Understanding Cancer in the Liver - A guide for people affected by primary liver cancer or secondary cancer in the liver

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Understanding
Cancer in the Liver
A guide for people affected by primary liver
cancer or secondary cancer in the liver

                                     Cancer
                                  information

www.cancercouncil.com.au
Understanding Cancer in the Liver
A guide for people affected by primary liver cancer or secondary cancer in the liver

First published October 2007. This edition July 2014.
© Cancer Council Australia 2014. ISBN 978 1 925136 32 6.

Understanding Cancer in the Liver is reviewed approximately every two years. Check the publication
date above to ensure this copy is up to date.

Acknowledgements
This edition has been developed by Cancer Council NSW on behalf of all other state and territory
Cancer Councils as part of a National Publications Working Group initiative.

We thank the reviewers of this booklet: A/Prof Vincent Lam, Sydney Medical School Hepatobiliary,
Pancreatic and Transplant Surgeon, Westmead Hospital, NSW; Prof Peter Angus, Medical Director,
Director of Gastroenterology and Hepatology and Professorial Fellow, Austin Hospital and University
of Melbourne, VIC; Jenny Berryman, Consumer; Ann Bullen, Cancer Care Coordinator, Royal Brisbane
and Women’s Hospital, QLD; Prof Jonathan Fawcett, Director, Queensland Liver Transplant Service,
Professor of Surgery, University of Queensland, QLD; Dr Dan Madigan, Interventional Radiologist, Royal
Adelaide Hospital, SA; Dr Monica Robotin, Medical Director, Cancer Council NSW; and Dr Simon So,
Interventional Radiologist, Westmead Hospital, NSW.

Some of the information from previous editions of this booklet was sourced from Macmillan Cancer Care, UK.

Editor: Laura Wuellner. Designer: Eleonora Pelosi. Printer: SOS Print + Media Group.

Note to reader
Always consult your doctor about matters that affect your health. This booklet is intended as a general
introduction to the topic and should not be seen as a substitute for medical, legal or financial advice.
You should obtain appropriate independent professional advice relevant to your specific situation and
you may wish to discuss issues raised in this book with them.

All care is taken to ensure that the information in this booklet is accurate at the time of publication.
Please note that information on cancer, including the diagnosis, treatment and prevention of cancer,
is constantly being updated and revised by medical professionals and the research community.
Cancer Council Australia and its members exclude all liability for any injury, loss or damage incurred
by use of or reliance on the information provided in this booklet.

Cancer Council NSW
Cancer Council is the leading cancer charity in NSW. It plays a unique and important role in the fight
against cancer through undertaking high-quality research, advocating on cancer issues, providing
information and services to the public and people with cancer, and raising funds for cancer programs.
This booklet is funded through the generosity of the people of NSW. To make a donation to help
defeat cancer, visit Cancer Council’s website at www.cancercouncil.com.au or phone 1300 780 113.

Cancer Council NSW
153 Dowling Street, Woolloomooloo NSW 2011
Cancer Council Helpline 13 11 20
Telephone 02 9334 1900 Facsimile 02 9334 1741
Email feedback@nswcc.org.au Website www.cancercouncil.com.au
ABN 51 116 463 846
Introduction
This booklet has been prepared to help you understand more
about cancer that affects the liver.

Many people feel shocked and upset when told they have primary
liver cancer or secondary cancer in the liver. We hope this booklet
will help you, your family and friends understand how cancer in
the liver is diagnosed and treated. We also include information
about support services.

We cannot give advice about the best treatment for you. You
need to discuss this with your doctors. However, we hope this
information will answer some of your questions and help you
think about other questions to ask your treatment team.

This booklet does not need to be read from cover to cover – just
read the parts that are useful to you. Some medical terms that may
be unfamiliar are explained in the glossary. You may also like to
pass this booklet to your family and friends for their information.

  If you’re reading this book for someone who doesn’t understand
  English, let them know that Cancer Council Helpline 13 11 20 can
  arrange telephone support in different languages. They can also call
  the Translating and Interpreting Service (TIS) direct on 13 14 50.
Contents
What is cancer?................................................................. 4

The liver.............................................................................. 6

Key questions.................................................................. 8
What is primary liver cancer?.............................................................. 8
What are the risk factors?................................................................... 8
Can primary liver cancer spread?....................................................10
What is secondary cancer in the liver?.............................................11
What are the symptoms?................................................................12
How common is cancer in the liver?................................................13

Diagnosis....................................................................... 14
Blood tests.......................................................................................... 14
Scans (imaging tests).......................................................................... 15
Biopsy...........................................................................................18
Further tests........................................................................................ 20
Staging cancer in the liver................................................................... 21
Prognosis............................................................................................ 22
Which health professionals will I see?................................................. 23
Key points........................................................................................... 25

Making treatment decisions........................................... 26
Talking with doctors............................................................................ 26
A second opinion................................................................................ 27
Taking part in a clinical trial................................................................. 27

Treatment......................................................................... 28
Surgery................................................................................................ 28
Tumour ablation................................................................................... 34
Chemotherapy..................................................................................... 36
Biological therapy................................................................................ 38
Radioembolisation (selective internal radiation therapy)..................... 39
Endoscopic stent placement............................................................... 40
Palliative treatment.............................................................................. 41
Key points........................................................................................... 42

Looking after yourself..................................................... 43
Relationships with others.................................................................. 44
Life after treatment.............................................................................. 45

Seeking support.............................................................. 47
Practical and financial help............................................................... 47
Talk to someone who’s been there...................................................... 47

Caring for someone with cancer................................... 49
Useful websites...........................................................50
Question checklist........................................................... 51
Glossary........................................................................... 52
How you can help............................................................ 56
What is cancer?
           Cancer is a disease of the cells, which are the body’s basic building
           blocks. The body constantly makes new cells to help us grow,
           replace worn-out tissue and heal injuries. Normally, cells multiply
           and die in an orderly way.

           Sometimes cells don’t grow, divide and die in the usual way. This
           may cause blood or lymph fluid in the body to become abnormal, or
           form a lump called a tumour. A tumour can be benign or malignant.

           Benign tumour – Cells are confined to one area and are not able
           to spread to other parts of the body. This is not cancer.

