Dr. Aditya Kulkarni is a Consultant of Laparoscopic and Robotic Gastrointestinal, Hepato-biliary-pancreatic, and Cancer Surgeon at the renowned Ruby Hall
What is the liver? What does it do?
The liver is a football-sized organ that sits in the upper right portion of the abdomen, beneath the diaphragm and above the stomach. It has nearly 400 functions in the body. These include cleansing of blood from alcohol, drugs and other chemicals. It Neutralizes and destroys poisonous substances. It regulates the body fuel supply, producing, storing and supplying quick energy (glucose) to keep the mind alert and the body active. It manufactures essential body proteins involved in clotting of blood, blood immunity. It controls balance of hormones like sex hormones, thyroid hormones and steroid hormones. It regulates body cholesterol, supply of vitamins and minerals like iron, copper etc. Importantly, it helps in production of bile which passes from the liver to the gut and helps in digestion of food. It is a vital organ without which we cannot survive.
Because the liver is made up of several different types of cells, several types of tumors can form there. Some of these are benign (noncancerous), and some are cancerous and can spread to other parts of the body (metastasize). These tumors have different causes and are treated differently. The outlook for health or recovery depends on what type of tumor the patient has.
Liver tumours can be benign (noncancerous) or malignant (cancerous).
Some of the benign liver tumours include: Hemangioma, Hepatic adenoma, Focal nodular hyperplasia, Cysts, Lipoma, Fibroma, Leiomyoma. Sometimes even the benign liver tumours may require surgery to remove the part of the liver that is affected.
Malignant or cancerous liver tumours are again of different types. The most common type of liver cancer is hepatocellular carcinoma, which begins in the main type of liver cell (hepatocyte). Other types of liver cancer, such as intrahepatic cholangiocarcinoma and hepatoblastoma, are much less common.
Cancer that spreads to the liver is more common than cancer that begins in the liver cells. Cancer that begins in another area of the body — such as the colon, lung or breast — and then spreads to the liver is called metastatic cancer rather than liver cancer. This type of cancer is named after the organ in which it began — such as metastatic colon cancer to describe cancer that begins in the colon and spreads to the liver.
Symptoms of liver cancer (FIG3)
Most people don’t have signs and symptoms in the early stages of liver cancer. In later stage, these signs and symptoms may be seen:
- Weight loss
- Loss of appetite
- Upper abdominal pain
- Nausea and vomiting
- General weakness and fatigue
- Abdominal swelling
- Yellow discoloration of skin and eyes (jaundice)
- White colour stools
Chronic viral hepatitis: Most common risk factor for liver cancer is chronic (long-term) infection with hepatitis B virus (HBV) or hepatitis C virus (HCV). These infections lead to cirrhosis of the liver. Viral hepatitis can spread from person to person through sharing contaminated needles (drug use), unprotected sex, or childbirth. They can also be passed on through blood transfusions.
Cirrhosis: Cirrhosis is a disease in which liver cells become damaged and are replaced by scar tissue. People with cirrhosis have an increased risk of liver cancer. There are several possible causes of cirrhosis, including alcohol, chronic HBV or HCV infections. (Figure 5)
Non-alcoholic fatty liver disease: This is a common condition in obese people. People with a subtype of this disease, known as non-alcoholic steatohepatitis (NASH), might go on to develop cirrhosis, sometimes leading to cancer.
Inherited metabolic diseases like primary biliary cirrhosis, hereditary hemochromatosis, tyrosinemia, alpha1-antitrypsin deficiency, porphyria cutanea tarda, glycogen storage diseases, Wilson disease
Heavy alcohol use: Alcohol abuse is a leading cause of cirrhosis in India, which in turn is linked with an increased risk of liver cancer.
Tobacco use: Smoking increases the risk of liver cancer.
Obesity: Being obese (very overweight) increases the risk of developing liver cancer. This is probably because it can result in fatty liver disease and cirrhosis.
Type II diabetes: Type II diabetes has been linked with an increased risk of liver cancer, usually in patients who also have other risk factors
Exposure to toxins: Exposure to certain toxins in food or at work can lead to liver cancer. Some examples are aflatoxins, vinyl chloride and thorium dioxide.
Anabolic steroids: Anabolic steroids are male hormones used by some athletes to increase their strength and muscle mass. Long-term anabolic steroid use can increase the risk of hepatocellular cancer.
If you have possible signs or symptoms of liver cancer, doctor may order some tests like-
- Ultrasound of abdomen
- CT scan- It can give specific information about the size, shape, and location of any tumors in the liver or elsewhere in the abdomen, as well as nearby blood vessels. CT scans can also be used to guide a biopsy needle precisely into a suspected tumor (called a CT-guided needle biopsy).
- MRI scan- Like CT scans, MRI scans provide detailed images of soft tissues in the body.
