China is a big country of hepatitis B. Most of the liver cancers in China are developed on the basis of hepatitis B cirrhosis. At present, China accounts for more than half of the global incidence and 55% of the global liver cancer patients, which has become a major killer that seriously threatens the health and life of our people and its danger should not be underestimated.
I. What is liver cancer? What are the causes of liver cancer?
Malignant tumors occurring in the liver include primary liver cancer and metastatic liver cancer, and people mostly refer to primary liver cancer when they talk about liver cancer in daily life. Primary liver cancer is one of the most common malignant tumors in clinical practice. According to the latest statistics, there are about 600,000 new liver cancer patients worldwide every year, ranking fifth among malignant tumors. Primary liver cancer can be divided into hepatocellular liver cancer, cholangiocellular liver cancer and mixed liver cancer according to cellular typing. According to the morphology of tumor, it can be divided into nodular type, giant type and diffuse type. Primary hepatocellular carcinoma is a high incidence in China, and generally more men than women.
It is worth noting that the incidence of primary liver cancer is on the rise all over the world, and about 250,000 people die from this disease every year, about 40% of which occur in China, which may be related to hepatitis virus infection. In recent years, China has made significant progress in research on the prevention and treatment of liver cancer. The discovery of subclinical hepatocellular carcinoma and small hepatocellular carcinoma is increasing, and the 5-year survival rate after surgical resection of small hepatocellular carcinoma reaches 69.4% according to Zhongshan Hospital of Shanghai Medical University. This is a leading position in the world. The introduction of the concept of subclinical hepatocellular carcinoma not only reflects a new shift in the theoretical understanding of hepatocellular carcinoma, but also promotes significant progress in treatment.
2. What are the causes of hepatocellular carcinoma?
In general, the etiology of primary liver cancer is still not completely clear, but it has been proved to be closely related to the following factors.
1. Viral hepatitis: epidemiological statistics show that areas where hepatitis B is prevalent are also areas with high incidence of liver cancer, and people who have hepatitis B have 100 times higher chance of developing liver cancer than those who do not have hepatitis B. Long-term clinical observations have revealed that hepatitis, cirrhosis, and liver cancer are an evolving trilogy. Recent studies have shown that viral hepatitis associated with liver cancer mainly includes hepatitis B (HBV) and hepatitis C (HCV), and among them, hepatitis B is the most common.
China is a large country of hepatitis B, and most of the liver cancers in China develop on the basis of hepatitis B cirrhosis. With the gradual recognition of hepatitis C, the number of hepatitis C patients is also increasing, and some of them will develop into liver cancer after suffering from hepatitis B and hepatitis C. At present, the number of hepatitis B and C patients in China accounts for more than half of the global incidence and 55% of the global liver cancer patients, which has become a major killer that seriously threatens the health and life of our people and its danger should not be underestimated.
2.Diet-related factors: the occurrence of liver cancer is closely related to living habits
(1) Alcohol
As the saying goes, “drinking alcohol hurts the liver”, drinking alcohol is not the direct cause of liver cancer, but its role is similar to that of a catalyst, which can promote the occurrence and progress of liver cancer. People who have a long-term alcohol addiction are prone to liver cancer. This is because after alcohol enters the body, it is mainly metabolized in the liver. The toxicity of alcohol to liver cells impairs the breakdown and metabolism of fatty acids, causing fatty liver deposits in the liver. The more alcohol is consumed, the more serious the fatty liver becomes, which in turn causes liver fibrosis, liver cirrhosis and liver cancer. If hepatitis patients drink a lot of alcohol, it will accelerate the formation and development of liver cirrhosis and promote the occurrence of liver cancer.
(2) Aflatoxin
Aflatoxin B1 is a substance that has been proven to have a clear carcinogenic effect and is mainly found in moldy food, such as corn, peanuts, rice, etc. In China’s high incidence of liver cancer in Jiangsu Qidong, Guangxi Fuzhou and other areas residents of the staple food is corn, peanuts, etc.. Due to improper harvesting and storage methods, food mold is caused, and people who consume such moldy food for a long time have a high incidence of liver cancer.
