Hepatocellular carcinoma (patient information)

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Editor-in-Chief: C. Michael Gibson, M.S., M.D. [mailto:mgibson@perfuse.org] Phone:617-632-7753; Associate Editor-In-Chief: Jinhui Wu, M.D.

Overview
The liver is the largest internal organ which lies under the right side of your ribcage just beneath your right lung. It is a very important organ for digestion and metabolism. Primary liver cancer starts in the liver. Metastatic liver cancer starts somewhere else and spreads to your liver. It is hard to detect hepatocellular carcinoma in its early stages. Frequent symptoms include pain and lump in the right abdomen, yellowing of the eyes and skin, marasmus and fatigue. Possible treatments include surgery, radiation therapy and chemotherapy. Prognosis is poor for most hepatocellular carcinoma patients.

What are the symptoms of hepatocellular carcinoma?
In its earliest stages hepatocellular carcinoma does not cause any symptoms. When the tumors grow larger, people may notice one or more of the following symptoms: Infections or other health problems may also cause these symptoms. Only a doctor can tell for sure. A person with any of these symptoms should tell the doctor so that problems can be diagnosed and treated as early as possible.
 * Abdominal pain and vague abdominal fullness: At first the location of the abdominal pain you are experiencing may be isolated on the upper-right part of your abdomen. It is usually relatively mild pain or no pain at all that is present with this life-threatening condition. With the development of the cancer, abdominal pain is usually persistent.
 * Abdominal lump: People can not find any lump at the beginning of the disease. When the tumor begins to enlarge, the lump may be obvious in the abdominal region.
 * Jaundice and itching: This is caused by hepatocellular necrosis and obstruction of bile in the bile ducts.
 * Nausea and vomiting: Hepatocellular carcinoma disturbs the normal functions of digestion.
 * Vomiting blood: This symptom is attributed to many factors such dysfunction of the liver and spleen.
 * Loss of appetite
 * General decline in health
 * Weakness or fatigue
 * Fever

Who is at risk for hepatocellular carcinoma?
There are some factors that may increase your risk of developing hepatocellular carcinoma. These risk factors include:
 * Chronic viral hepatitis B or C
 * Cirrhosis
 * Inherited metabolic diseases such as hemochromatosis, tyrosinemia, alpha1-antitrypsin deficiency, porphyria cutanea tarda, glycogen storage diseases, and Wilson disease.
 * Diabetes Mellitus
 * Aflatoxins
 * Anabolic steroids
 * Arsenic
 * Vinyl chloride and thorium dioxide
 * Obesity

Diagnosis
It is hard to diagnose hepatocellular carcinoma in its early stages. Other problems can also cause the same symptoms such as stomach discomfort, gallbladder diseases and pancretic diseases. So, if you have those symptoms, you had better go to see your doctor to do some tests. They include lab tests and image tests.
 * Alpha fetoprotien test: This is a blood test. AFP(alpha-fetoprotein) can be found in the blood of unborn babies, but it disappears shortly after birth. When the level of AFP is higher than normal, it suggests that the patient may have hepatocellular carcinoma. Detecting AFP can be used to look for early tumors in people with a high risk for hepatocellular carcinoma.
 * Ultrasound: This test is used to find tumors in the liver by ultrasound. Tumor tissue may produce a different echo from normal tissue. So different echo patterns can help tell whether there is a tumor present and some details such as the size, boundary and so on.
 * Computed tomography (CT) scan and biopsy: CT scans are often used to diagnose hepatocellalar carcinoma. It can confirm the location of the cancer and show the organs near the tumor, as well as lymph nodes and distant organs where the cancer might have spread. This is helpful in staging the cancer and in determining whether surgery is a good treatment option. CT scans can also be used to guide biopsy in which a biopsy sample is removed and looked at under a microscope by a pathologist.
 * Magnetic resonance imaging (MRI): An MRI uses magnetic fields, which is a different imaging type from computed tomography (CT) to produce detailed images of the body. MRI scans are very helpful when diagnosing hepatocellular carcinoma. Sometimes they can be used to distinguish a benign tumor from a cancerous one. Like computed tomography (CT), a contrast agent may be injected into a patient’s vein to create a better picture. MRI scans take a longer time than a CT scan to complete.
 * Laparoscopy and biopsy: During this test, a thin, lighted scope is put in through a small cut in abdomen to look at the liver and other organs. The test can help the doctor in diagnosis or treatment plans. Also through this tube, the doctor can use small probes to take out tissue samples to be checked under the microscope by pathologists.

