Patient information
Being diagnosed with a liver tumour can be a bewildering experince. With many types of tumour - both benign and malignant - and with a specific range of treatment options available in each individual, you might find some of the following information helpful as you come to grips with your condition and treatment plan.
Symptoms
Patients with liver cancer can present with a whole spectrum of symptoms. At very early stages the liver tumour is often diagnosed incidentally while the patient is undergoing investigation for some other cause of abdominal pain. Some patients can also present with pain, jaundice and abdominal swelling.
As a general rule if the patient has no symptoms then their cancer is likely to be at an earlier stage and therefore more likely to be suitable for treatment. The best advice for patients is if you have specific abdominal symptoms for more than two weeks you should consult your GP for further investigations and management.
Investigations
Examination
If you present to your GP with abdominal pain the GP would most likely perform an abdominal examination. He or she may have found a lump in your belly or swelling related to fluid.
Blood test
All patients with liver problems should undergo a full blood count which looks at the red cells, white cells, platelets and the electrolytes. This assesses how well your body is functioning including your kidneys and liver function. When a liver function test is abnormal, they are a very sensitive indication of liver abnormality. However, not all liver cancers cause liver function test abnormalities.
Tumour markers
Liver cancers make certain proteins that are secreted into the body and finding a higher level of these proteins (or 'tumour markers') may indicate that liver cancer is present. However, an elevation of these cancers can also occur in benign diseases such as lung problems.
Ultrasound imaging
Ultrasound should be the first investigation with a suspected liver problem. It is safe, does not involve radiation and can be performed relatively quickly. The ultrasound can look at the structure of the liver including any lumps and bumps within the liver itself. It can also look at your gall bladder and comment on the presence or absence of gallstones as well as other liver associated problems.
CT scan with contrast
CT scan is the next investigation for patients with a suspected diagnosis of liver cancer. It is a very detailed investigation of not just the liver but the rest of the abdominal cavity. It involves injecting a contrast medium via a blood vessel as well as drinking and oral contrast. It is important when you see a specialist that you have had both a CT and an ultrasound of your liver for the specialist to adequately assess your condition. (Please note a very small of the population is allergic to the contrast used and may not always be suitable for a CT scan.)
MRI
MRI (magnetic resonance imaging) is a highly sophisticated imaging of the liver. It does not involve radiation but uses magnetic fields. There are no specific contrast agents which are used in the diagnosis of liver cancer. Your doctor will advise you on the suitability of organising an MRI.
Types of liver tumour
Benign liver tumours
Haemangioma
Haemangioma is a benign collection of blood vessels. This can actually occur on many parts of the body and it is not linked specifically to the liver. Most haemangiomas cause no symptoms in the patient and are generally diagnosed on a CT scan or ultrasound during an investigation for abdominal pain. An MRI is also particularly useful to differentiate a haemangioma from other liver lesions.
A haemangioma can have a very slight association with the oral contraceptive pill and female hormones. Most haemangiomas require no further treatment apart from follow-up with a regular ultrasound and/or CT scan every six months to one year. Only in very extreme cases, ie. massive haemangiomas causing pain or anaemia, should surgery be contemplated. Very rarely extremely large haemangiomas have the potential to rupture causing severe pain and threatening the patient's life.
Focal Nodule Hyperplasia (FNH)
A focal nodule hyperplasia is not a true lesion but is probably a result of a fibrous reaction to a blood vessel within the liver. It is commonly seen in young women and on CT scan had a characteristic appearance. There is a very slight association with the oral contraceptive pill. When FNHs are large, patients may present with some non-specific upper abdominal pain. The main difficulty with this lesion is to differentiate it from other malignant lesions.
Adenoma
An adenoma is a benign lesion of the liver which has a solid appearance on CT scan and ultrasound. Large lesions (more than 3cm in size) can actually bleed and rupture. These lesions have the strongest association with the oral contraceptive pill and it is recommended when these lesions are diagnosed the pill should be ceased. When the lesions are more than 3cm in size, there is a small malignant potential in these lesions. When the lesion is under 2cm it is safe to take a 'watch and see' approach. When lesions are large, ie. more than 3cm, there is strong role for a liver operation to remove these tumours.
Focal Fatty Change/Focal Fatty Sparing
This is not a real tumour but is simply a focal area of the liver which has been spared from a fatty infiltration. It can sometimes be confused with liver cancer on ultrasound and CT scanning.
Primary liver tumours
Primary liver cancer means the cancer had started off from one of the cells within the liver itself. The most common type is a hepatocellular carcinoma, or hepatoma for short.
