Types of liver cancer

• Primary liver tumours
  • The most common primary tumours are
    • Hepatocellular carcinoma - 90%
    • Cholangiocarcinoma - 10%
  • Less common primary tumours include**:**
    • Hepatoblastoma
    • Sarcomas (Rare)
    • Lymphomas
    • Carcinoids (most often secondary although primary may occur)
• Secondary liver tumours (metastatic disease)
  • 90% of liver tumours are secondary metastases
    • Primary cancers are commonly the lung, stomach, colon, breast and uterus
  • Management is usually investigation to find the primary cancer
  • Treatment/prognosis then varies with the type/extent of the primary but chemotherapy may be effective
  • Hep C is the most common cause in Europe
  • Hep B is the most common cause worldwide

Primary hepatocellular carcinoma

• These account for the bulk of the primary liver tumours
• Its incidence increases in areas that
• Most often occurs on a background of chronic inflammatory activity - such as
  • Cirrhotic liver (many causes - including chronic hepatitis, ALD, NAFLD, PBC, haemochromatosis)
  • Aspergillus aflatoxin
  • Parasites
  • Anabolic steroid use
  • Chronic hepatitis B infection
• Rare in UK, but more common in China and Africa
• Most cases arise when there is existing cirrhosis, with a mass discovered on screening ultrasound.

Presentation

• Symptoms
  • Non specific fever, malaise and weight-loss
  • RUQ pain
• Signs
  • Hepatomegaly
    • May be smooth or hard/irregular
  • Ascites - late
  • Signs of chronic liver disease/decompensation
  • Abdominal mass/bruit over the liver
  • Jaundice is a late sign ****
    • C.F - cholangiocarcinoma

Diagnosis

• Bloods
  • FBC
  • LFT
    • Often deranged
    • Bilirubin for jaundice
    • Albumin acts as a marker of synthetic function
  • Clotting
    • Provides markers of synthetic function
  • Hepatitis serology
  • Alpha-fetoprotein
    • Tumour marker for liver cancer
    • Elevated in >50% of cases
    • The testis should be examined in males as testicular tumours may also cause raised AFP
  • CA 19-9, CEA and CA 125 - tumour markers for other cancers, such as cholangiocarcinoma
• CT and MRI
  • Imaging modalities of choice
  • Used for staging and to distinguish benign and malignant lesions
  • PET CT may be used to identify occult nodal disease.
• Biopsy
  • Often avoided as it seeds tumours cells through a resection plane
  • Can be done via ERCP if there is diagnostic uncertainty
• In cases of diagnostic doubt serial CT and αFP measurements are the preferred strategy

Treatment

• Surgical resection
  • Mainstay of treatment in operable cases
  • Most commonly for solitary tumours <3cm
  • As most cases occur in an already diseased liver, the peri and intra-operative risks are greater than for metastectomy (excision of liver metastases)
  • If very cirrhotic liver → consideration may be given to primary whole liver resection and transplantation
  • At least 2 segments of the liver must be left in situ (~25%)