           Malignant tumour – This is made up of cancerous cells, which
           have the ability to spread by travelling through the bloodstream or
           lymphatic system (lymph fluid).

How cancer starts

    Normal cells                 Abnormal                               Angiogenesis
                                 cells

            Boundary
Lymph vessel
         Blood vessel

    Normal cells            Abnormal cells   Abnormal cells         Malignant or
                                                multiply          invasive cancer

4          Cancer Council
The cancer that first develops in a tissue or organ is called the
primary cancer. A malignant tumour is usually named after the
organ or type of cell affected.

A malignant tumour that has not spread to other parts of the
body is called localised cancer. A tumour may invade deeper
into surrounding tissue and can grow its own blood vessels
(angiogenesis).

If cancerous cells grow and form another tumour at a new site,
it is called a secondary cancer or metastasis. A metastasis keeps
the name of the original cancer. For example, liver cancer that
has spread to the bones is still called liver cancer, even though the
person may be experiencing symptoms in the bones, while breast
cancer that has spread to the liver is still called breast cancer.

How cancer spreads
Primary cancer

Local invasion

Angiogenesis –
tumours grow their
own blood vessels

Lymph vessel

Metastasis –
cells invade other
parts of the body via
blood vessels and
lymph vessels

                                                         What is cancer?   5
The liver
    The liver is the largest organ inside the body. It is on the right
    side of the tummy area (abdomen), next to the stomach. It
    is found under the ribs, just beneath the right lung and the
    diaphragm. The diaphragm is a sheet of muscle that separates
    the chest from the abdomen.

    The liver is made up of two sections: the right and left lobes.
    Blood flows into the liver from the hepatic artery and the portal
    vein. Blood from the hepatic artery carries oxygen, while blood
    from the portal vein carries nutrients and waste products (toxins).

    The liver performs several important functions including:
    • producing bile to help dissolve fat so it can be easily digested
    • converting sugar and fat into energy
    • storing nutrients
    • making proteins and chemicals the body needs
    • helping the blood to clot
    • breaking down substances, such as alcohol and drugs,
      and getting rid of waste products.

    Unlike other internal organs, the liver can usually repair itself.
    It can function even if only a small part of it is working. After
    surgery or injury, a healthy liver can grow back to normal size
    in 6–8 weeks.

    Bile is made in the liver and is stored in the gall bladder. When
    needed, bile is released into the bowel to help break down fats.

6   Cancer Council
The liver

  Lung

  Hepatic vein                                          Diaphragm

                                                         Liver (left)
  Liver (right)
                                                         Stomach

  Gall bladder

                                                    Hepatic artery

                                                         Pancreas
                  Common
                  bile duct

                              Portal vein

                                            The liver              7
Key questions
    Q: What is primary liver cancer?
    A: This is when a malignant tumour starts in the liver. There are
          different types of primary liver cancer:

          • Hepatocellular carcinoma (HCC) – starts in the
            hepatocytes, the main cell type in the liver. HCC, also called
            hepatoma, is the most common type of primary liver cancer.
          • Cholangiocarcinoma – starts in the cells lining the
            bile ducts, which connect the liver to the bowel and the
            gall bladder. It is also called bile duct cancer.
          • Angiosarcoma – a rare type of liver cancer starting in the
            blood vessels. It usually occurs in people over 70.

    Q: What are the risk factors?
    A: The majority of liver cancer cases are related to long-term
          (chronic) infection caused by the hepatitis B or C viruses.

          Other causes of liver cancer aren’t always known, but some
          factors that increase the risk include:
          • liver scarring (cirrhosis) due to: hepatitis B or C,
            alcohol, fatty liver disease or genetic disorders, such as
            haemochromatosis or alpha 1-antitrypsin deficiency
          • type 2 diabetes
          • high alcohol consumption
          • eating a high-fat diet and/or being overweight or obese
          • smoking tobacco
          • exposure to certain chemicals or substances (such as
            aflatoxins, vinyl chloride and arsenic).

8   Cancer Council
The link between hepatitis and liver cancer
  About eight in ten of HCC cases worldwide are attributable
  to chronic hepatitis infection. In Australia, hepatitis C and
  hepatitis B infections are the biggest known risk factors for
  primary liver cancer.

  It’s estimated that more than a third of the world’s population
  has been infected with the hepatitis B virus. People can spread
  either type of hepatitis without knowing they’re infected.
  Hepatitis is spread by contact with infected blood, semen,
  or other body fluids. Spread can occur through sex with an
  infected partner or sharing personal items, such as razors or
  toothbrushes, with an infected person.

  The most common way that hepatitis B is spread is during
  birth, from mother to baby. Although the infection usually goes
  away (is cleared) in adults, if hepatitis is acquired in infancy or
  early childhood, it can lead to chronic hepatitis infection.

  Chronic infection with hepatitis B affects the liver cells
  (hepatocytes). This stimulates the body’s immune system
  to attack the virus. The immune response causes liver
  inflammation, which can lead to ongoing damage and can
  cause liver cancer.

People with chronic hepatitis infection often develop cirrhosis,
which increases the risk of liver cancer.

                                                          Key questions   9
To reduce the spread of hepatitis B and the incidence of
           primary liver cancer, all at-risk people should be vaccinated
           against the virus. These include:
           • migrants from South-East Asia, Africa and the Pacific Islands
           • sexually active partners of infected individuals
           • people in the same household as someone with hepatitis B
           • recipients of blood products
           • infants and children (as part of Australia’s national
             immunisation program).

           Vaccination is not effective if you are already infected with
           the virus. In this case, you need regular monitoring to ensure
           you don’t develop health problems, including liver cancer.
           If you are concerned about hepatitis, contact your doctor for
           more information.

     Q: Can primary liver cancer spread?
     A: If primary liver cancer isn’t found in its early stages, or if
           treatment is unsuccessful, it can spread. It typically spreads
           to other parts of the liver first, then the lungs, lymph nodes
           and bones.

           The two most common ways that liver cancer spreads are
           through the bloodstream or the lymphatic system. The
           lymphatic system is part of the body’s defence system against
           infection and disease. It includes a network of thin lymph
           vessels, which carry a clear fluid called lymph to and from
           tissues, before emptying it into the bloodstream.