- Angiography- Angiography can be used to show the arteries that supply blood to a liver cancer, which can help doctors decide if a cancer can be removed and to help plan the operation
- Alpha-fetoprotein blood (AFP) test
- Tests for viral hepatitis: Your doctor might order blood tests to check for hepatitis B and C.
- Liver function tests (LFTs)
A biopsy is the removal of a sample of tissue to see if it is cancer. If a biopsy is needed, it can be done in several ways like needle biopsy, laparoscopic biopsy or surgical biopsy.
There is a single tumour lesser than 2 cm, or more than 2 but less than 5 cm. It has not yet spread to the blood vessels. This is a very early stage and generally it is detected by chance without any symptom or signs. Additional tests are required to confirm the stage. Since it is an early stage, surgery is possible if the liver is healthy.
Either a single tumor larger than 2 cm (4/5 inch) that has grown into blood vessels, OR more than one tumor but none larger than 5 cm (about 2 inches) across (T2). In many of these patients, surgery may be the initial treatment. Other option that is very often done is to give chemotherapy. However, surgery is the only treatment that can cure this cancer. The surgeon takes the decision based on the case findings.
There is more than one tumor, with at least one tumor larger than 5 cm across (T3) or at least one tumor (any size) that has grown into a major branch of a large vein of the liver (the portal or hepatic vein) (T4). Stage III includes locally advanced cancers where the treatment can be surgery when it is possible. However, if some important structures like major blood vessels are involved, surgery would not be possible. In these cases a combination of chemotherapy and radiotherapy is preferred.
Stage IV is when the cancer is spread to lymph nodes or other organs like liver and lung. At this stage disease is treated with chemotherapy or symptomatic and supportive care, as indicated.
Treatment for liver cancer is based on the type of cancer, the stage at which it is detected, overall health of the patient and the conditions of the liver, whether it is healthy or not.
Surgery (Figure 8)
Liver cancer surgery
The best option to cure liver cancer is with surgical resection (removal of the tumor with surgery). If all cancer in the liver is completely removed, you will have the best outlook. Small liver cancers may also be cured with other types of treatment such as ablation or radiation. Liver transplant can also be an option in few selected cases.
Partial hepatectomy (Figure 9)
Partial hepatectomy is surgery to remove part of the liver. Only people with good liver function who are healthy enough for surgery and who have a single tumor that has not grown into blood vessels can have this operation.
People with cirrhosis are typically eligible for surgery if there is only one tumor (that has not grown into blood vessels) and they will still have a reasonable amount (at least 30%) of liver function left once the tumor is removed. This assessment is made by the doctor.
Surgery to remove the cancer can be used alone or in combination with other treatments.
Open surgery: It involves large cuts or incisions on the patient’s body to make a big opening through which the surgery is done. It is highly painful; there is chance of increased blood loss, infection and prolonged recovery.
Minimal invasive surgery: (Figure 10)
Laparoscopic or robotic surgery can be performed in order to remove the liver cancer. In these surgeries, the entire procedure is performed using small keyhole incisions, which leads to less pain, less blood loss, faster recovery of the patient. Using a robot, liver cancer surgery can be performed with improved comfort and safety. For complete removal of tumour by open technique, the abdomen has to be opened with a long incision called laparotomy. This causes severe pain immediately after surgery and leads to long recovery and increased hospital stay. Liver resection when performed by laparoscopy or robotic surgery avoids most of the complications which are related to access wound. With open surgery, visibility and access for surgical procedure is a problem. Robotic surgery is done through tiny incisions and gives far better visibility to the surgeon. This makes surgeries far safer.
Localized treatments for liver cancer are those that are administered directly to the cancer cells. These include:
- Heating cancer cells by Radiofrequency ablation
- Freezing cancer cells by Cryoablation
- Injecting alcohol into the tumor
- Injecting chemotherapy drugs into the liver (Chemoembolization)
- Placing beads filled with radiation in the liver (Radioembolization)
This treatment uses high-powered energy from sources such as X-rays and protons to destroy cancer cells and shrink tumors. Radiation therapy might be an option if other treatments aren’t possible or if they haven’t helped.
Targeted drug therapy
Targeted drug treatments focus on specific abnormalities present within cancer cells.
Chemotherapy uses drugs to kill rapidly growing cells, including cancer cells. Chemotherapy is sometimes used to treat advanced liver cancer.
Liver cancer surgery carries a risk of serious complications, such as infection, bleeding, liver failure and even death in some cases. It is one of the most challenging surgeries. However, the outcome of this surgery is more likely to be successful if performed by a qualified and experienced GI cancer surgeon. (Figure 11)
Dr. Aditya Kulkarni is the best liver cancer surgeon, laparoscopic cancer surgeon and robotic surgeon in Pune, Maharashtra, who is qualified and experienced in gastrointestinal cancer surgery.