Hepatocellular Carcinoma- What The Patient Needs To Know

World Liver Day April 19th

Liver does that kind of work which no machine can ever do. A diseased liver threatens all-around health; without a liver, life would be impossible. The liver can be a seat of cancer. They can be primary or secondaries from tumours of the gastrointestinal tract.

Primary liver tumours are the malignant tumours that arise from the liver.  The tumours from Hepatocytes are called Hepatocellular carcinoma (HCC) and those from intrahepatic bile ducts are called Cholangiocarcinoma. Tumours from other organs when they spread to the liver are called Liver secondaries. Secondaries in the liver are usually a late stage of the disease.

Hepatocellular carcinoma is the fifth most common cancer in men and the eighth most common cancer in women worldwide.

Cholangiocarcinoma is on the rise particularly in the  Gangetic belt of Northern India. HCC is common among Alcoholic Cirrhosis and in patients with HBV and HCV infection. The disease is largely preventable by immunising against hepatitis B virus infection.

Symptoms of primary liver tumour:

HCC is often asymptomatic to start with and may develop weight loss, blood in the stool, jaundice, liver failure, fatigue or fluid in the abdomen. The clotting function is affected and patients develop coagulation and bleeding disorders. The biliary flow is obstructed and obstructive jaundice occurs. Blood vomiting can occur in cirrhotics.  The tumours are solitary or multiple. Tumours are multifocal within the liver in 75% of the time. These tumours press the normal liver and produce liver cell failure.

HCC in younger age is common in the Asian population probably due to HBV & HCV infections. Median survival from time of diagnosis is generally 6 months. It depends on the volume of uninvolved normal liver cells.

Treatment: 

liver cancer

Recent studies suggest that antiviral treatment of chronic HCV infections may reduce the risk of hepatocellular carcinoma significantly.

Hepatocellular carcinoma in hemochromatosis is an Iron storage disorder affecting the liver. Various carcinogens are responsible for the development of HCC.

Alpha-fetoprotein (AFP is a tumour marker detected in the blood test) is elevated in 75% of cases. The level of elevation correlates inversely with prognosis. An elevation of greater than 400 ng/mL predicts for hepatocellular carcinoma. Tumour markers are increasingly found useful in oncology to monitor the course of the disease.

Abdominal scanning using ultrasonogram is available, easy and non-invasive. Ultrasonogram scanning of the abdomen detects the tumour while other imaging studies like CT scan, MRI scan, Angiography helps in studying full extent of the tumour. Doppler scanning using USG helps in assessing blood flow. MRI – MRCP helps in diagnosing obstructive jaundice.

Needle biopsy often helps in confirming the pathology but may be skipped in inoperable early tumours with significant AFP elevation ( which is diagnostic).  In the early tumours, needle biopsy can result in needle tract cancer cell implantation.

A biopsy can be done by percutaneous route or CT / MRI image guided or by using Laparoscopy.

Pathologically the tumours are well-differentiated tumours or anaplastic tumours. The fibrolamellar subtype is associated with a better prognosis. It occurs in young non-alcoholics and non-cirrhotics. Many advanced molecular lever studies are available and the information given by the pathologist is of immense value in the diagnosis and treatment of HCC.

There are many algorithms and staging classifications. These help the surgeon to stratify tumours that are early, operable from advanced tumours.

Surgical resection and liver transplantation are the only chances of cure. Resecting lobes, segments and subsegments are now possible and advances in surgical technique have achieved cure in early stage tumours.

5%-10% the patients only present early as most of the patients present late with extensive both lobe of the liver involvement.

There are many palliative procedures for patients with advanced disease.

Systemic chemotherapy like  doxorubicin, cisplatin, gemcitabine and capecitabine and fluorouracil are also helpful in controlling HCC.

Liver transplantation, or localized tumour ablation, systemic chemotherapy remains the mainstay of therapy when the tumour is not resectable. Poor liver function precludes stronger chemotheraeutic agents.