10   Cancer Council
Q: What is secondary cancer
   in the liver?
A: Secondary cancer in the liver is cancer that started in another
     part of the body but has spread (metastasised) to the liver.

     Most cancers can spread to the liver. Cancers that start in
     the digestive system (including cancers of the oesophagus,
     stomach, pancreas and large bowel) are most likely to
     spread to the liver. This is because blood cells flow from the
     digestive organs through the liver, and cancerous blood cells
     can get stuck (lodge) in the liver.

     Melanoma and cancers of the breast, ovary, kidney and lung
     can also metastasise to the liver.

     Secondary cancer in the liver is sometimes found at the same
     time that the primary cancer is diagnosed. However, it can
     also be diagnosed soon after the primary cancer, or it may be
     diagnosed months or years after someone has been treated
     for primary cancer.

     It could also be diagnosed before the primary cancer is
     found. If other tests don’t show what the primary cancer is,
     this is called cancer of unknown primary (CUP).

     If you have secondary cancer in the liver, it may be useful to
     read information about the primary cancer, or about CUP
     if the primary cancer is unknown. Call 13 11 20 or go to your
     local Cancer Council website to access relevant publications.

                                                          Key questions   11
Naming secondary cancers
        A secondary cancer is named        cancer with liver secondaries,
        after the primary site where       colorectal metastasis,
        it began.                          metastatic bowel cancer or
                                           advanced bowel cancer.
        For example, bowel cancer that
        has spread to the liver is still   In this booklet, we use the term
        called bowel cancer. To indicate   ‘secondary cancer in the liver’
        that the cancer has spread,        to refer to any cancer type that
        doctors may call it bowel          has spread to the liver.

     Q: What are the symptoms?
     A: Primary liver cancer doesn’t tend to cause symptoms in
           the early stages, but they may appear as the cancer grows
           or becomes advanced. Secondary liver cancers may cause
           similar symptoms.

           Symptoms can include:
           • weakness and tiredness (fatigue)
           • pain in the upper right side of the abdomen
           • severe abdominal pain
           • appetite loss and feeling sick (nausea)
           • weight loss
           • yellowing of the skin and eyes (jaundice)
           • pale bowel motions
           • swelling of the abdomen (ascites)
           • fever.

12   Cancer Council
Q: How common is cancer
   in the liver?
A: Primary liver cancer is one of the less common cancers in
     Australia. About 1400 people are diagnosed with it every
     year. It is more than twice as common in men, and the
     average age at diagnosis is 66.

		   The incidence of primary liver cancer is increasing, mainly
     because the rate of hepatitis infection is increasing, and more
     people are developing serious damage from fatty liver disease.

		   HCC, the most common type of primary liver cancer, is
     common in Asia, Mediterranean countries and Africa due
     to the high rates of chronic hepatitis B infection. In Australia,
     it is more common in migrants from Vietnam, Hong Kong
     and Korea – countries where hepatitis B infection is prevalent.

     Secondary cancer in the liver is much more common than
     primary liver cancer. It occurs about 20 times more often,
     with about 28,000 people in Australia diagnosed every year.

                                                           Key questions   13
Diagnosis
     Primary liver cancer and secondary cancer in the liver are
     diagnosed using a number of tests. These include blood tests
     and scans. Tissue examination (biopsy) is rarely done.

     Blood tests
     You will probably have a blood test to check how well the liver is
     working (liver function) and how well your blood clots. You may
     also have liver function tests before, during and after treatment.

     If primary liver cancer is suspected, you will have blood tests to
     check for hepatitis B or C and various genetic problems. You may
     need a blood test to check the level of certain chemicals known
     as tumour markers, which are produced by cancer cells and can
     help identify some types of cancer. The tumour markers used to
     diagnose primary liver cancer include:
     • alpha-fetoprotein (AFP)
     • cancer antigen 19-9 (CA19-9)
     • carcinoembryonic antigen (CEA) – this is also helpful in
        diagnosing secondary cancer that has spread from the large bowel.

     Tumour markers do not rise in all people with cancer. Also, some
     conditions, such as pregnancy, hepatitis and jaundice, can increase
     tumour marker levels without cancer being present. If the markers
     are high due to cancer, they should fall if the treatment works.

     After blood tests, other tests will need to be done to confirm
     your diagnosis of primary liver cancer or secondary cancer in
     the liver.

14   Cancer Council
Scans (imaging tests)
You will have at least one of these scans, but you may have more
than one if the doctor needs further information about the cancer.

Ultrasound
An ultrasound is the most common scan used to look for primary
liver cancer. It’s often used to monitor high-risk patients, such as
people with cirrhosis.

The scan uses soundwaves to create a picture of a part of your body.
It can show the size and location of abnormal tissue in your liver.

During the ultrasound, you will lie down and a gel will be spread
over your abdomen to help conduct the soundwaves. A small
paddle-shaped device called a transducer is then moved over the
area. It creates soundwaves that echo when they meet something
dense, like an organ or tumour.

The soundwaves are sent to a computer and turned into a picture.
This process takes about 15 minutes and is painless.

If a solid lump is found, the scan will help show whether it is
cancer. Non-cancerous (benign) tumours in the liver can also be
found during an ultrasound.

  You will be asked to not eat or drink for about four hours before
  the ultrasound.

                                                                Diagnosis   15
CT scan
     The CT (computerised tomography) scan is a type of x-ray that
     takes three-dimensional pictures of several organs at the same
     time. It helps doctors make a diagnosis and see if the cancer has
     spread. It can also help doctors plan surgery.

     The test usually takes 10–30 minutes. You will need to drink
     a liquid dye (contrast) or have an injection of contrast into a
     vein beforehand to make the pictures clearer. The injection may
     be uncomfortable and the dye may briefly make you feel hot
     and sweaty. Some people can’t have this scan because of poorly
     functioning kidneys or an allergy to the contrast (see below).
     In this case, a different scan will be arranged.

     You will lie on a table while the CT scanner, which is large and
     round like a doughnut, takes the pictures. The scan itself is painless.

