Liver cancer: what are we dealing with…!

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Dr Prasad Wagle, HOD, Hepatopancreaticobiliary Surgery and Dr Rajvilas A Narkhede, Consultant, Gastrointestinal and Hepato-pancreatico-biliary surgery at Nanavati Super Speciality Hospital open up about liver cancer resulting in 9 per cent of deaths worldwide

Liver cancer is the fifth commonest cancer worldwide accounting for almost 9 per cent of all the cancer-related deaths which makes liver cancer the second commonest cause of cancer related deaths. The incidence of liver cancer has increased by 75 per cent worldwide from 1990 to 2015 and is still increasing.

Hepatocellular cancer (HCC), a primary liver cancer, comprises of almost 90 per cent of the cancers of liver globally. Other liver cancers like intra hepatic cholangiocarcinoma, hilar cholangiocarcinoma and sarcomas occur less commonly. The occurrence of liver cancer is increasing with rise in epidemic of liver cirrhosis. Although incidence of liver cancer is variable, there is growing occurrence of hepatocellular cancer in India owing to high endemicity of hepatitis B and hepatitis C viral infections and growing epidemic of metabolic syndrome (Obesity with diabetes are often associated with non-alcoholic fatty liver disease). Almost 7 males and 2 females develop hepatocellular cancer for a 1,00,000 population each. The death rate related to liver cancer closely matches the incidence of the disease leading to approximately 7 lacs of deaths worldwide annually.

The recognised risk factors for HCC include chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection, exposure to dietary aflatoxin, fatty liver disease, alcohol-induced cirrhosis, obesity, smoking, diabetes, and iron overload. In India, 70 – 80 per cent of HCC detected in patients are hepatitis B infection, 15 per cent in hepatitis C infection, 5 per cent in patients with alcohol related liver disease. Almost in 10 per cent patients no associated cause is found which are called sporadic HCC. Obesity is also driving up liver cancer rates. The association of obesity have increased from 26 per cent in 2000 to 36 per cent in 2010.

Liver cancer is commonly diagnosed in patients with liver cirrhosis on routine screening amounting to 90 per cent of the total case burden of the disease where there are no symptoms. Even often it gets detected incidentally while being investigated for unrelated symptoms. Liver cancer can also present with abdominal pain or discomfort, lump in abdomen, weight loss or loss of appetite. Rarely it can present with bleeding in the abdomen with tumour rupture.

Since most patients are asymptomatic, these patients seek medical attention in a very advanced stage and because of this only 25 per cent patients with large tumours can be offered curative surgery. Hence it is very important to identify and treat these tumours at the earliest. Screening is usually recommended in high risk patients for liver cancers like patients with liver cirrhosis, hepatitis B or C infections. There are no screening recommendations for general population. Screening of liver cancer can be done with blood levels of AFP (Alpha-feto-protein) and abdominal sonography. Liver cancer is diagnosed with CT scan and MRI of liver with reasonable accuracy. In ambiguous cases, biopsy from the tumour can be necessary to ascertain the diagnosis.

Prevention is critical for reducing liver cancer deaths. As the death rate of liver cancer is very high, prevention of the disease becomes very important. Patients with hepatitis B and C infections can be treated with state-of-the-art anti-viral medications to prevent development of liver cirrhosis and subsequently liver cancer. Similarly preventing other risk factors like reducing obesity, stopping excessive alcohol ingestion or smoking can help preventing liver cancer.

Liver cancer can be cured completely with surgical removal of the tumour provided that it has not spread outside liver and adequate volume of liver is available after surgery. In liver surgery, liver surgeon removes part of liver containing the cancer leaving a healthy liver behind adequate enough to support its functions. Open surgery has been the traditional way for liver cancer operations. With technical innovations a key hole surgery can also be done either with laparoscopic surgery or robotic surgery to reduce scar and to provide early recovery. In patients with liver cirrhosis having liver cancer, if the liver functions are deranged, liver transplantation provides curative treatment wherein complete liver containing the tumour is removed and is replaced by another liver (donated by a brain dead donor or part of liver (donated by a living donor). Other treatment options for treatment for inoperable tumours or tumours spread outside liver are TACE (direct chemotherapy to the tumour through the blood vessels supplying the tumour) or TARE (delivering radiotherapy to the tumour through the blood vessels supplying the tumour) or oral chemotherapy. Only surgery, percutaneous ablation or liver transplantation provides curative treatment.