Disease Introduction
Liver cancer refers to malignant tumors occurring in the liver, including 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.
China is a large country of hepatitis B. Most of the liver cancers in China develop on the basis of hepatitis B cirrhosis, and the number of hepatitis C patients is also increasing gradually, and hepatitis B will also develop into liver cancer afterwards. 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 people’s health and lives in China, and its danger should not be underestimated.
Causes of the disease
In general, the causes of primary liver cancer have not been fully elucidated so far, but they have 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 suffered from hepatitis B have 10 times higher chances of developing liver cancer than those who have not suffered from hepatitis B. Long-term clinical observations have revealed that hepatitis, cirrhosis, and liver cancer are a trilogy that constantly migrates and evolves. Recent studies have shown that viral hepatitis related to liver cancer mainly includes hepatitis B (HBV) and hepatitis C (BCV), among which hepatitis B is the most common.
Alcohol: As the saying goes, “drinking alcohol hurts the liver”, drinking alcohol is not a 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 with 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 will be, which will lead to liver fibrosis, cirrhosis and liver cancer. If hepatitis patients drink a lot of alcohol, it will greatly accelerate the formation and development of liver cirrhosis and promote the occurrence of liver cancer.
3.Diet-related factors: The occurrence of liver cancer is closely related to living habits. Long-term consumption of moldy food, food containing nitrosamines and lack of trace elements of selenium are also important factors that promote liver cancer. Aflatoxin B1 is a substance that has been proven to have a clear carcinogenic effect, mainly found in moldy food, such as corn, peanuts, rice and so on.
In addition, when ingesting a large amount of food containing nitrite, nitrite accumulation in the body can not be discharged in time, can be converted into nitrosamines in the body, high nitrite content of food smoked or salt-cured meat products as the most important, has a clear carcinogenic effect. Meanwhile, the occurrence of liver cancer is also related to genetic factors and parasitic infection.
Disease Symptoms
The early manifestations of liver cancer are very atypical and often easy to be overlooked. The following symptoms are available for reference.
1.Significant loss of appetite: abdominal stuffiness, indigestion, sometimes nausea and vomiting;
2.Hidden pain in the right upper abdomen: there may be continuous or intermittent pain in the liver area, and sometimes it may be aggravated by the change of position;
3, weakness, wasting, unexplained fever and edema;
4, jaundice, ascites, itchy skin;
5.Often manifested as nosebleeds, subcutaneous bleeding, etc. Some typical symptoms of hepatocellular carcinoma will only occur when the disease progresses to the middle and late stage, and by then the opportunity of surgery is often lost, so the usual self-examination is very important. 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 upper right side of the 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.
Disease diagnosis
The main tests include serum alpha-fetoprotein (AFP) and liver imaging. AFP is commonly used and the most simple and practical. More than 60% of liver cancer cases in China have serum AFP>400μg/L, 95% of liver cancer patients have background of hepatitis B virus (HBV) infection, 10% have background of hepatitis C virus (HCV) infection, and some patients have overlapping HBV and HCV infection, so if AFP>400μg/L is combined with viral liver disease, it should be highly suspected.
Therefore, if AFP > 400 μg/L is combined with viral liver disease, the possibility of liver cancer should be highly suspected, and imaging-related examinations should be improved as early as possible to achieve early detection, diagnosis and treatment.
Modern medical imaging methods also provide great help to the diagnosis of liver cancer and provide a reliable basis for the localization, characterization, quantification, regularity and treatment plan of liver cancer.
1. The most commonly used is liver ultrasound examination. Ultrasound examination is non-invasive and has no adverse effects on human tissues. It is simple, intuitive, accurate, inexpensive, convenient, non-invasive and widely used for liver cancer screening and post-treatment follow-up.
2.CT has become an important routine means for liver cancer diagnosis. Enhanced CT scan of abdomen can clearly show the size, number, shape, location, boundary, richness of tumor blood supply and relationship with intrahepatic ducts of liver cancer, which is important for further clarifying the diagnosis, differentiating from other benign liver occupations, as well as clarifying the staging and grading of liver cancer, guiding the treatment and judging the prognosis. The image analysis software can also reconstruct the intrahepatic ducts, which can be accurate to the vascular alignment of each hepatic segment, the relationship between tumor and blood vessels, simulate the surgical resection plane, and measure the volume of pre-resected tumor and remaining liver volume, which greatly improves the safety of surgery.
3. Liver-specific MRI can improve the detection rate of small hepatocellular carcinoma. It is also more helpful for differentiating hepatocellular carcinoma from focal hyperplastic nodules in liver and hepatic adenoma, etc. It can be an important supplement to CT examination.
4.PET (Positron Emission Computed Tomography)-CT whole body scan can understand the overall condition and evaluate the metastasis of tumor, and more comprehensively judge the stage and prognosis of tumor, but it is more expensive and generally not as the first choice examination.
5. Selective hepatic arteriography is an invasive examination. Because hepatocellular carcinoma is rich in blood supply and mainly supplied by hepatic artery, therefore, selective hepatic arteriography can clearly show small lesions in liver and tumor blood supply, and after clear diagnosis, iodine oil can be injected to block tumor feeding vessels for treatment purpose. Patients with hepatitis B and C should be reviewed regularly, and if possible, annual checkups should be conducted, and liver ultrasound is the most basic examination.