     Some people are allergic to the contrast used in a CT or MRI scan.
     If you have any known allergies, let your doctor know in advance.
     You should also tell your health care team if you have a pacemaker
     or other metallic device in your body. These may interfere with the
     MRI scan.

     MRI scan
     An MRI (magnetic resonance imaging) scan uses both a magnetic
     field and radio waves to take detailed cross-sectional pictures of
     the body.

16   Cancer Council
These show the extent of the tumour and whether it is affecting
the main blood vessels around the liver. The pictures are taken
while you lie on a table that slides into a metal cylinder – a large
magnet – that is open at both ends. You may be given an injection
of contrast into your veins to make the pictures clearer.

An MRI is painless but some people find that lying in the cylinder is
too confined (claustrophobic) and noisy. If you feel uncomfortable,
let your doctor or nurse know. They can give you medication to
ease this feeling or earplugs to reduce the noise level. You can also
usually take someone into the room with you for company.

      I had various scans when I was diagnosed with primary
liver cancer. At first, I found the MRI was frightening, going
into the cylinder head first and having to hold my breath.
But now when I have this scan during check-ups, I count to
myself. This helps me feel more in control.         Robyn

PET-CT scan
A positron emission tomography (PET) scan combined with a
CT scan (see page 16) is a type of imaging test available at some
major metropolitan hospitals. It produces a three-dimensional
colour image that may show where cancers are in the body.

PET scans are most commonly used for secondary liver cancers,
such as bowel cancer or melanoma that have spread to the liver.
They are not often used to detect primary liver cancers.

                                                             Diagnosis   17
For the PET scan, you will be injected in the arm with a glucose
     solution containing a small amount of radioactive material. It
     takes 30–90 minutes for the solution to go through your body.
     During this time you will be asked to sit quietly.

     Your whole body will then be scanned for high levels of
     radioactive glucose. Cancer cells show up brighter on the scan
     pictures because they are more active and take up more of the
     glucose solution than normal cells.

     During PET scans, you will be exposed to radioactive material, but
     doses are low and generally not harmful. The nuclear medicine staff
     who perform the scan will discuss this with you.

     Biopsy
     A biopsy involves removing a small amount of tissue to examine
     under a microscope. This can sometimes show if the cancer in
     your liver is a primary or secondary cancer. A biopsy is usually
     done for:
     • people without liver cirrhosis
     • people who have cirrhosis but have other inconclusive or
       abnormal test results
     • before surgery or other treatment, if there is uncertainty about
       the diagnosis.

     A biopsy may not be needed if you are able to have a transplant
     (see page 35).

18   Cancer Council
Before a biopsy, you may have a test to check how well your blood
clots. This is because the liver contains many blood vessels.

Biopsy is done either by fine needle aspiration or laparoscopy:

Fine needle aspiration
You will have a local anaesthetic to numb the area, then a thin
needle is passed through the skin into the tumour. An ultrasound or
CT scan will be done at the same time to help the doctor guide the
needle. Cells are drawn into the needle and removed.

Afterwards, you will stay in hospital for a few hours. If there is a
high risk of bleeding, you may need to stay overnight.

Sometimes the results of this biopsy are not clear and it will need
to be repeated.

Laparoscopy
This operation is also called keyhole surgery. It allows the
doctor to look at the liver and surrounding organs using a thin
tube containing a light and a camera (a laparoscope). It is often
done if your doctor thinks the cancer may be in other areas of
the body.

A laparoscopy is done under general anaesthetic. A small cut is
made in your lower abdomen for the laparoscope to be inserted.

During the procedure, carbon dioxide gas is used to increase
the size of your abdomen to make space for the surgeon to see.

                                                               Diagnosis   19
The surgeon can take tissue samples, then after the laparoscope
     is removed, the small cut is closed with a couple of stitches.

     The most common risks of laparoscopy are wound infection
     and bruising. There is a slight risk of bleeding, but this is rare.
     The carbon dioxide can also cause shoulder pain and wind for
     a few days.

     Usually you will need to stay in hospital overnight for monitoring.
     Some people need to stay in hospital for a few days.

     Further tests
     If you have not been diagnosed with cancer and the tests
     described on pages 14–19 show you have secondary cancer in the
     liver, you may need further tests to find out where the primary
     cancer started.

     Some people have:
     • an examination of the bowel (colonoscopy), the stomach
       (endoscopy) and, for women, the breasts (mammogram)
     • blood  tests to look for different tumour markers
     • a urine test to check the kidneys or bladder
     • other imaging tests, such as a PET-CT scan, to see different parts
       of the body.

     In other cases, it will be clear where the primary cancer began, as
     you may have been diagnosed and treated for cancer in the past.
     This is common for people who have bowel cancer.

20   Cancer Council
ICG test
  An indocyanine green              During an ICG test, green dye
  (ICG) test may be done for        is injected into the blood. Over
  people who have primary liver     the next 15 minutes, readings
  cancer and cirrhosis. The test    are taken using a probe placed
  helps surgeons assess how well    on the finger. The probe
  the liver is functioning and      measures how quickly the
  determine if surgery is a         liver clears the dye from the
  treatment option.                 bloodstream.

  ICG may be done before            If the dye is cleared quickly,
  surgically removing part of the   this shows that the liver is
  liver. This is because healthy    working well. However, if it is
  people can withstand an           slow, it may be too dangerous
  operation (the liver may regrow   to remove parts of the liver. In
  during recovery), but a person    this case, the medical team
  with cirrhosis has liver damage   will discuss other available
  that can impair liver regrowth.   treatment options.

Staging cancer in the liver
The tests described in this chapter will show whether you have:
• primary liver cancer
• primary liver cancer that has spread
• secondary cancer that has spread to the liver from elsewhere.

Working out whether the cancer has spread from the primary
cancer site – and if so, how far – is called staging. This helps your
doctor recommend the best treatment for you.

                                                                Diagnosis   21
Ask your doctor to explain more about the stage of the cancer and
     how it relates to your diagnosis and treatment.

     The different stages of cancer are based on how far away from the
     original tumour site the cancer is found. Different types of cancer
     have different staging systems. Secondary cancers in the liver are
     staged using the system relating to the primary cancer.