(3) Drinking water pollution
A large number of surveys have found that drinking water pollution is closely related to the occurrence of liver cancer, and areas with high incidence of liver cancer, such as Qidong and Haimen in Jiangsu and Nanhui District in Shanghai, suggest that the mortality rate of liver cancer is significantly higher for those who drink water from ditches and ponds than those who drink water from wells, especially deep well water. There are more than 100 kinds of organic carcinogenic, carcinogenic and mutagenic substances in the water, such as: organochlorine pesticides, multiple health partners choose to choose the water to block the Mi
Genetic factors: From the genetic point of view, some families are indeed prone to liver cancer, whether it is a similar living environment or a genetic mutation, it is still not clear.
What are the symptoms of liver cancer?
The early manifestations of liver cancer are very atypical and often easy to be ignored.
Some typical symptoms of liver cancer will only occur when the disease progresses to the middle or late stage, and by then, the chance of surgery is often lost. When fatigue and weakness cannot be relieved, it is likely to be an omen of liver disease; a dull feeling in the heart fossa, or a dull pain in the right upper abdomen, a feeling of pressure and discomfort, weight loss, sometimes unexplained fever and jaundice, you should go to hospital for examination as soon as possible.
The following symptoms may already be in the middle or late stage if they occur.
1.Significant loss of appetite: abdominal stuffiness, indigestion, sometimes nausea, vomiting;
2, vague pain in the right upper abdomen: persistent or intermittent pain in the liver area, sometimes aggravated by changes in position;
3, weakness, wasting, unexplained fever and edema;
4, jaundice, ascites, itchy skin;
5.Often manifested as nosebleeding, subcutaneous bleeding, etc.
Complications of liver cancer
Many patients die not from liver cancer itself, but from complications. So what are the morbidities of liver cancer?
Rupture and bleeding of liver cancer: It is a serious and fatal common complication of liver cancer patients, with an incidence rate of about 5.46%-19.8%, and is also one of the main causes of death of liver cancer patients, accounting for 9%-10% of the causes of death of liver cancer, and occupying the 4th place among the causes of death of liver cancer. Because of the sudden onset of the disease, it is often accompanied by shock. Therefore, its treatment is difficult and the prognosis is not good, and most patients die rapidly.
2. Hepatic encephalopathy: also known as hepatic coma, is a common complication of end-stage hepatocellular carcinoma. It is characterized by dysfunction of central nervous system and metabolic disorder, with mental retardation, consciousness impairment, neurological signs and liver damage as the main clinical manifestations, and is also one of the common causes of death in hepatocellular carcinoma, leading to the death of about 30% of patients.
3.Hepatorenal syndrome: it is also one of the common complications. When patients with hepatocellular carcinoma are in serious condition, it is caused by hypoalbuminemia and endotoxemia due to portal hypertension and liver dysfunction. Difficulty in urination, or even death due to anuria, may occur.
4.Gastrointestinal bleeding: Most of the patients bleed due to portal hypertension caused by cirrhosis or cancer embolism, which leads to rupture of esophagogastric fundic vein.
There are several cases of combined gastrointestinal bleeding in patients with hepatocellular carcinoma, as follows
(1) Esophagogastric fundic varices: patients with hepatocellular carcinoma are often combined with liver cirrhosis.
(2) Portal hypertensive gastropathy: Due to portal hypertension, the function of the damaged gastric mucosal barrier is reduced.
(3) Coagulation dysfunction: reduced liver function in hepatocellular carcinoma patients leads to reduced synthesis of coagulation factors, resulting in coagulation dysfunction, and once gastrointestinal bleeding occurs, it is often not easy to stop on its own.
(4) When liver cancer nodules rupture and bleed, blood may flow out from the biliary system and drain into the intestine.
