatment that destroys the tumour without removing it. Ablation techniques include the use of radio waves or microwaves to heat the tumour, cryotherapy to freeze the tumour, and alcohol injection. Chemotherapy is medication that kills cancer cells. It is given intravenously, as tablets, or as transarterial chemoembolisation, which delivers the chemotherapy directly into the tumours. Other treatments for cancer in the liver include biological therapies and selective internal radiation treatment. These are also used when tumours cannot be surgically removed. Palliative treatment helps improve quality of life by reducing symptoms. Chemotherapy, medications and endoscopic stent placement are options. Treatment 37

40 Making treatment decisions Sometimes it is difficult to decide on the right treatment. You may feel that everything is happening so fast you don t have time to think things through. If you are feeling unsure about your options, check with your doctor how soon your treatment should start, and take as much time as you can before making a decision. Understanding details about the disease, the available treatments and their possible side effects will help you make a well-informed decision. This decision will also take into account your personal values and the things that are important to you and your family. It is common to feel overwhelmed by information so it may help if you read and talk about the cancer gradually. Weigh up the advantages and disadvantages of different treatments, including the impact of any side effects. If only one type of treatment is recommended, ask your doctor why other choices have not been offered. If you have a partner, you may want to discuss the treatment options together. You can also talk to friends and family. You have the right to accept or refuse any treatment offered by your doctors and other health care professionals. Some people with advanced cancer choose treatment even if it only offers a small benefit for a short period of time. Others want to make sure the benefits outweigh the side effects so that they have the best possible quality of life. Some people choose options that focus on reducing symptoms and make them feel as well as possible. 38 Cancer Council