     In primary liver cancer, generally stage 1 and stage 2 tumours are
     confined to the liver. Usually stage 3 and stage 4 describes cancer
     that has spread away from liver.

     Prognosis
     Prognosis means the expected outcome of a disease. You may wish
     to discuss your prognosis with your doctor, but it is not possible
     for any doctor to predict the exact course of your disease. Factors
     used to assess your prognosis include:
     • test results
     • the type of cancer, where it is in the body, and the rate of growth
     • the treatment available
     • how well you respond to treatment
     • your age, fitness and medical history.

     Doctors often use numbers (statistics) when considering someone’s
     prognosis. Statistics reflect the typical outcome of disease in large
     numbers of patients. While statistics give doctors a general idea
     about a disease, they won’t necessarily reflect your situation.

22   Cancer Council
Liver transplantation or surgical resection (removal of the
diseased section of the liver) may be an option to treat some
people with primary liver cancer. These procedures may offer
the chance of a cure.

Other treatments for primary liver cancer and secondary cancer in
the liver may enable you to live for much longer than if you were
to have no treatment.

Which health professionals will I see?
Your general practitioner (GP) will arrange the first tests to
assess your symptoms. If these tests do not rule out cancer, you
will probably be referred to a gastroenterologist who will organise
further tests for you and advise you about treatment options.

You may need to see other specialists, such as a surgeon or
a medical oncologist, who can discuss the different types of
treatment with you.

A range of health professionals who specialise in different
aspects of your treatment will care for you. This is called a
multidisciplinary (MDT) team, and includes doctors, nurses and
allied health professionals, such as a physiotherapist and dietitian.

Some people in non-metropolitan areas will have to travel to
appointments with specialists. Your GP can be kept informed of
all your test results and treatment. They can answer questions you
have in-between appointments with specialists.

                                                              Diagnosis   23
Health professional       Role

                               a doctor who specialises in surgery of the
     hepatobiliary surgeon
                               liver and its surrounding organs

                               a specialist in diseases of the digestive
     gastroenterologist
                               system, including the liver

                               a gastroenterologist who specialises in
     hepatologist
                               diseases of the liver

                               prescribes and coordinates the course of
     medical oncologist
                               chemotherapy

                               help to diagnose cancer by interpreting
     radiologist and nuclear   results of diagnostic tests, and delivers some
     medicine specialists      treatments, including those with chemical
                               compounds

     cancer care               provide care, information and support
     coordinators and          throughout your treatment, and administer
     nurses                    drugs, including chemotherapy

     social worker,            provide information and support with
     physiotherapist,          practical matters, such as mobility, and link
     occupational therapist    you to community support services

                               determines if you are getting enough
     dietitian                 nutrients, and recommends an eating plan for
                               you to follow during treatment and recovery

                               assists you with symptom management and
     palliative care team
                               emotional support for you and your family

24          Cancer Council
Key points

• There are a number of tests       a colonoscopy or endoscopy
  used to diagnose primary          to find out where the primary
  liver cancer or secondary         cancer started.
  cancer in the liver.
                                  • All of these tests will help
• Blood tests show how the          your doctor work out the best
  liver is working and whether      treatment options for you and
  there are tumour markers in       whether it may be possible to
  the blood that might indicate     try and cure the cancer.
  cancer in the liver.
                                  • Your doctor may tell you what
• Imaging tests include a           stage the cancer is at. This
  range of scans that allow         describes how far the cancer
  doctors to see your organs        has spread in your body.
  and determine whether there
  are any abnormal tissue or      • You may wonder about the
  tumours. Sometimes non-           likely outcome of the disease
  cancerous (benign) lumps          (the prognosis). There are
  are found.                        many factors in considering
                                    your prognosis, such as test
• A biopsy is when tissue is        results, the type of cancer you
  removed for examination           have and your medical history.
  under a microscope. This is
  not done very often. If it is   • You will see many health
  done, it is done using a fine     professionals when you have
  needle or during surgery.         tests and treatment. These
                                    include specialists, cancer
• If you have secondary             care coordinators, nurses, and
  cancer in the liver, you may      other health professionals,
  also need tests such as           such as social workers.

                                                           Diagnosis   25
Making treatment
     decisions
     Sometimes it is difficult to decide on the type of treatment to have.
     You may feel that everything is happening too fast. Check with
     your doctor how soon your treatment should start, and take as
     much time as you can before making a decision.

     Understanding the disease, the available treatments and possible
     side effects can help you weigh up the pros and cons of different
     treatments and make a well-informed decision that’s based on
     your personal values. You may also want to discuss the options
     with your doctor, friends and family.

     You have the right to accept or refuse any treatment offered. Some
     people with more advanced cancer choose treatment even if it
     only offers a small benefit for a short period of time. Others want
     to make sure the benefits outweigh the side effects so that they
     have the best possible quality of life.

     Talking with doctors
     When your doctor first tells you that you have cancer, you may
     not remember the details about what you are told. Taking notes
     or recording the discussion may help. Many people like to have
     a family member or friend go with them to take part in the
     discussion, take notes or simply listen.

     If you are confused or want clarification, you can ask questions –
     see page 51 for a list of suggested questions. If you have several
     questions, you may want to talk to a nurse or ask the office
     manager if it is possible to book a longer appointment.

26   Cancer Council
A second opinion
You may want to get a second opinion from another specialist to
confirm or clarify your doctor’s recommendations or reassure you
that you have explored all of your options. Specialists are used to
people doing this.

Your doctor can refer you to another specialist and send your
initial results to that person. You can get a second opinion even if
you have started treatment or still want to be treated by your first
doctor. You might decide you would prefer to be treated by the
doctor who provided the second opinion.

Taking part in a clinical trial
Your doctor or nurse may suggest you take part in a clinical trial.
Doctors run clinical trials to test new or modified treatments and
ways of diagnosing disease to see if they are better than current
methods. For example, if you join a randomised trial for a new
treatment, you will be chosen at random to receive either the best
existing treatment or the modified new treatment.

Over the years, trials have improved treatments and led to better
outcomes for people diagnosed with cancer.