(5) Liver cancer metastasizes to stomach and directly infiltrates the mucosal vessels of gastrointestinal tract, causing gastrointestinal bleeding.
(6) Chest and ascites: Hypoproteinemia can cause generalized swelling and chest and ascites, and liver cancer on the diaphragmatic surface can also directly infiltrate or metastasize through blood flow or lymph, causing pleural fluid, commonly on the right side.
(7) Secondary infection: Due to the long-term consumption of cancer, the resistance is weakened, especially after radiation and chemotherapy, the blood leukocytes decrease, and it is easy to complicate various infections, such as pneumonia, intestinal infection and fungal infection. It often occurs in the middle and late stages of liver cancer, and is one of the main causes of death of liver cancer patients.
(8) Internal environment disorders: acid-base balance, electrolyte balance imbalance (and these are the causes of hepatic coma and hepatorenal syndrome)
2.Diagnosis method
Besides clinical manifestations, we can clarify the diagnosis of hepatocellular carcinoma based on some tests
(1) Fetoprotein
Alpha-fetoprotein is a commonly used diagnostic method for liver cancer screening. It is necessary and convenient for patients with hepatitis to review regularly, and AFP is often elevated in liver cancer matters.
(2) Ultrasonography
Ultrasonography is a common tool for detecting liver cancer and is also commonly used for post-treatment follow-up and screening of the disease, which is often detected first by ultrasound.
(3) CT examination
CT examination can clearly show the size, shape, number and boundary of the tumor.
(4) Magnetic resonance imaging
This diagnostic method is better for the examination of milder disease and smaller tumor to achieve early diagnosis, and often complements CT diagnosis.
What should I do if I have liver cancer? Can it be treated?
In the last century, the survival time of liver cancer is less than six months. Many people were afraid of cancer and thought that liver cancer was an incurable disease, but nowadays, there is no need to be so alarmed. At present, China has achieved certain results in the prevention and control of liver cancer. When liver cancer is diagnosed, first of all, you should have a correct attitude because there are many treatment methods for liver cancer, which involve the joint collaboration of many disciplines, and if you can get correct and reasonable treatment, the long-term outcome of liver cancer is still relatively ideal. The general principle of liver cancer treatment is early detection and diagnosis, and the implementation of standardized and comprehensive treatment is emphasized.
1.Treatment methods
(1) Chemotherapy for liver cancer.
(2) Radiotherapy for liver cancer: general radiotherapy and precise radiotherapy.
(3) Guided therapy for liver cancer
(4) cellular biological immunotherapy
(5) gene therapy.
(6) local treatment of liver cancer: radiofrequency, freezing, laser, microwave, alcohol injection, etc.
(7) Surgical treatment of liver cancer (including liver transplantation).
2.Surgical treatment
Surgery is the preferred treatment for liver cancer, which can achieve cure through complete removal of tumor tissues. Whether it can be removed and the efficacy of removal are not only related to the size and number of tumor, but also very closely related to liver function, degree of cirrhosis, tumor site, tumor boundary, presence of intact envelope and venous cancer thrombus. Meanwhile there is no extrahepatic tumor metastases and the tumor site is limited rather than multiple or diffuse distribution. The survival rate of early hepatocellular carcinoma is over 80% in one year and over 50% in five years after surgical resection. If postoperative treatment is supplemented with comprehensive treatment, better results can be achieved.
In addition to liver resection, liver transplantation is also an option for surgical treatment, especially for small hepatocellular carcinoma patients with combined cirrhosis and liver function loss, liver transplantation is the best choice. At present, about 4000 liver transplants are performed in China every year, among which the proportion of liver cancer patients is as high as 40%.
Patients who cannot undergo surgery can only take other treatments
These include radiofrequency ablation, microwave ablation, high-intensity focused ultrasound, arterial chemoembolization, alcohol injection, cryotherapy, radiotherapy, molecular targeted therapy, immunotherapy and Chinese medicine treatment, etc., which are mainly used for patients who cannot receive surgical treatment for various reasons.
