HPB Cancers - Liver Cancer
The Liver
The liver is the heaviest organ in the body and is situated in the upper abdomen, where it is protected by the lower ribs. It is surrounded by a tough, fibrous capsule, beneath which it is divided into eight segments, forming left and right lobes. The liver receives all of the blood draining the intestines and is connected to the upper intestine, or duodenum, by a tube called the bile duct [Figure1].
The liver has a myriad of functions that are key to the maintenance of health, including metabolism of carbohydrates, fats and vitamins, production of proteins and breakdown of toxins (such as alcohol) into forms which can be passed out of the body in the stools or urine. The liver also produces bile, a substance which passes into the intestine via the bile duct, where its aids the digestion of dietary fat.
The liver is unique in its ability to repair itself, but even when damaged can maintain its normal functions despite having only a small part in working order.
Figure 1: The liver and surrounding structures
What is liver cancer?
A tumour is a growth of tissue in which cells multiply in an abnormal, increased fashion. Tumours may be either noncancerous (benign) or cancerous (malignant). Malignant tumours of the liver may be divided into those which arise from within the liver itself (primary cancers) and those which spread to the liver from other sites (secondary or metastatic cancers).
What are the symptoms of liver cancer?
The symptoms of primary and secondary liver cancers are similar and may include:
Pain: liver enlargement due to tumour deposits may stretch the capsule of the liver, resulting in vague upper abdominal discomfort or pain, that is sometimes also felt in the right shoulder.
Jaundice: jaundice is a yellow discolouration of the eyes and skin, occurring when bile produced by the liver cannot pass down the bile duct and, instead, flows back into the bloodstream. This may occur either if there is a blockage of the bile duct or if a large amount of the normal liver is replaced by cancer. Jaundice is commonly associated with dark urine, pale stools and itching.
Indigestion, loss of appetite, nausea (sickness), tiredness and weight loss.
Fever: fever, in the absence of infection, is occasionally seen in liver cancer.
Abdominal swelling: liver cancers may be associated with abdominal fluid (ascites). This may arise due to the spread of cancer cells to the lining of the abdomen, resistance to blood flow through the liver due to tumour deposits and/or the presence of underlying liver disease, as is commonly the case in patients with primary liver tumours
No symptoms: liver tumours are often asymptomatic, being detected on routine examination or investigation, particularly during follow-up after primary colorectal cancer surgery.
It is important to remember, however, that these symptoms are not diagnostic of liver cancer and may be seen in many other conditions.
How is liver cancer investigated?
Following a thorough physical examination, investigations of possible liver cancer are aimed at establishing a diagnosis and then confirming the degree of cancer spread, both within and outside the liver.
Investigations include:
Blood tests - in addition to routine blood tests to assess general fitness and liver function, blood samples are tested for 'tumour markers', which are substances that may be released in large amounts by tumour cells.
Ultrasound scanning - this rapid technique uses sound waves to create a picture of the liver and surrounding organs.
Computed tomography (CT) scanning - this technique uses x-rays to produce pictures of 'slices' through the body, so building up a detailed image of the liver, as well as showing evidence of spread to other sites, such as the lungs.
Magnetic resonance imaging (MRI) - this technique is similar to CT scanning, but uses magnetic fields rather than x-rays to produce a detailed image of the liver.
Laparoscopy - laparoscopy or 'key-hole' surgery uses a mini-telescope (laparoscope) inserted through a small cut in the abdomen to directly visualise the liver and abdominal organs for cancer. A second cut is then used for the insertion of instruments to allow a thorough examination, including an ultrasound probe which can be placed directly on the liver. This combination of direct visualisation and ultrasound scanning provides a detailed assessment of the exact location of the cancer(s) within and outside the liver.
Liver biopsy - if the diagnosis is in doubt, a small sample of the abnormal liver tissue may be taken for examination under a microscope. This may either be achieved by a biopsy during laparoscopy or a biopsy done through the skin under local anaesthetic in the x-ray department. Biopsy is not necessary for secondary liver cancers where the primary site is known.
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