It may be helpful to talk to your specialist or clinical trials nurse,
or to get a second opinion. If you decide to take part, you can
withdraw at any time. For more information, call the Helpline for
a free copy of Understanding Clinical Trials and Research or visit
www.australiancancertrials.gov.au.

                                                  Making treatment decisions   27
Treatment
     Your treatment will depend on whether you have primary liver
     cancer or secondary cancer in the liver; the size and spread of the
     cancer; and whether any other disease, such as cirrhosis, affects
     your liver. Your doctor will also consider your age and general
     health, as well as the options available at your hospital.

     • Primary liver cancer – The most common treatments are
       tumour ablation using heat (radiofrequency or microwave
       ablation) and chemotherapy delivered directly into the cancer,
       known as transarterial chemoembolisation (TACE). Surgery is
       used for about 5% of people.

     • Secondary cancer in the liver – The main treatments are
       chemotherapy or a combination of surgery and chemotherapy.

     Surgery
     During surgery, part of the liver that contains cancer is removed.

     Primary liver cancer – Only a small number of people are
     suitable for surgery. Your ability to have an operation depends on
     the size, number and position of the tumours, how much of the
     liver is affected and whether you have cirrhosis. Operating on
     patients with cirrhosis is complicated because the liver may not
     function well or regrow afterwards.

     For some people, it is not possible to remove part of the liver. These
     patients may be considered for a transplant. This means the whole
     liver is replaced (see page 31).

28   Cancer Council
Secondary cancer in the liver – Surgery may be possible if
there is enough healthy liver and the cancer hasn’t spread to other
parts of the body where it can’t be removed (such as the bones).
Liver transplantation isn’t an option.

Some people need surgery for both the secondary cancer in the liver
and the primary cancer. These operations may be done separately or
at the same time.

    The hardest part of the operation was knowing how
much progress I had to make after the operation. The
nurses wrote some goals for me: pain control, breathing
exercises, tubes out, getting out of bed.    Earl

Partial hepatectomy
Surgery to remove part of the liver is called a partial hepatectomy.
The amount of liver removed depends on your circumstances.
In some cases, the surgeons will remove one half of your liver
(hemihepatectomy). In other cases they will only need to cut out
a small section (segmentectomy). The gall bladder is also taken out,
as it is attached to the liver on the border between the right and left
sides. Occasionally, part of the diaphragm muscle may be removed.

The liver can repair itself easily if it is not damaged. The portion
of the liver that remains after resection will start to grow, even if
up to three-quarters of it is removed. The liver will usually be back
to normal size within a few months, although its shape may be
slightly changed.

                                                                Treatment   29
Surgical approaches
        In the majority of liver          abdomen and use a camera
        operations, a large cut is made   to view the organs.
        in the upper abdomen. This is
        called an open approach.          While recovery is faster after
                                          keyhole surgery, you will still
        However, it’s becoming            be in hospital for at least one
        more common for some liver        night and you will need pain
        operations to be done with        medication.
        a smaller incision (known
        as keyhole or laparoscopic        Keyhole surgery is not available
        surgery). Your surgeon            in all hospitals. Talk to your
        will make small cuts in the       surgeon for information.

     Two-stage surgery (two-stage hepatectomy)
     People with tumours in both sides of the liver sometimes need
     two operations:

     1. A partial hepatectomy is done to remove tumours from one side
       of the liver. Sometimes this operation is combined with tumour
       ablation (see page 34) or removal of the primary tumour.

       The patient is given about two months to recover. During this
       time, the liver may regrow. Before a second operation, the size
       of the liver will be checked.

     2. If enough of the liver has regrown, the tumours in the second
     		side will be removed during another partial hepatectomy.

30   Cancer Council
Liver transplantation
Transplantation involves removing the entire liver and replacing it
with a liver from another person (a donor). There is a possibility
that this treatment could cure primary liver cancer, but it is
generally only used in people with small tumours.

Several factors are taken into account before someone is eligible
for a liver transplant. Their overall health must be good, they
cannot smoke or take illegal drugs, and they must have stopped
drinking alcohol.

Donor livers are scarce, and waiting for a suitable liver may take
many months or years. During this time, the cancer may continue
to grow. As a result, most people have other treatment to control
the cancer while they wait for a donor.

If you have a liver transplant, it may take 3–6 months to recover.
You will probably find it takes a while to regain your energy. You
will also be given medications to reduce the chance of infection
and stop the body rejecting the new liver (immunosuppressants).
You will need to take immunosuppressants for the rest of your life.

After you return home, you will need frequent check-ups to
monitor your health and the success of the transplant.

  There is no cost for having a liver transplant in Australia, when it is
  performed in a public hospital.

                                                                  Treatment   31
After surgery
     You will spend 5–10 days in hospital after a partial hepatectomy,
     and up to three weeks in hospital following a transplant.

     If you have a laparoscopy, the recovery time is shorter – you
     should allow about one week to recover before returning to your
     usual activities.

     Drips and drains – Different tubes will be in place to drain
     post-operative fluids, urine and bile. You will also have a drip
     (intravenous tube) giving you fluids and nourishment, as you may
     not be able to eat or drink for a few days. When you are able to eat,
     you will be given clear fluids at first, and then solid foods.

     Pain relief – As with many types of surgery, you may
     experience pain, as well as breathing difficulties and nausea.
     The hospital staff will try to make you comfortable by giving
     you pain relief. You may have a tube called an epidural catheter
     placed in your back to deliver pain medication, or you may
     be given what is known as an intravenous patient-controlled
     analgesic (PCA) system.

     The PCA system allows you to control the pain by pressing a
     button to give yourself a dose of pain relief when you need it.
     It is not possible to give yourself an overdose of medication using
     a PCA system.

     Let your doctor or nurse know if the pain control is not working,
     as it may be possible to adjust the medication or dosage.

32   Cancer Council
Fatigue – You will probably feel quite tired and weak after the
operation, but this should improve within a few weeks.

Mobility – A physiotherapist can help with your recovery by
giving you exercises to improve your breathing, strength and
ability to walk (mobility).

Check-ups – After you return home, you will need frequent
check-ups to monitor your health and the success of the surgery.
Your doctor will tell you how often you should have check-ups.

