Cancer in the liver can either originate from the liver (primary liver cancer) or another cancer such as bowel or breast cancer (secondary liver cancer). Primary and secondary liver cancers behave very differently, and in Australia and New Zealand, secondary liver cancers are much more common. Around 1,700 Australians and 300 New Zealanders are diagnosed with primary liver cancer every year and the numbers are increasing quickly. There are two types of primary liver cancer: Hepatocellular Carcinoma, and Cholangiocarcinoma (bile duct cancer)
Hepatocellular Carcinoma (HCC) is the more common type, and it arises from abnormal liver cells that grow and invade the normal liver. The liver produces bile that helps digest fat in food as it passes through the small intestine. Similar to streams becoming a river, bile from liver cells flows from small to larger bile ducts and finally into the small intestine.
Cholangiocarcinoma is a rare cancer that arises from abnormal cells lining the bile ducts.
The chance of a ‘cure’ or recovery (prognosis) depends on many factors. Early, small HCC can be more easily treated with local treatments than larger HCC.
HCC often reappears in a new part of the liver after successful local treatment. The general function of the liver, and the size and number of cancer lesions have a strong influence on a patient’s prognosis. HCC spreading to other organs, such as lungs or bones, is much less common compared with most other cancers. Survival after a secondary liver cancer diagnosis varies widely and depends on factors such as the site of the original cancer and the other organs affected.
What Are the Causes of Liver Cancer?
There are some factors that increase your chance of getting primary liver cancer. It is important to understand that these “risk factors” do not mean that you will get cancer.
The main risk factors for primary liver cancer include:
• Hepatitis B or hepatitis C virus infection – having both hepatitis B and hepatitis C means you are even more at risk
• Liver cirrhosis (irreversible liver scarring), which is caused by Hepatitis B or C, or heavy alcohol drinking for many years
• Fatty liver disease (unrelated to alcohol) – Fatty liver disease causes cirrhosis which leads to liver cancer. This condition is usually associated with obesity and diabetes mellitus which causes excess fat around the abdomen, high blood sugar, high blood pressure or high unhealthy cholesterol.
• Iron overload (an inherited condition called ‘haemochromatosis’)
• Environmental toxins – Aflatoxin, a fungal poison that can grow on foods (e.g., corn, soybeans and peanuts), or Betel nut chewing
What Are The Symptoms of Liver Cancer?
Many patients known to be at risk of developing liver cancers are part of a screening programme designed to find cancers before they cause symptoms.
If you have any of the risk factors mentioned above and have any of the following symptoms, please visit your doctor.
• Persisting pain or discomfort in the right upper abdomen
• A hard lump under the right rib cage
• Unexplained swelling of the abdomen
• Jaundice (skin and white of the eyes turning yellow)
• Pale bowel movements and dark urine
• Easy bruising or bleeding
• Loss of appetite, weight loss without trying
• Feeling full after eating smaller meals than usual
• Nausea and vomiting
What Are The Treatments for Liver Cancer?
There are many treatment options for patients with both primary and secondary liver cancer.
Usually, a group of highly experienced specialists make recommendations to best suit each patient. Specialists consists of:
• Hepatologist (a liver disease specialist)
• Liver surgeon
• Interventional radiologist (a specialist who performs minimally invasive procedures guided by imaging)
• Radiation oncologist (a cancer specialist who treats cancer with radiation therapy)
• Medical oncologist (a cancer specialist who treats cancer with medical therapies)
• Pathologist (a specialist who diagnoses diseases using tissue samples or surgically removed specimens)
Primary Liver Cancer Treatments
Surveillance: A hepatologist will observe the growth of very small lesions with regular screening.
Surgical Resection: A surgery to remove the part of the liver containing the cancer is a good treatment option for patients who have well-functioning livers. Even after removing a large part of the liver, the remaining healthy liver takes over the liver function and may regrow. For several reasons, many patients are not suitable for the surgical removal of liver cancer.
Liver Transplant: A liver transplant involves replacing the entire liver with a donated healthy liver and it is a great treatment option. However, it is only possible for patients with cancer only in the liver and when there is a donated liver. It is common for patients to receive other types of treatments while waiting for a liver transplant.
Ablation Therapy: Ablative therapy destroys cancer without physically cutting it out. Common types of ablative therapy include:
• Radiofrequency ablation (RFA): An interventional radiologist inserts special needles through the skin or a small cut in the abdomen. Radio waves heat the needles to heat the cancer and destroy the cancer cells.
• Microwave ablation (MWA): Microwaves produce heat to kill cancer cells.
• Stereotactic Body Radiation Therapy (SBRT): This is an emerging therapy also known as Stereotactic Ablative Radiation Therapy (SABR) which uses high-energy x-rays to kill cancer cells. SBRT is an emerging liver cancer therapy so currently patients who are unable to have surgery or RFA or TACE receive SBRT.
Embolisation Therapy: Cancer needs oxygen to survive, and embolisation therapy blocks the blood supply to the cancer to destroy cancer cells. There are two main types of embolization therapy:
• Transarterial chemoembolization (TACE): A small, flexible tube is inserted into the inner thigh through a small cut and threaded into the artery that supplies oxygen to the liver. An anti-cancer drug (chemotherapy) is injected into the part of the liver containing the cancer. The amount of the drug delivered to other body parts is small.
