When two important organs are hit
Liver cancer ( Hepatocellular carcinoma)
The liver is one of the largest organs in the body, located in the upper right portion of the abdomen. The liver has many important functions, including clearing toxins from the blood, metabolising drugs, making blood proteins, and making bile which assists digestion.
What is hepatocellular carcinoma (HCC)?
Hepatocellular carcinoma is a cancer that arises in the liver. It is also known as hepatoma or primary liver cancer.
Who gets HCC?
Individuals with the hepatitis B and/or hepatitis C virus infection are at increased risk of developing HCC. Alcohol related liver disease is also a risk factor for the development of HCC.
There are certain chemicals that are associated with liver cancer-aflatoxin B1 & vinyl chloride. Aflatoxin is the product of a mould called Aspergillus flavus and is found in foods such as peanuts, soybeans & corn. Vinyl chloride, is a compound found in plastics.
Hemochromatosis, a condition in which there is abnormal iron metabolism, is strongly associated with liver cancer.
Individuals with cirrhosis from any cause such as the hepatitis virus, hemochromatosis and alpha-1-antitrypsin deficiency are at increased risk of developing HCC.
What are the symptoms of HCC?
Abdominal pain is the most common symptom of HCC and usually is present when the tumour is very large or has spread. Unexplained weight loss or unexplained fevers are warning signs in patients with cirrhosis. Sudden appearance of abdominal swelling (ascites), yellow discoloration of the eyes and skin (jaundice), or muscle wasting suggests the possibility of HCC.
How is HCC diagnosed?
The diagnosis of HCC cannot be made by routine blood tests. Screening by a blood test for the tumour marker, alpha- fetoprotein (AFP), and radiological imaging must be performed. Doctors may advocate measurement of AFP and imaging every 6- 12 months in patients with cirrhosis in an effort to detect small HCC. Sixty percent of patients with HCC will have an elevated AFP level and the remainder may have normal AFP. Therefore, a normal AFP level does not exclude HCC.
Radiological imaging studies are very important and may include one or more of the following-ultrasound, CT scan (MRI magnetic resonance imaging) and angiography.
Ultrasound examination of the liver is frequently the initial study if HCC is suspected. CT scan is a very common study used in the USA for the workup of liver tumours. The ideal study is multi-phase CT scan with the use of oral and IV contrast.
MRI can provide sectional views of the body in different planes. MRI can actually reconstruct images of the biliary tree and the arteries and veins of the liver.
Angiography is a study where contrast material is injected into a large artery in the groin. X-ray pictures are then taken to evaluate the arterial blood supply to the liver. If the patient has HCC, a characteristic pattern is seen because of the newly formed abnormal small blood vessels that feed the tumour.
Biopsy may not be needed in patients with a risk factor for HCC and elevated AFP. Biopsy can be performed if there is some question as to the diagnosis of HCC or if the doctor feels the management may be changed by the biopsy results.
What are the treatment options for HCC?
Chemotherapy:
This may include injection of anti-cancer chemicals into the body through a vein or through chemoembolization.
The technique of chemoembolization is a procedure where chemotherapeutic drugs are given directly into the blood vessels that supply the tumour and small blood vessels are blocked so that the drug stays within the area of the tumour. Chemotherapy can provide some relief of symptoms and possibly decrease tumour size (in 50% of patients) but it is not curative.
Ablation:
Ablation (tissue destruction) therapy in the form of using radiofrequency waves, alcohol injection into the tumour or proton beam radiation to the tumour site are other options for treatment.
Surgery:
Surgery is only available to patients with excellent liver function who have tumours less than 3-5 cm that are confined to the liver. If the patient is able to undergo surgery successfully, the five year survival is 30-40%. Many patients may have recurrence of HCC in another part of the liver.
Liver transplantation is a treatment option for patients with end-stage liver disease and small HCC.
Is liver cancer always HCC?
Most cancers that are found in the liver are ones that spread or metastasize from other organs. These cancers are not HCC, as HCC cancers begin in the cells of the liver. Cancers that commonly metastasize to the liver include colon, pancreatic, lung and breast cancer.
Pancreatic cancer
The pancreas makes pancreatic juices, which help digest food in the small intestines, and hormones, including insulin. It is located behind the stomach in the back of the abdomen. The duct of the pancreatic gland opens into the first portion of the small intestine (called the duodenum) through a nipple like opening called the ampulla.
What causes pancreatic cancer?
It is not known exactly why certain people get pancreatic cancer. Research shows that there are certain risk factors that increase the chance of getting pancreatic cancer. Smoking is a major risk factor. Heavy alcohol consumption, a diet rich in animal fat and chronic pancreatitis may also be risk factors. People with a condition called hereditary pancreatitis are also at increased risk for getting pancreatic cancer.
What are the symptoms of pancreatic cancer?
Early pancreatic cancer usually does not cause symptoms and is therefore known as the “silent” disease. As the tumour gets larger, the patient may have one or more of the following:
Jaundice- If the tumour blocks the bile ducts (the major bile duct passes through the pancreas), the patient may develop jaundice, a condition where the skin and eyes may become yellow and the urine may become dark in colour.
Abdominal pain- As the cancer grows, the patient may have pain in the abdomen which may radiate to the back. Pain may increase with eating or lying down.
- Nausea
- Decreased appetite
- Weight loss
4. How is cancer of the pancreas diagnosed?
In addition to taking a complete history and performing a physical examination, the doctor may perform certain endoscopic and radiologic tests such as a CT scan or ultrasound. Endoscopic ultrasound may also be performed. This test may help in finding small tumours that may be less than 2-3 cms (one inch). A biopsy of an abnormal area of the pancreas may be performed in certain cases by inserting a needle into the pancreas under ultrasonic guidance.
ERCP (endoscopic retrograde cholangiopancreatogram), a special x-ray study of the pancreatic duct and the common bile duct may also be used to make the diagnosis. For this test, a flexible tube with a light and a camera at the end is passed through the mouth into the stomach and then the small intestines. Sedation is given. A dye is then injected into the pancreatic duct and the bile duct to look for abnormal filling or obstruction of these ducts by the tumour. During this procedure, biopsies can be taken using a brush that is inserted into the bile duct. The biopsy specimens are then examined under a microscope to look for cancer cells.
What is the treatment?
Cancer of the pancreas is only curable if it is found in the early stages. Surgery, radiation and chemotherapy are possible treatment options. Surgery may be done to remove all or part of the pancreas and surrounding tissues if needed. Radiation therapy can be used to damage the cancer cells and prevent them from growing. Radiation maybe used in certain trials after surgery to help kill any remaining cancer cells. Chemotherapy will not cure pancreatic cancer but may have some effect on slowing the rate of progression of the tumour or to improve the patient’s quality of life. Many new drugs are being investigated for chemotherapy of pancreatic cancer.
Pain control may be a difficult problem in patients with pancreatic cancer. Oral pain medication may be used, or patients may be referred for a nerve block which is performed by injecting alcohol into the bundle of nerves (celiac plexus) near the pancreas to decrease pain signals from the pancreatic cancer to the brain.
(The writer is a Consultant Physician)