When to seek urgent medical care?
Call your health care provider if symptoms of hepatocellular carcinoma develop. If one or more of the following symptoms emerges, seek medical care as soon as possible:
 * Sudden severe abdominal pain and a decrease in blood pressure: The reason a person with hepatocellular carcinoma has sudden severe abdominal pain is sometimes due to a ruptured carcinoma. This is the result of cancer developing very fast. Sometimes if the carcinoma invades a main vessel it results in a hemorrhage into the peritoneal cavity and the patients may feel sudden abdominal pain.
 * Vomiting a lot of blood: This is the result of complications such as dysfunction of the liver or synthetic blood coagulation factors and esophago-gastric fundus vein rupture. An abundant amount of blood loss due to vomiting may lead to shock and even death.

Treatment options
Patients with hepatocellular carcinoma have many treatment options. The type of treatment depends on the stage of the tumor. The options are surgery, radiation therapy, chemotherapy, or a combination of methods and palliative treatment.

Surgery
 * Surgical Resection (Partial Hepatectomy): The surgeon can judge whether the patient is able to handle this surgery.
 * Liver transplant: If available, a liver transplant may be the best option for patients with small liver tumors (either 1 tumor smaller than 5 cm or 1 to 3 tumors no larger than 3 cm).
 * Tumor ablation or embolization: Ablation refers to local methods that destroy the tumor without removing it, such as Radiofrequency ablation (RFA), Ethanol (alcohol) ablation, Cryosurgery (cryotherapy), Hepatic artery  embolization, Chemoembolization and Radioembolization.

Radiation therapy: This is a cancer treatment that kills cancer cells or keeps them from growing by using high-energy x-rays or other types of radiation.
 * External beam radiation therapy
 * Radioembolization

Targeted therapy: This new therapy uses a drug named Sorafenib (Nexavar) to lengthen the lifetime of patients with hepatocellalar carcinoma. Sorafenib is a targeted drug which can slow the progression of advanced hepatocellalar carcinoma by blocking both angiogenesis (new blood vessel growth in tumors) and growth-stimulating molecules in cancer cells. At present, Sorafenib has been studied in hepatocellalar carcinoma patients with relative normal liver function.

Before treatment starts, ask your health care team about possible side effects and how treatment may change your normal activities. Because cancer treatments often damage healthy cells and tissues, side effects are common. Side effect may not be the same for each person, and they may change from one treatment session to the next.

Diseases with similar symptoms
Other health problems may also cause similar symptoms. Go to see your doctor to verify your diseases as early as possible. Diseases with similar symptoms are listed below:
 * Hepatitis (B、C), cirrhosis， liver hemangioma
 * Gastric diseases: Gastritis, peptic ulcer and stomach cancer
 * Gallbladder diseases: Cholelithiasis, cholecystitis and gallbladder cancer
 * Pancreatic diseases: Pancreatitis, pancreatic cancer

Where to find medical care for hepatocellular carcinoma?
Directions to Hospitals Treating hepatocellular carcinoma

Prevention of hepatocellular carcinoma
Epidemiological data shows the following may be helpful to reduce the risk of hepatocellular carcinoma:


 * Avioding alcohol abuse: Alcohol abuse is the most common cause in west countries.
 * Prevention of infection with hepatitis B or C: Hepatitis B or C are the main cause in Asian countries. Childhood vaccination against hepatitis B may reduce the risk of liver cancer in the future.
 * Hemochromatosis screening: Certain autoimmune diseases of the liver may be related to the development of hepatocellular carcinoma. Early screening may be helpful.

What to expect (Outook/Prognosis)?
The prognosis of hepatocellular carcinoma is poor and it depends on the following:


 * Whether or not the tumor can be removed by surgery
 * The stage of the cancer: the size of the tumor, whether the cancer has spread outside the liver
 * The patient’s general health
 * Whether the cancer has just been diagnosed or has recurred

Resources

 * Cancer.org


 * Medlineplus