Liver cancer – hepatocellular carcinoma
Hepatocellular carcinoma is the name for primary liver cancer. It appears mainly at the patients with cirrhosis (80 – 90 of cases). It is estimated a mortality of 33% among the people with cirrhosis due to the hepatocellular carcinoma. The mortality in the U.S. is 14 000 per year.
The major risk for developing liver cancer is the bearers of the liver virus. The risk is higher for B virus carriers than for the C virus, the appearance of hepatocellular carcinoma in infected people with virus B, not being preceded in all cases of cirrhosis. Cirrhosis is more severe and occurs more frequently in people with hepatitis. Haemochromatosis is also a risk factor and causes hepatocellular carcinoma.
Appearance of a hepatocellular carcinoma (liver cancer) is due primarily to a process of liver regeneration, usually requiring a liver disease that evolved long before. Hepatocellular carcinoma is usually a nodule form, single – center, but there are multicenter liver cancers with diffuse development.
To discover in time, patients with this kind of liver cancer, are recommended ultrasound supervision and dosage of alpha fetoprotein to patients with:
Chronic hepatitis B or C virus (risk of cancer depends on the severity of the inflammation, fibrosis, and the level of viral DNA, patients with hepatitis B);
Cirrhosis of alcoholic etiology;
haemochromatosis genetically transmitted;
The primitive biliary cirrhosis.
Hepatocellular carcinoma symptoms and clinical signs of liver cancer: sudden and rapid weight loss, ascites evolving rapidly, severe and does not respond to the treatment with diuretics, low grad fever or fever, liver pain. At the palpitation of the liver, it may feel rough, with a tumor surface. Both symptoms and clinical signs may be absent in many cases, there are a large number of asymptomatic cases discovered by ultrasound.
For a diagnosis of the liver cancer it is dosed the alpha fetoprotein and the patients’ blood and is used the imaging method in identifying a possible hepatocellular carcinoma (ultrasound, CT, MRI).
Alpha fetoprotein has normal values between 10 and 20 ng/ml and has sensitivity in the diagnosis of liver cancer under 60 – 70%. Alpha protein still may have values also in a form of testicular cancer. Values of alpha protein above 200 ng/ml are defining for a hepatocellular carcinoma appeared in a patient at risk. However, there are cases hepatocellular carcinomas with less than 4 cm in size, which do not produce alpha protein (two – thirds of the cases) and 20% of the total hepatocellular carcinoma, even with large sizes do not produce alpha protein.
Ultrasound put out the lesions of liver cancer (at a rate of 85-95% lesions size between 3 and 5 cm). On a cirrhotic liver, lesions smaller than 1cm can be harder to emphasize. For lesions between 1 and 2 cm, hepatocellular carcinoma specific, ultrasound as a diagnostic method with a sensitivity between 60 – 80%. The ultrasound contrast increases the ultrasound performance to describe the specific nodules of a hepatocellular carcinoma.
The CT scan and the MRI with the contrast material represents an ancillary diagnostic imaging method.
Recommendation for the diagnosis of a hepatocellular carcinoma:
Ultrasound is used as a screening method for liver cancer to appear in people at risk;
Used to determine the alpha protein with same purpose if the ultrasound is not accessible or very sophisticated;
An optimum interval (not necessarily ideal) repetition of ultrasound for precocious detection of hepatocellular carcinoma is 6 months.
When classical criteria (imaging +/- alpha protein) determination are not sufficient to establish a diagnosis, it is recommended a biopsy of suspected hepatocellular carcinoma nodule. Liver biopsy is done under ultrasound guidance, fine needles (less than 1 mm). If the lesion suspected as liver cancer seems operable, the biopsy is contraindicated due to the risk of dissemination of 1-3% of the cases.
Treatment of liver cancer
The first choice in the treatment of hepatocellular carcinoma is surgical resection (if the functional reserve of the liver allows it) or liver transplant (treatment for liver cancer and cirrhosis).
The large tumors where surgical resection is not possible they can opt for chemoembolization tumor with doxorubicin and lipiodol through the hepatic artery on the vascular branch which is corresponding with the malignant node. This method of treatment for liver cancer shall cease the blood feeding of the tumor.
For small tumors (less than 5cm) can be used as a treatment the method of fortification of tumor ultrasound guided. By this method it is introduced directly in the hepatic malignant nodule, using a fine needle, absolute alcohol. This process is repeated several therapeutic sessions. For these types of hepatocellular carcinoma, radiofrequency ablation (RFA) is an alternative.
If the treatment techniques for liver cancer, listed above cannot be used (case of very large tumors metastases or partial thrombosis), therapy with Sorafenib (Nexavar) 800 mg/day for a lifetime is a solution. Nexavar is an expensive antiangiogenic treatment, preventing the formation of new vessels to feed the tumor.
For hepatocellular carcinoma with small liver tumors, multiple incurred or the merits of cirrhosis, liver transplantation is the most indicated.