  • Start doing light exercise as       • If you have an incision, follow
    soon as you are able to. Try          your health care team’s
    walking slowly or standing            instructions about cleaning
    while doing chores.                   the area. Contact your doctor
                                          if it becomes red or inflamed.
  • Wait six weeks and consult
    your doctor before doing            • Avoid alcohol for at least
    vigorous exercise, such as            one month and only drink
    running, weight-lifting or            alcohol in moderation after
    playing sport.                        this time. If you have cirrhosis,
                                          you must not consume any
  • If you are taking strong (opioid)     alcohol. Your medical team
    pain-killers, follow your
                                          will talk to you about this.
    doctor’s advice about driving.

    I had an 11 cm long hepatocellular carcinoma, but
I was lucky that the tumour was operable. After surgery, the
physiotherapy exercises helped my recovery.       Robyn

                                                                  Treatment   33
Tumour ablation
     Tumour ablation is treatment that destroys a tumour. Ablation
     works best when there are only one or two small tumours (less than
     3 cm in size). It is used most commonly for small primary liver
     cancers, and it is rarely used for secondary cancer in the liver.

     The most common ablation treatments use radio waves
     (radiofrequency) or microwaves to heat and destroy cancer
     cells. This can be done with a needle inserted through the skin
     (percutaneously) or with a surgical cut.

     Less common types of tumour ablation include alcohol injection
     and cryotherapy (see opposite).

     Percutaneous ablation
     During this procedure, a CT or ultrasound scan is used to guide
     a fine needle through the skin and into the tumour. Radio
     waves or microwaves are passed through the needle and into
     the tumour to destroy it. This is done in the x-ray department
     or operating theatre while you are under local or general
     anaesthetic. It takes 1–3 hours, but you will usually stay in
     hospital overnight.

     Afterwards you will probably feel quite drowsy. Side effects, which
     include pain, nausea or fever, can be managed with medication.

     Ablation with surgery
     If the tumours are close to the surface of the liver, you may
     have an operation to avoid damage to the diaphragm muscle or

34   Cancer Council
nearby organs. A cut is made in the skin to access the liver, and
probes are inserted to do the ablation.

Recovery from ablation with surgery is usually similar to liver
surgery (see pages 32–33).

Alcohol injection
During alcohol injection, pure alcohol is inserted directly into a
tumour to destroy cancer cells. It isn’t available at all hospitals, but is
occasionally used if other forms of ablation aren’t possible.

Treatment is given under local anaesthetic, and an ultrasound
is used to guide the needle into the tumour. You may be given
more than one injection over several sessions.

You may have some pain or a fever after the alcohol injection, but
these side effects can be managed with medication.

Cryotherapy
Cryotherapy (or cryosurgery) is a procedure used to freeze and
kill cancer cells, but it is not widely available.

You will be given a general anaesthetic, then a cut will be made in
your abdomen. A probe is inserted through the cut into the centre
of the tumour. The probe releases liquid nitrogen that freezes and
kills the cancer cells.

Cryotherapy takes about 60 minutes, and recovery is similar to
having surgery (see pages 32–33).

                                                                    Treatment   35
Chemotherapy
     Chemotherapy is the use of drugs to kill, shrink or slow the
     growth of tumours.

     Depending on the type of cancer you have, you will either have
     chemotherapy that spreads throughout your body (systemically)
     or goes directly into the tumour (TACE).

     Systemic chemotherapy
     Systemic chemotherapy is generally not used to treat primary liver
     cancer unless the cancer has spread to other parts of the body. It
     may occasionally be used to shrink a secondary cancer enough
     so that it can be operated on later. It can also be used as palliative
     treatment to slow down cancer growth and reduce pain.

     Chemotherapy may also be given following other treatment, such
     as cryotherapy or surgery, to get rid of any remaining cancer cells.
     This is called adjuvant chemotherapy. If given systemically, you
     may have intravenous chemotherapy (through a drip) or tablets
     over weeks or months.

     Systemic chemotherapy can cause side effects because the
     drugs circulate through the whole body and affect normal,
     healthy cells.

     Whether or not you have chemotherapy depends on factors such as
     your overall health, liver function, and if you have advanced cirrhosis.

36   Cancer Council
Transarterial chemoembolisation (TACE)
Chemoembolisation, or TACE, is a way of delivering
chemotherapy directly into a primary cancer. By targeting the
tumour directly, stronger drugs can be used without causing
many of the side effects of systemic chemotherapy.

TACE is rarely used for secondary cancers.

You will be given a local anaesthetic before TACE, and possibly some
medication to relax (a sedative). During treatment, chemotherapy
drugs are injected through a thin tube (catheter) that has been
inserted into the hepatic artery. Tiny plastic beads or soft, gelatine
sponges may be placed in the smaller arteries that lead to the
tumour. This blocks the arteries, keeping the chemotherapy in the
tumour and starving the cancer of oxygen and nutrients.

Usually treatment is given only once, or once every few months.
It is done in the hospital x-ray department. After each TACE
treatment, you will need to remain lying down for about four hours.
You may also need to stay in hospital overnight or for a few days.

Side effects of chemotherapy
The side effects of chemotherapy vary, depending on if you have
systemic chemotherapy or TACE.

Side effects of systemic chemotherapy depend on the drugs used.
Temporary side effects may include:
• nausea and loss of appetite
• tiredness

                                                              Treatment   37
• hair loss and skin changes
     • tingling or numbness in fingers and toes
     • mouth sores
     • an increased risk of developing infections.

     After chemoembolisation (TACE), it is common to develop a fever
     the next day, but this usually passes quickly. Other side effects,
     such as pain, are less common, but can be severe. You will be given
     medication to help control your side effects.

     There are many ways to manage side effects. For information,
     talk to your medical team or read Cancer Council’s booklet about
     chemotherapy. Call the Helpline on 13 11 20 for a free copy or visit
     your local Cancer Council website.

     Biological therapy
     Biological therapies (also called biotherapies) are a range of
     treatments derived from natural substances in the body, which are
     concentrated and purified for use as drugs. The therapies work
     against cancer cells by either stopping their growth and the way they
     function, or by helping the body’s immune system destroy them.

