Liver Cancer

Liver cancer, also known as hepatic cancer or primary hepatic malignancy, typically presents with symptoms such as a lump or pain in the right side below the rib cage, swelling of the abdomen, yellowish skin, easy bruising, weight loss, and weakness. These symptoms are more frequent in individuals aged 55 to 65 years old.

Specific types of liver cancer can present unique symptoms; for instance, cholangiocarcinoma is associated with sweating, jaundice, abdominal pain, weight loss, and liver enlargement, while hepatocellular carcinoma (HCC) can present with an abdominal mass, abdominal pain, vomiting, anaemia, back pain, itching, fever, and jaundice.

Signs and Symptoms

The leading causes of liver cancer include cirrhosis due to hepatitis B, hepatitis C, or alcohol consumption. Other causes are aflatoxin exposure, non-alcoholic fatty liver disease, and liver flukes. Hepatitis B and C viruses are major contributors, accounting for 80% of HCC cases globally.

Secondary liver cancers, or liver metastases, are more common and occur when cancers from other body sites spread to the liver, frequently originating from the gastrointestinal tract, breast, ovaries, lungs, or other organs.

Diagnosis

Diagnosis of liver cancer involves blood tests, medical imaging, and tissue biopsy. Imaging modalities such as ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) are commonly used. Tumour markers like alpha-fetoprotein (AFP) can aid in diagnosis and monitoring. In cases of cholangiocarcinoma, markers like carbohydrate antigen 19-9 (CA 19-9), carcinoembryonic antigen (CEA), and cancer antigen 125 (CA125) are useful.

Prevention

Prevention strategies include immunisation against hepatitis B, treating those infected with hepatitis B or C, reducing alcohol consumption, and decreasing exposure to aflatoxin. Management of obesity and diabetes can also reduce the risk. Screening is recommended for individuals with chronic liver disease, with ultrasounds every 6 months being suggested for those at risk for HCC.

Treatment

General Treatment Approaches

Treatment options for liver cancer include surgery, targeted therapy, radiation therapy, ablation therapy, embolisation therapy, and liver transplantation. The choice of treatment depends on the type and stage of cancer.

Hepatocellular Carcinoma

For HCC, partial surgical resection is the recommended treatment when patients have sufficient hepatic function reserve. Liver transplantation is considered in cases where resection is not viable. Percutaneous ablation, including radiofrequency ablation, is an option for small, localised tumours. Systemic chemotherapy is generally not effective, but local chemotherapy via transarterial chemoembolisation (TACE) and targeted therapies like sorafenib are used for advanced HCC. Transarterial radioembolisation (TRACE) is an emerging option.

Intrahepatic Cholangiocarcinoma

Resection is an option for intrahepatic cholangiocarcinoma, but fewer than 30% of cases are resectable at diagnosis. Photodynamic therapy can improve quality of life and survival time in unresectable cases. Systemic chemotherapies like gemcitabine and cisplatin are sometimes used. Radiofrequency ablation, transarterial chemoembolisation, and internal radiotherapy can also be considered.

Hepatoblastoma

Treatment for hepatoblastoma involves surgical resection or liver transplantation, often combined with chemotherapy, including cisplatin, vincristine, cyclophosphamide, and doxorubicin.

Angiosarcoma and Hemangiosarcoma

These rare and aggressive cancers are often not amenable to surgical treatment. Options include surgical resection of affected liver parts, but liver transplantation and chemotherapy are largely ineffective.

Epidemiology

Liver cancer is globally common and increasing, ranking as the sixth-most common cancer and the fourth-leading cause of cancer death. The Global Burden of Disease Liver Cancer Collaboration found a 75% increase in new cases from 1990 to 2015. Liver cancer prevalence is highest in regions such as Northern and Western Africa, Eastern and South-Eastern Asia, with China accounting for 50% of HCC cases globally.

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Self-assessment MCQs (single best answer)

Which of the following is a common symptom of liver cancer?

Which virus is a major contributor to hepatocellular carcinoma (HCC) globally?

What is a typical method for diagnosing liver cancer?

Which preventative measure can reduce the risk of liver cancer?

What is a common treatment option for hepatocellular carcinoma (HCC) when surgical resection is not viable?

Which of the following is a marker used to aid in the diagnosis of cholangiocarcinoma?

Which region has the highest prevalence of liver cancer?

Which type of liver cancer is associated with an abdominal mass and jaundice?

Which treatment is considered for small, localised hepatocellular carcinoma (HCC) tumours?

What is the leading cause of cirrhosis in the Western world?