Hepatoma
The incidence of hepatoma is rising throughout the world particularly in Australia. It has a very strong association with hepatitis B and C as well as alcoholism. In 70 per cent of cases the underlying liver has been damaged from the hepatitis or alcohol with a gradual hardening of the liver. This condition is called cirrhosis. The combination of cirrhosis and hepatoma is particularly difficult to treat. The other 30 per cent of cases occur in patients whose liver remains 'normal'. Patients with a 'normal' liver and hepatoma are easier to treat and surgery offers the best chance of cure.
Cholangiocarcinoma
Cholangiocarcinomas is also a primary tumour of the liver but starts from the bile ducts. It has no association with hepatitis B, C or alcohol intake. Often no underlying cause is found however there is a specific sub-group which is associated with recurrent infections of the bile ducts or they develop an immune disease where the body attacks the bile ducts. Surgery provides the best chance of cure these patients.
Secondary liver tumours
Secondary liver cancers occur when a cancer cell from a separate part of the body has travelled through the blood stream, lymphatic system or direct invasion into the liver itself. Common primary sites include bowel cancer, breast cancer, pancreatic cancer and melanoma. Patients with secondary cancer to the liver are best treated in a multi-disciplinary approach involving liver surgeon, oncologists, interventional radiologists and the GP.
Colorectal cancer liver metastases
Unfortunately once colorectal cancer has spread to the liver only 20 per cent of patients are eligible for upfront liver surgery. However, with the event of giving chemotherapy prior to surgery this percentage has been increased to possibly 30 per cent. Surgery is the only chance of cure for patients whose bowel cancer has spread to the liver.
Surgery for this condition has also progressed significantly in the last five years. In selective cases patients have a 60 per cent chance of being alive at five years after liver surgery as opposed to no chance when surgery cannot be offered. With the advent of newer chemotherapeutic agents and special antibodies, even patients who are not suitable for liver surgery can expect to have at least two years of survival.
Carcinoid tumours liver metastases
Carcinoid tumours are a special sub-group of cancers which release hormones throughout the body. They are termed carcinoid because they look like cancer, behave like cancer but they spread at a much slower rate hence the added term 'oid'. Patients with carcinoid tumours are best treated with a liver operation. Patients can expect more than 60 per cent five year survival in selected cases. In patients who are not suitable for surgery, nuclear 'therapy' plus targeted radiation have led to patients being alive for 3 or 4 years from the diagnosis.
Others
In very select cases certain patients with breast cancer, liver metastases, melanoma and others might be a suitable candidate for surgery. In this group of patients they can expect 40 per cent chance of being alive at five years after suitable liver operations.
Treatment
The treatment for all patients with liver cancer, whether that is primary or secondary, is complex. These patients need to have a combined approach to the treatment which will often include a liver surgeon, an oncologist, a radiologist and the GP.
Primary liver cancer (hepatoma) treatments
Hepatomas are difficult to treat because doctors often have to deal with both the underlying liver scarring as well as the cancer itself. Surgery (cutting part of liver out or transplanting a liver into the patient) provides the best chance of cure. However, surgery can only be offered to a very small percentage of patients as most patients when diagnosed are not suitable for this treatment.
Chemotherapy into the liver
Hepatomas are particularly sensitive when chemotherapy is directed straight into the liver via a catheter. This is called trans arterial chemo embolisation (TACE). The patients who are not suitable for liver operation (surgery or transplantation) are often referred for TACE.
Systemic chemotherapy
When patients have evidence of disease that has spread outside the liver or the liver disease itself is significant, the patient may also still benefit from a new oral chemotherapeutic agent. Your specialist doctor will advise you if you are suitable for this treatment.
Cholangiocarcinoma
The only treatment for cholangiocarcinoma is a liver resection. It offers the best chance of cure.
Secondary liver cancer treatments
Colorectal
Patients with metastatic colorectal cancer are the most common reason why liver surgery is performed. Because the underlying liver is not damaged patients can have up to 75% of the liver removed. Patients with this condition are treated in a multidisciplinary approach where they may be offered either upfront surgery, or chemotherapy and then surgery. Your surgeon and oncologist will advise you on the best method of treatment. Sometimes patients present with both the bowel cancer and liver cancer secondaries at the same time. In the past this was considered a death sentence. However with the advancement of liver surgery and chemotherapy these patients are now treated aggressively with both surgery and chemotherapy. Patients with this condition can still be cured.
Others
In very select cases patients with other melena conditions of the liver can still undergo a liver resection.
Follow up
After successful treatment of your liver cancer your specialist will initially organise an appointment every three months where you will have a new blood test and scan to make sure the cancer has not returned. The frequency of your review will be then be six monthly when you are more than two years out from your liver surgery. When you have reached five years from your liver surgery your doctor will only want to see you once a year. You will then be considered cured from your cancer.