Liver Cancer

 

Liver cancer 

          Liver cancer, like other cancers or diseases, from the time of diagnosis to the treatments of chemotherapy, trans-arterial embolization, radiofrequency ablation, ethanol injection, radiotherapy, to targeted therapy, requires joint efforts from a multi-disciplinary team comprised of internists and surgeons of the Hepatobiliary, Pancreas, and Abdominal Organ team, radio oncologists, pathologists, radiotherapists, and oncologists.  During the treatment, case managers, nursing staff, and social workers also play an important role to help produce the best possible treatment outcome while maintaining the quality of life for patients.

          Primary malignant tumors of the liver are the more commonly seen in cancer of the liver in Asia, where hepatitis viral infection is endemic.  Indeed, primary liver cancer is one of the leading causes of cancer death in Taiwan, and the fifth most common cancer worldwide. Hepatic mets are equally common, arising mostly from malignancies of the breast, lung, and gastrointestinal tract. 

 

Diagnosis

            Patients usually present with constitutional symptoms such as fatigue, fever, weight loss and anorexia accompanied by a palpable mass, or dull, constant and not well localized pain in the right upper abdomen.  Jaundice usually appears late in the disease but it may occur early if hilar ductal obstruction occurs.  Hepatic mets may be discovered in asymptomatic patients during surgeries of a primary lesion or during staging for curative procedures. 

            Like diagnosis for all cancers, aside from the clinical features and physical exams, laboratory investigations and radiologic studies with pathological confirmation are a must.   Our goals are to distinguish primary liver cell cancer from a benign liver tumor or metastatic carcinoma, assess the extent of the tumor, and also to assess the residual liver function.  Usually liver function tests reveal common findings such as leukocytosis, erythrocytosis, hypercalcemia, and hypoglycemia.  Ultrasonography and intravenous contrast-enhanced CT are the main imaging modalities for liver lesion diagnosis.  Differentiation among HCC, benign liver tumors, and metastatic lesions may require the use of a combination of CT, MRI, arteriography (angiography), and nuclear medicine scans.   Chest x-ray, CT of the chest, abdomen, and pelvis, portal venograpy, and bone scanning are used to assess the extent of local disease and possible distant mets. 

 

Treatments

            In 2011, 1.1%. of the newly diagnosed liver cancer patients in Taiwan were treated in our hospital.  Surgical removal of the liver tumor is the most effective method, with hopes for cure for patients with resectable lesions, which account for only 15-20% of the HCC patients, leaving 70+ % of them non-candidates for surgery.  The latter must have the ultrasound guided fine needle aspiration of the lesion for tissue proof before a trans-arterial chemo-embolizationof the liver (TACE) is performed.  When the lesion is too difficult for the ultrasound detection, then a CT guided aspiration will be needed. 

            When surgical resection is rendered unsuitable, the non-surgical treatment for liver cancer can be TACE, percutaneous ethanol (pure alcohol) injection, local ablative therapy, or chemotherapy.    Extent of disease within the organ and distant intra-abdominal and extra-abdominal mets, large tumor size, bilobar involvement, existing chronic disease, level of liver function, and severity of cirrhosis are all factors that will affect the treatment choices between surgical or non-surgical, partial, and transplantation approaches.   

            For a recurrent liver cancer, studies showed that surgical resection is still highly viable with the same indicators as the primary liver cancer which are: 1) local confinement without clinical symptoms of other organs and without distant mets, and 2) liver and other organs in functioning condition good enough to undergo the surgery.  Statistically, in recurrent liver diseases, the respectability, operation-related complications and mortality rates are about the same as those for the first surgery.  So the surgical approach is deemed safe for the second time around.  However, technically the second surgery presents more challenges because of the peritoneal adhesions from the previous surgery, changes in the location of blood vessels and dissection, and possibility of liver failure, which may lead to increase of blood loss or co-morbidity.   