Among them, the principle of radiofrequency ablation or microwave ablation treatment for liver cancer is to use the thermal effect of microwave or radiofrequency to cause thermal coagulation in the target area, which is commonly known as burning the tumor and can achieve a radical curative effect comparable to liver cancer resection and liver transplantation. It is suitable for patients with small single hepatocellular carcinoma and far from important blood vessels, recurrence of hepatocellular carcinoma after surgical resection or poor liver function reserve function that cannot tolerate surgical resection.
Hepatic artery interventional embolization chemotherapy: i.e., to reach the hepatic artery through arterial placement and inject embolic agents or anti-cancer drugs, which is commonly used for patients with intermediate and advanced hepatocellular carcinoma that cannot be surgically resected and can achieve the purpose of controlling the disease and prolonging survival.
Radiation therapy for hepatocellular carcinoma: it has undergone changes such as whole liver radiation, local radiation, whole liver mobile strip radiation, local super-segmented radiation and stereoscopic radiation. Radiation therapy is suitable for unresectable liver cancer whose tumor is still limited. The treatment of liver cancer that cannot be removed surgically with gyroscope has also achieved good results.
Cellular immunotherapy achieves the purpose of cancer treatment by collecting human body’s own immune cells, culturing them in vitro to increase their quantity thousands of times and enhance their targeted killing function, and then returning them to human body to activate and enhance the body’s immune ability to kill cancer cells and cancer tissues existing in blood and tissues. At present, the most mature and effective tumor biological therapy with the most obvious prolongation of survival is autoimmune cell therapy.
Chinese medicine is still the main treatment method for most patients because most patients cannot remove liver cancer clinically, so conservative treatment is still the main treatment method for most patients.
The main mechanisms of TCM treatment for liver cancer include: improving immune function and microcirculation.
The new molecular targeting drug sorafenib, which has been introduced in recent years, can slow down tumor progression and prolong survival to a certain extent, but the drug is more expensive and may be associated with more serious adverse effects such as diarrhea, rash, hypertension, hand-foot syndrome, etc. The effects need to be further evaluated.
So far, there is no uniform and fixed treatment plan that can be applied to all liver cancer patients. Therefore, the treatment of liver cancer should be individualized, and in the treatment of each liver cancer patient, multidisciplinary disciplines such as surgery, imaging, interventional medicine and medical oncology need to complement and organically combine with each other. The choice of early treatment plan will greatly affect the prognosis of liver cancer patients. Therefore, early detection, early diagnosis, early treatment and prevention are especially important.
Comprehensive treatment based on surgery should be chosen for hepatocellular carcinoma, and individualized plan should be adopted for specific patients. After a patient is diagnosed, the first step is to determine whether the patient can be treated surgically. For patients with better physical condition, less severe cirrhosis and small tumor, surgical resection is the first choice. If surgical resection is not possible and the lesion is limited, surgical transvascular treatment and local treatment via surgery can be chosen. For more extensive lesions, interventional treatment can be chosen. Ultrasound-guided percutaneous local treatment is suitable for patients with small lesions, easy to puncture, patients in poor physical condition, unable to tolerate surgery and recurrence. Like gyroscopic knife is especially suitable for patients with obstructive jaundice caused by tumor compression. There should be a correct understanding of the role of cellular immunotherapy and Chinese medicine treatment: as the main treatment for patients in the middle and late stages. As an adjuvant therapy to surgery, radiotherapy and chemotherapy.
3.Prevention
Hepatitis, cirrhosis and liver cancer are the trilogy for the development of liver cancer, so we must do the work of preventing liver cancer before hepatitis.
The following points should be noted in daily life.
(1) Quit bad lifestyle or habits: avoid smoking and alcohol, do not eat moldy food, and eat less cured meat products, etc;
(2) Regularity of life, daily living, outdoor activities, diet and nutrition, physical exercise, regularity;
(3) Avoid infection with hepatitis B and C. This is a long way to go for the prevention and treatment of liver cancer.