     Biotherapies may be used after or in conjunction with other
     treatments for primary liver cancer or secondary cancer in the liver.

     Side effects of biological therapies depend on the types used.
     Your doctor will discuss any possible side effects with you.

38   Cancer Council
Radioembolisation
(selective internal radiation therapy)
Radioembolisation (also known as selective internal radiation
therapy or SIRT) is a type of treatment that targets liver tumours
directly with high doses of internal radiation placed in tiny
radioactive beads.

SIRT is used for both primary and secondary cancers in the liver
when the tumours can’t be removed with surgery. It’s often used if
there are many small tumours spread throughout the liver.

Before treatment (work-up day) – If SIRT is an option, you will
have a number of tests, including an angiogram and a simulation
of the treatment. An angiogram shows up the blood vessels in the
liver and helps to map where the radioactive beads need to go.

This test takes about 90 minutes and you will be observed for
3–4 hours afterwards. You may also have CT and lung scans,
which take about an hour. If the results of these tests are good,
treatment will be scheduled for about 1–2 weeks later.

During treatment (delivery day) – You will have another
angiogram. Afterwards, the tiny radioactive beads, which are
known as SIR-Spheres®, are inserted through a catheter that leads
from your groin to your liver.

The procedure takes about 60 minutes and you will be monitored
closely for 3–4 hours before being taken to a general ward where
you will recover overnight.

                                                              Treatment   39
Side effects of SIRT can include flu-like symptoms, nausea, pain
     and fever. These can be treated with medication, and you usually
     can go home within 24 hours.

     SIRT is not available in all hospitals, and in most states and
     territories you will need to fund the treatment yourself if you don’t
     have private health insurance. Talk to your doctor about SIRT and
     the costs involved.

     Endoscopic stent placement
     Sometimes cancer in the liver can obstruct the bile ducts,
     particularly if it started in the ducts. If this happens, bile builds up
     in the liver and can cause symptoms of jaundice, such as yellowish
     skin, itchiness, pale stools or dark urine.

     Your doctor may recommend that a thin tube (stent) is placed in
     your liver to drain the bile and ease your symptoms. The earlier
     the stent is inserted, the less severe the symptoms.

     Endoscopic stent placement is done as a day procedure. You will
     have a local anaesthetic and possibly a sedative to reduce discomfort.

     A gastroenterologist or a surgeon inserts a long, flexible tube with
     a camera and light on the end (endoscope) through your mouth,
     stomach and small bowel into the bile duct. Pictures of the area
     show up on a screen so that the doctor can see where to place the
     stent. The stent is put in via the endoscope, which is then removed.

40   Cancer Council
Recovery from endoscopic stent placement is fairly fast. Your
throat may feel slightly sore for a short time and you may be kept
in hospital overnight.

There is a risk of infection of the bile duct and inflammation of
the pancreas after stent placement – your doctor will talk to you
about this.

Palliative treatment
Palliative treatment helps to improve people’s quality of life by
reducing symptoms of cancer without trying to cure the disease.
It is particularly important for people with secondary cancer.
However, it is not just for end-of-life care and it can be used at
different stages of cancer.

Often treatment is concerned with pain relief and stopping the
spread of cancer, but it also involves the management of other
physical and emotional symptoms. Treatment may include
chemotherapy, endoscopic stent placement or medications.

Call the Helpline on 13 11 20 for free resources about palliative
care and advanced cancer.

    The chemotherapy has stopped the secondary cancer
from spreading further, but it makes me very tired. Barbara

                                                             Treatment   41
Key points

     • The most common treatments         tumour. Ablation techniques
       for primary liver cancer           include the use of radio
       are radiofrequency tumour          waves or microwaves to heat
       ablation and transarterial         the tumour, cryotherapy to
       chemoembolisation (TACE).          freeze the tumour, and alcohol
                                          injection.
     • The most common treatments
       for secondary cancer in the      • Chemotherapy is medication
       liver are chemotherapy or a        that kills or slows the
       combination of surgery and         growth of cancer cells. It
       chemotherapy.                      is given intravenously, as
                                          tablets, or as transarterial
     • Surgery is used to remove          chemoembolisation (TACE),
       tumours that are small,            which delivers chemotherapy
       accessible and haven’t spread      directly into the tumour.
       widely throughout the liver.
                                        • Other treatments for cancer
     • Some people with primary           in the liver include biological
       liver cancer are able to have      therapies and selective internal
       a transplant, but it can take      radiation treatment (SIRT).
       many months before a donor         These are also used when
       becomes available.                 tumours can’t be surgically
                                          removed.
     • After surgery, you will need a
       number of days in hospital to    • Palliative treatment helps
       recover. You will be monitored     improve quality of life
       closely during this time.          by reducing symptoms.
                                          Chemotherapy, medications
     • Tumour ablation is localised       and endoscopic stent
       treatment that destroys the        placement are options.

42   Cancer Council
Looking after yourself
Cancer can cause physical and emotional strain. It’s important to
try to look after your wellbeing as much as possible.

Nutrition – Eating healthy food can help you cope with treatment
and side effects. A dietitian can help you manage special dietary
needs or eating problems, and choose the best foods for your
situation. Call Cancer Council Helpline 13 11 20 for a free copy of
the Nutrition and Cancer booklet.

Staying active – Physical activity may help to reduce tiredness,
improve circulation and elevate mood. The amount and type of
exercise you do depends on what you are used to, how you feel,
and your doctor’s advice. Cancer Council’s Exercise for People
Living with Cancer booklet provides more information about the
benefits of exercise, and outlines simple exercises that you may
want to try.

Complementary therapies – These therapies are used with
conventional medical treatments. You may have therapies such
as massage, relaxation and acupuncture to increase your sense of
control, decrease stress and anxiety, and improve your mood. Let
your doctor know about any therapies you are using or thinking
about trying, as some may not be safe or evidence-based.

Alternative therapies are used instead of conventional medical
treatments. These therapies, such as coffee enemas and magnet
therapy, can be harmful. For more information, call 13 11 20 for a
free copy of the Understanding Complementary Therapies booklet
or visit your local Cancer Council website.

                                                   Looking after yourself   43
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