• Radioembolisation: Radioembolisation is commonly known as selective internal radiation therapy (SIRT). Small beads filled with radioactive material destroy the blood supply to the part of the liver with cancer and also directly destroys cancer cells.
Targeted Systemic Therapy (Medical Therapy): Sorafenib is a tablet form of anti-cancer medicine used to treat patients with advanced hepatocellular carcinoma. There are currently many clinical trials assessing new medicines. A clinical trial is research designed to find out if a new cancer treatment is safe, effective, and better than the current best treatment. Please ask your specialist.
Secondary Liver Cancer Treatments
Treatments for secondary liver cancer depend on many factors, such as where the cancer came from and how much the cancer has spread. Each scenario is different but the main treatment options are:
• Systemic therapy with anti-cancer drugs
• Radiation therapy
Stereotactic Body Radiation Therapy (SBRT) For Liver Cancer
Radiation therapy uses high-energy x-rays to destroy cancer cells. There are different types of radiation therapy but the most commonly used type is called External Beam Radiation Therapy (EBRT).
EBRT delivers radiation therapy via a machine that produces and delivers x-rays from outside the body to the cancer. It is a painless, non-invasive treatment that is highly effective for many cancers. EBRT was not regularly used to treat liver cancer until recent years. It was technically impossible to deliver a high dose of radiation to kill liver cancer without damaging the healthy part of the liver. Treating liver cancer with EBRT is particularly difficult because the liver moves with every breath.
Recent revolutionary improvements in technology allow visualisation and control of the liver movement while a patient is receiving therapy. Modern technology also allows for the delivery of highly precise, focused radiation to the cancer target while minimising the damage done to healthy tissues.
SBRT combines the new technologies to deliver a high dose of radiation using an EBRT machine in a shorter time frame than traditional treatments. Radiation therapy usually means daily treatments (Monday through Friday) for several weeks. A course of SBRT on the other hand typically requires 5 treatments over 2 weeks.
Before the SBRT treatment begins, patients will have a special CT scan (planning CT) and MRI scan. Sometimes, small markers are inserted into the liver near the cancer to help localise the cancer while patients are having SBRT treatment. This procedure is very similar to having a biopsy. The radiation oncology team will combine all of the scans to create an individualised treatment plan. The preparation time before starting the treatment is usually about 2 weeks.
SBRT is an outpatient treatment and each treatment takes between 40 and 60 minutes. During the treatment, patients lie on a special body length bean bag moulded to the body’s shape to help stay still. Usually, patients feel well during and after the treatment session, and most of the common side effects can be easily controlled with medication.
How Effective is Radiation Therapy for Liver Cancer?
So far, there is no high-standard research comparing different types of therapies for liver cancer. SBRT is relatively new compared to surgery and RFA, but international experience over the last decade has shown promising results. 7-10 out of 10 cancers are successfully treated (75-100%). Survival after treatment depends on how healthy the remaining liver is and also the extent to which the cancer is affecting the liver and the rest of the body.
What Are the Side Effects of Radiation Therapy?
Side effects during/soon after treatment (Early or ‘acute’ side effects)
Acute side effects usually set in after the first few treatments and settle weeks after the treatment course.
General – Fatigue is common for most patients receiving radiation therapy. The severity of fatigue is variable between patients. Many patients return to a normal level of activity within a few weeks after the completion of radiation therapy.
Local – Sunburn-like skin changes are common. Usually, patients notice skin redness from the second week of the treatment course. Skin in the treatment area may turn red but also blister or peel. By 4-6 weeks after SBRT, most patients’ skin will return to normal.
Nausea with or without vomiting is also common because the small bowel is sensitive to radiation therapy. The small bowel surrounds the liver, and even a small dose of radiation therapy can trigger nausea in some patients.
Some patients may experience swelling of the abdomen from fluid build-up inside the abdomen.
What can help reduce side effects?
Resting can help with fatigue, and most other side effects can be alleviated with oral medications.
Side effects well after treatment (Long-term or ‘late’ side effects)
Late side effects develop few months or years after the treatment course, but they are uncommon.
Local – Liver SBRT may weaken parts of the ribs and can cause chest pain and, on rare occasions, rib fractures. Although extremely uncommon, liver SBRT can cause stomach or duodenal ulcer and bleeding.
Within three months following SBRT, the liver may become enlarged, the abdomen can swell from fluid build-up, and blood tests may show a worsening in liver function. This condition is called radiation-induced liver disease (RILD), and the risk of developing this problem is less than 5 in 100.
There is a slightly higher risk of developing “nonclassic RILD,” which includes the reactivation of viral hepatitis, and blood tests showing a worsening liver function. For liver cancers located in the centre of the liver, there is a very small risk of developing narrow bile ducts.
What can be done to treat late side effects?
Patients treated with liver SBRT will have regular follow-up appointments. At each appointment, a liver specialist and or radiation oncologist will request a blood test to evaluate the liver health. It is routine for patients to have regular scans (MRI and or CT) to assess treatment response, and also to look for new suspicious masses within the liver. If you develop any worrying symptoms described above, please do not hesitate to contact your team.
The best person to discuss liver SBRT with is a radiation oncologist with SBRT expertise. You can ask your liver specialist, surgeon or general practitioner for a referral to have a consultation with a radiation oncologist about whether radiation therapy is a suitable treatment option for you.
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