(4) Avoid mood swings, maintain an optimistic mental state, and try to avoid or reduce various stimulating activities that cause mood swings;
(5) Avoid overexertion: excessive mental or physical labor can not only lower the resistance of liver cancer patients’ organism, but also aggravate the damage of liver function and lead to deterioration of the disease.
What should be done for patients with hepatitis B virus (HBV) and/or hepatitis C virus (HCV) infection with abnormal liver function?
The relationship between hepatocellular carcinoma and hepatitis B virus (HBV) is firstly discussed; the chance of hepatocellular carcinoma is more than 100 times higher in HbsAg positive patients (hepatitis B virus surface antigen carriers) than in negative ones, and about 85% of liver cancer patients in China are hepatitis B virus surface antigen carriers.
Hepatocellular damage and regenerative nodule formation due to HBV infection are the basis for the development of cirrhosis, which in turn is the basis for the development of hepatocellular carcinoma.
In addition, when HBV infects host hepatocytes in the form of gene integration, it can lead directly to liver cancer without cirrhosis.
From the above trilogy of hepatitis, cirrhosis and liver cancer development, it is easy to see that treatment of hepatitis is the key to prevent liver cancer.
The key to the treatment of hepatitis is antiviral therapy.
Anti-viral for hepatitis C is mainly interferon plus ribavirin, but there is no longer any indication for interferon treatment for patients with cirrhotic decompensated hepatitis C. Early anti-viral treatment can reduce the occurrence of cirrhosis and hepatocellular carcinoma.
For hepatitis B, in addition to interferon, there are also nucleoside (acid) drugs. For hepatitis B patients who have developed cirrhosis and are decompensated, they still need antiviral treatment with nucleoside drugs, which can reduce the occurrence of liver cancer.
Patients with hepatitis are generally examined every three months for liver function, ultrasound, viral load, and alpha-fetoprotein, and at any time if there is weakness or loss of appetite. For AFP >400 μg/L without liver occupancy on ultrasound, CT and/or MRI should be performed after excluding pregnancy, active liver disease, and tumors of embryonic origin in the gonads.
If AFP appears elevated but does not reach the diagnostic level, in addition to the above-mentioned conditions that may cause increased AFP should be excluded, the dynamic changes in AFP should be followed closely, the interval between ultrasound examinations should be shortened to 1 to 2 months, and CT and/or MRI examinations should be performed when needed. And you can receive descending AFP treatment.
V. Summary of the trilogy of hepatitis, cirrhosis and liver cancer
Liver cancer is dangerous, but still controllable and preventable.
1. The focus of prevention is hepatitis vaccination and change of living habits.
2. Patients with hepatitis B and C should be actively treated with antiviral therapy, and blood AFP level and liver ultrasound should be reviewed regularly to achieve early detection, diagnosis and treatment of liver cancer.
3. For patients with liver cancer developed on the basis of hepatitis and cirrhosis, the importance of antiviral treatment should be emphasized, as early antiviral treatment can effectively control the progress of liver cancer.
4. Once liver cancer is diagnosed, reasonable individualized treatment plan for liver cancer should be selected according to the size, location, presence of metastasis inside and outside the liver and patient’s general condition. At present, surgical resection is still the most effective means of liver cancer treatment. Multimodal comprehensive treatment and joint treatment by multidisciplinary team can significantly improve the prognosis of patients. For patients who cannot be operated, radiotherapy, local treatment (radiofrequency, heat therapy, etc.), immune cell therapy, molecular targeted therapy, etc. should be actively adopted.
5.Liver transplantation is an effective means to cure liver cancer, especially for small liver cancer patients with combined cirrhosis and liver function loss, but its indications should be strictly grasped for advanced liver cancer.
6. Regular review after liver cancer surgery is very important, and imaging examination and dynamic detection of AFP changes should be performed regularly.
Finally, let’s join hands to protect the environment and stay away from cancer! Thank you!