Hepatocellular carcinoma or hepatocellular carcinoma is the most frequent primary tumour of the liver. It is a disease in which malignant (cancer) cells form in the tissues of this organ.
It occurs mainly in the context of liver damage caused by chronic hepatitis B(HBV) or C (HCV) virus infection, alcoholic cirrhosis and non-alcoholic stomatitis (Non-Alcoholic Steato Hepatitis, NASH), a disease that consists of an accumulation of fat and inflammation of the liver and that occurs in patients with insulin resistance or type 2 diabetes mellitus with poor metabolic control.
Frequent health control in this group of patients is essential to detect lesions in early stages susceptible to treatment.
Liver cancer symptoms
There is no specific symptomatology of liver cancer since many of its symptoms can appear in diseases of the digestive system, such as hepatitis, gallbladder stones, pancreatitis, etc.
Since most of the time, hepatocarcinoma develops on a cirrhotic liver, the patient may suffer from the symptoms of cirrhosis.
A small percentage of patients whose hepatocarcinoma develops on a healthy liver may present non-specific symptoms. Sometimes a lump may appear on the right side of the abdomen as a result of liver growth, which may be accompanied by pain radiating to the right side of the back. Other times the bile cannot be adequately eliminated and accumulates in the blood, giving a yellow colour to the skin (jaundice).
DIAGNOSIS OF LIVER CANCER
Patients with chronic liver damage should be followed up every six months through a blood test that measures the tumour marker alpha-fetoprotein. The measurement of this marker allows an early diagnosis of 90% of tumours. When the result is positive, an abdominal ultrasound, a dynamic multislice helical CT scan or nuclear magnetic resonance are added.
The TNM classification -used to stage other types of tumours- is not helpful for hepatocellular carcinoma in clinical practice because it only includes the size of the primary tumour, the presence of lymph node infiltration and the presence of metastatic or distant disease. In liver cancer, the degree of deterioration of liver function, the number of tumour nodules and the functional possibilities (according to the normality or not of the liver tissue) of being able to carry out a local treatment with curative intent are much more critical.
In liver cancer, the main prognostic factor is the functional stage of the liver, assessed internationally by the CHILD-PUG classification.
The size of the liver tumour lesion or the number and size of existing tumour lesions is also relevant in considering a curative treatment.
Thus, a small tumour in a severely damaged liver may have a poor prognosis as a giant tumour or several tumour nodules in a functionally healthy liver.
Practically, liver cancer is divided into three categories:
Localized tumour: The tumor is solitary, or there are several tumours smaller than 3 centimetres.
A localized tumour that cannot be operated on: The cancer is in the liver or affects neighbouring organs. However, surgical intervention is not indicated, either because of the tumour’s location or cirrhosis.
Advanced tumour: In this situation, hepatocellular carcinoma has spread to other body parts, such as the lymph nodes, bones, or lungs.
Given that liver cancer appears in most cases associated with liver cirrhosis and that the degree of liver function will determine the therapeutic options and survival regardless of the presence of the tumour itself, it is essential to be able to establish a prognostic evaluation, jointly consider the degree of liver dysfunction and tumour extension.
Currently, the only predictive system that links staging with treatment and has also been validated in Europe, the US and Asia is the Barcelona Clinic Liver Cancer (BCLC) system. This system includes the variables associated with tumour stage, liver function, physical status and the presence of cancer-related symptoms. Also, it establishes the prognosis according to four steps linked to the possible indication for treatment. The initial stage includes patients with good liver function (Child-Pugh A and B) with a single nodule or up to three smaller than three centimetres. These patients can be treated with curative intent with resection, liver transplant or percutaneous ablation achieving 5-year survival rates of between 50-75%. A subgroup of patients with an excellent prognosis would be those with very early tumours, asymptomatic, with nodules <2 cm, without vascular invasion or spread over-compensated cirrhosis (stage 0), in this resection or percutaneous ablation would allow survival to be achieved at five years close to 100%.
It is essential that before starting any therapy, the patient is evaluated by a surgeon with training in Oncological Digestive Surgery and who is also part of a multidisciplinary team to discuss rationality (depending on the site of origin) and complexity (depending on the amount of disease) from the removal of the tumour.
The specialist must rule out metastases outside the liver and perform imaging tests to see the structure and hepatic circulation. It is also necessary that the patient has good liver function without cirrhosis.
Once the tumour has been removed, frequent follow-ups should be carried out. If cancer recurs again in the liver, a second surgical resection may be considered.
Conventional systemic chemotherapy has little antitumor activity in hepatocarcinoma, probably related to the high expression of proteins associated with multi-drug resistance and the limited doses due to the underlying liver disease. Cytotoxic drugs have many side effects and can further impair liver function.
Therefore, it is considered a palliative systemic treatment, in which the drug is introduced into the bloodstream, travels through the body, and can kill cancer cells outside the liver.
External radiation therapy can sometimes shrink liver tumours to relieve symptoms, such as pain. Although liver cancer cells are sensitive to radiation, this treatment cannot be used in high doses because normal liver tissue can also be damaged by radiation. With newer radiation techniques, liver tumours can be better targeted with less radiation to nearby healthy tissue.