Immunotherapy using interferon-alpha and Antiangiogenesis agents (Bevacizumab) are also used. Orthotopic liver transplantation can be considered for patients who meet the Milan criteria—one tumour less than 5 cm or up to 3 tumors all less than 3 cm. These highly selected patients have excellent survival rates.

Locally ablative therapy like Chemoembolization and radiofrequency ablation (RFA) are also considered. Radiofrequency ablation (RFA) is ablating hepatocellular carcinoma using radiofrequency thermal energy. Chemoembolization is the delivery of high concentrations of chemotherapeutic agents directly to the hepatocellular carcinoma tumour via the hepatic artery, which provides the tumour with most of its blood supply. The remainder of the liver may be spared because it can rely on the portal vein for its blood supply.

HCC is a lethal tumour if detected late, aged, and in alcoholic and patients with poor liver function.

Liver regeneration and Greek Mythology

Source: wikipedia

In Greek mythology, Prometheus is a Titan, culture hero, and trickster figure who is credited with the creation of man from clay, and who defies the gods and gives fire to humanity, an act that enabled progress and civilization. Prometheus is known for his intelligence and as a champion of mankind.

The punishment of Prometheus as a consequence of the theft is a major theme of his mythology, and is a popular subject of both ancient and modern art. Zeus, king of the Olympian gods, sentenced the Titan to eternal torment for his transgression. The immortal Prometheus was bound to a rock, where each day an eagle, the emblem of Zeus, was sent to feed on his liver, which would then grow back to be eaten again the next day. In ancient Greece, the liver was thought to be the seat of human emotions. In some stories, Prometheus is freed at last by the hero Hercules.

( Source: Internet)

Interesting facts about the liver:

  • The liver is the largest and heaviest internal organ, weighing around 3.5 lb.(1.6 kilos). It contains 300 billion cells.
  • The liver is the only internal organ that will completely regenerate itself if partly damaged. Up to 25% can be removed and within a short period of time it will grow back to its original size and shape.
  • It is the centre of our metabolism, a complex chemical factory and filter that controls the body’s absorption of food. It carries out more than 500 separate processes concerned with regulating all the main chemicals in blood and many other life-supporting functions.
  • Despite its complexity, the liver is remarkably resilient. It can keep going even if it loses as many as 80 percent or even 90 percent of its cells through disease or surgery.
  • Unlike any other organ, the liver has a double blood supply. Oxygenated blood from the heart to the liver, which needs about a quarter of the heart’s total output – 1.75 pints (1 litre) a minute – comes via the hepatic artery. This subdivides into many branches within the liver to provide oxygen to all its cells.
  • It aids digestion by helping the absorption of fat and vitamins.
  • It distributes nutrients in food.
  • It helps to cleanse the blood by removing toxins.
  • It produces important proteins for the blood, notably albumin (which regulates the exchange of water between blood and tissues) and complement (which plays a part in the immune system)
  • It provides coagulation factors essential for clotting blood after injury.
  • It supplies globin, a constituent of oxygen-carrying haemoglobin in the blood.
  • It makes cholesterol and proteins which help carry energy-supplying fats around the body.
  • It stores glucose that the body does not need immediately in the form of glycogen, which it converts back to glucose and releases into the bloodstream when needed.
  • It regulates the blood level of amino acids, chemicals which are the building blocks of proteins.
  • It protects the body by removing bacteria and neutralising toxins that would otherwise accumulate.
  • It filters many chemical substances and waste products from the blood.
  • It secretes up to two pints (1.14 litres) of bile daily which remove waste products – food and water contain thousands of non-nutrients that require constant liver processing and detoxification.
  • It banks vitamins A, B, D, E, K and others for release into the bloodstream when supplies get low.
  • It turns sugars and fats into protein, and vice-versa, maintaining the blood sugar level.
  • It regenerates itself – it creates new cells as old or damaged ones die off.
  • By far the most common cause of liver disease is too much alcohol. Drink-related disorders, notably acute hepatitis (liver inflammation), which can become chronic, and cirrhosis (liver cell death and scarring) greatly outnumber the incidence of all other liver diseases added together.

 

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