Liver Cancer

Chronic hepatitis C infections are an important cause of hepatocellular carcinoma, or primary liver cancer, throughout the world. In the United States, hepatocellular carcinoma is responsible for over 12,000 deaths per year. Worldwide, it causes over a million deaths per year, making it one of the most common malignancies in adults. It is more common in men than women, and in blacks than whites. It is especially prevalent in parts of Asia and Africa, although it is related to endemic hepatitis B infection and environmental exposures in those regions. In the United States, primary liver cancer—that is, cancer that begins in the liver—is most prevalent in people of East Asian origin.

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Alcohol appears to play a role in the development of liver cancer in patients with hepatitis C. Whether this is related to a more aggressive disease because of a combination of hepatitis C virus and alcohol or whether alcohol is an independent factor remains unknown.

In the United States, primary liver cancer is often detected during screening for underlying liver disease. Most people with liver cancer have no symptoms until the disease is advanced. Later stages of liver cancer, when the cancer is very large or when it impairs the functions of the liver, can produce more obvious symptoms such as abdominal pain, weight loss, lack of appetite, and finally jaundice and abdominal swelling.

Most hepatocellular carcinomas are first diagnosed with CT scans, magnetic resonance imaging, or ultrasound scans. These tests range from 60 percent to 100 percent accuracy, depending on the size of the tumor, with larger tumors being more visible. About 70 percent of patients with hepatocellular carcinoma have elevated blood concentrations of a tumor marker called alpha-fetoprotein; however, it is not specific for this condition. If there is doubt about the presence of liver cancer, the definitive diagnosis is made by liver biopsy.

Treatment of liver cancer is based on the size and location of the tumor, the spread of the cancer to blood vessels, and nearby or distant organs. Surgery, in which a portion of the liver is removed, or "resected," offers a potential cure for the disease and the best long-term chance of survival. Patients with smaller tumors and without cirrhosis or metastases to other organs are the best candidates for liver resection. New surgical techniques such as cryosurgery (freezing the tumor and tissue around it), radio-frequency ablation (destroying the tumor with a heat probe), or transarterial chemoembolization (TACE, in which chemotherapy drugs are injected directly into the tumor) may work for some patients who are not good candidates for liver resection.

In patients with small tumors but advanced cirrhosis, liver transplantation offers the potential for cure and is the treatment of choice. The obvious benefit of transplantation is that it removes not only the tumor but the diseased liver as well. The cancer must be confined to the liver, without invasion into the surrounding blood vessels. The five-year survival rate after liver transplantation for small hepatocellular carcinomas is approximately 75 percent. Patients with large (more than 5 to 6 centimeters) or more extensive tumors have a high risk for early recurrence after liver transplantation and therefore are not candidates. Patients with these types of tumors may be treated with embolization or ablation techniques.

Traditional systemic chemotherapy and radiation are not effective for treating liver cancer.

Early detection of liver cancer improves the chances of survival after treatment. Patients with chronic hepatitis B should undergo yearly liver cancer screening with a blood test for tumor markers and a liver ultrasound, CT scan, or MRI beginning at about age 30. Asians, Asian-Americans, and native Africans, who may develop chronic hepatitis B infections at birth, have a high risk of liver cancer at an early age. The risk is greater in men and those with a family history of liver cancer. Universal hepatitis B vaccination may ultimately reduce the incidence of this cancer worldwide.

All patients with cirrhosis from any cause (including hepatitis C) should be screened for liver cancer with imaging of the abdomen every six to 12 months. Other than antiviral therapy, there is no effective strategy to decrease the risk of developing liver cancer. Thus, early detection through repetitive screening is of paramount importance.