Five- and 10-year AJCC LiverCancer Survival by Stage in KFSYSCC 1990-2011

	I	II	III	IV	Unclear	Total
# of patients	336	518	480	625	228	2,187
% of patients	15.4%	23.7%	22.0%	28.6%	10.4%
5-year survival	65.6%	42.4%	17.0%	8.9%		28.4%
10-year sruvival	47.6%	25.3%	8.2%	4.5%		17.9%

  

Data source: KFSYSCC Annual Report 2011

 

Survival rates by stage of patients with operable liver cancer 1990-2011

Stage	I	II	III	Total
# of patients	161	170	81	412
5-year survival rates	81.8%	64.9%	58.3%	66.8%
10-year survival rates	63.6%	46.5%	24.0%	48.5%

Data source: KFSYSCC Annual Report 2011

 

Survival rates of liver cancer patients who received chemoembolization 1990-2011

Stage	I	II	III	IV	Unclear	Total
# of patients	148	297	316	373	118	1,252
5-year survival rates	49.8%	33.1%	22.8%	9.1%		21.1%
10-year survival rates	28.0%	12.6%	-	5.0%		10.4%

Data source: KFSYSCC Annual Report 2011

 

Comparison of survival rates of liver cancer by gender - KFSYSCC vs. Taiwan 2006-2010（%）

	KFSYSCC				Island wide
Survival	All patients		Men	Women		Men	Women
	1990-2011	2006-2010	2006-2010	2006-2010		2006-2010	2006-2010
1-year	62.5	66.8	64.0	75.1		52.5	56.4
2-year	47.9	52.2	48.4	63.3		40.0	43.4
3-year	39.1	41.6	37.4	53.5		32.1	35.3
4-year	33.4	37.7	33.5	49.9		26.7	29.4
5-year	27.9	32.9	29.1	43.8		22.9	24.3

Data source: Health Promotion Administration, Ministry of Health and Welfare（2013）
                       KFSYSCC Annual Report 2011

 

Comparison of 5-year survival rates of liver cancer - KFSYSCC vs. Taiwan 2004-2010（%）

Stage	KFSYSCC	Island wide
I	67.5	51.0
II	43.5	35.8
III	21.0	11.5
IV	10.1	3.0

Data source: Health Promotion Administration, Ministry of Health and Welfare（2012）
Data source: KFSYSCC Annual Report 2011

 

Relative survival rate reported by SEER in the US vs. the KFSYSCC liver cancer survival rate  (2004-2010) （%）

	KFSYSCC			SEER#
	All patients	Male	Female	All patients	Male	Female
Survival rates	32.9	29.8	41.1	16.6	16.4	17.2

# SEER Cancer Statistics Review 1975-2011，relative survival rates 
Data source: KFSYSCC Annual Report 2011

 

Laparoscopic Liver Resection           

Traditional liver surgery takes off some abdominal muscles and leaves a scar about 25 – 35 cm on top of the pains and multiple wound complications.   We offer the latest minimally invasive laparoscopic liver resection which brings the wound size down to 3 cm which requires no anesthesia for pain control and mobility off the bed the next day.   Indications for the laparoscopic liver resection are: tumor under 5 cm that is located in the left lobe or at the periphery of the right lobe.

            Since our first case of laparoscopic liver resection in May 2008, we’ve had 33 successful cases of pure laparoscopic procedure.  11 of them were the left hepatectomy - removal of the left lobe – which takes about 4 hours with average blood loss of 400c.c.  Our developments in the liver surgical skills received international recognitions in 2010 from the laparoscopic surgery associations.   

 

Facing cancer

Facing cancer is facing a threat to one’s very existence.  The blow from cancer hits not just the physical being but often scars the mental and emotional presence of the patient as well as the patient’s family.  The different phases of reactions, from shocking blank to angry denial, are normal and expected. But if not managed well, they could add more pain and damage on top of the cancer itself.   Anxiety, sense of loss, fear of uncertainty, insomnia, guilt, depression, despair, and anger are among the commonly seen symptoms which require professional help as well as social support. 

 

Stress Screening

About 50% of cancer patients worldwide develop psychological symptoms but only 8 – 10 % would voice their concerns and seek help.  In our hospital, a Distress thermometer is offered to every patient upon their first visit to assess their distress level.  When necessary, the social psychotherapy team and the social workers are asked to join the multidisciplinary team to help the patient and the family cope with cancer and to safeguard the quality of life for the patient.   There are also various cancer support groups and religious support organizations that will offer to accompany the patient in their walk with cancer and fight against cancer.

 

A letter to the family

Being there for the patient means the world to the patient.  Support and company from the family and relatives are a critical part in cancer care.   Listening to the patient and respecting the patient’s wishes bring positive energy.    When a member in the family gets cancer, the rest of the family is affected in many aspects: physical, psychological, financial, and emotional, to where the whole family system could collapse.  When providing the much deserved and much needed care to the patient, the family members must remember to also provide an equal amount of care to one another and to oneself.   In the event of exhaustion or burn-out, remember to seek professional help.