Disease treatment
Many people are afraid of cancer and think that liver cancer is an incurable disease, but in fact, there is no need to be so alarmed. At present, the prevention and control of liver cancer in China has achieved certain results. When liver cancer is diagnosed, first of all, you should have a proper attitude and treat it correctly and objectively. Because there are many treatment methods for liver cancer, which involve the joint collaboration of many disciplines, if correct and reasonable treatment can be obtained, the long-term efficacy of liver cancer is still relatively ideal. The general principle of liver cancer treatment is early detection and early diagnosis, and the implementation of standardized and comprehensive treatment is emphasized.
Surgery is the preferred treatment method for liver cancer, which can achieve cure through complete removal of tumor tissues. With the increasing advancement of modern liver surgery technology, tumor size is not the key factor limiting surgery. In addition to the size and number of tumors, the ability to resect and the efficacy of resection are also very closely related to liver function, degree of cirrhosis, tumor location, tumor boundary, presence of intact envelope and venous cancer thrombus.
Patients undergoing surgical resection are generally required to have good general condition, i.e. no organic lesions of important organs such as heart, lung and kidney, normal or near normal liver function, specifically objective liver function reserve assessment indexes such as jaundice level, albumin level, indocyanine green retention rate, etc., as well as no extrahepatic tumor metastases and limited tumor site rather than multiple or diffuse distribution. The survival rate of early hepatocellular carcinoma after surgical resection is over 80% in one year and over 50% in five years. 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. Currently, about 4,000 liver transplants are performed in China every year, and the proportion of liver cancer patients is as high as 40%. There are many criteria regarding the indications for liver transplantation for liver cancer, mainly focusing on the size and number of tumors and the presence of vascular invasion and lymph node metastasis.
Collectively, these criteria are relatively consistent for the absence of large vessel invasion, lymph node metastasis and extrahepatic metastasis, but the requirements for the size and number of tumors vary. Our standards have expanded the range of indications for liver transplantation for hepatocellular carcinoma compared with the international standards for liver transplantation. Patients with hepatocellular carcinoma beyond the standards may eventually experience recurrence and metastasis after liver transplantation, but their quality of life and survival time are significantly better than other treatment modalities, so a comprehensive judgment should be made to select the indications based on the ratio of donor-recipient requirements.
Other treatments for liver cancer include radiofrequency ablation, microwave ablation, high-intensity focused ultrasound, arterial chemoembolization, alcohol injection, cryotherapy, radiotherapy, molecular targeted therapy, immunotherapy and Chinese medicine treatment, which are mainly used for patients who cannot receive surgical treatment due to various reasons.
Among them, radiofrequency ablation or microwave ablation treatment for liver cancer uses the thermal effect of microwave or radiofrequency to heat liver tissues through the oscillation of polar molecules in tissues, especially water molecules, so as to cause thermal coagulation in the target area, which is commonly known as burning the tumor, and can achieve a 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., reaching the hepatic artery through arterial placement and injecting embolic agents or anti-cancer drugs, is commonly used for patients with mid- to late-stage hepatocellular carcinoma that cannot be surgically resected. For patients who are not suitable for hepatic artery intervention and certain patients after palliative surgery, combined or sequential chemotherapy can be used, but hepatocellular carcinoma is not effective in chemotherapy and often fails to achieve good therapeutic effect.
The new molecular targeted drug sorafenib, which has been introduced in recent years, can delay tumor progression and can prolong survival to some extent. The results of clinical trials at home and abroad show that sorafenib can prolong patients’ survival time up to 2-3 months and delay disease progression by 73%, but the drug is more expensive and may be accompanied by more serious adverse effects such as diarrhea, rash, hypertension and hand-foot syndrome. The effects need to be further evaluated.
Disease prevention
So far, there is no uniform and fixed treatment plan that can be applied to all liver cancer patients, so the treatment of liver cancer should be individualized, and the treatment of each liver cancer patient requires the complementary and organic combination of surgery, imaging, interventional medicine, medical oncology and other disciplines. 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 particularly important.
For men ≥35 years of age with hepatitis B virus (HBV) and/or hepatitis C virus (HCV) infection and high risk of alcoholism, screening is generally performed at 6-month intervals. For those with AFP >400 μg/L without liver occupancy on ultrasound, CT and/or magnetic resonance imaging (MRI) should be performed after excluding pregnancy, active liver disease, and germinal gland tumors of embryonic origin.
If AFP appears elevated but does not reach the diagnostic level, in addition to the above-mentioned conditions that may cause an increase in 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. If hepatocellular carcinoma is highly suspected, digital subtraction angiography (DSA) hepatic artery iodine oil angiography is recommended. One should be highly alert to symptoms such as anorexia, malaise, poor mental health, prolonged low-grade fever, edema, and pain in the liver area for early detection.
The following points should be noted in daily life.
1, avoid mood swings, maintain an optimistic mental state, should try to avoid or reduce the various stimulating activities that cause mood swings ;
2. Avoid overwork: 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 the deterioration of the disease;
3. Quit bad life style or habits: avoid smoking and alcohol, do not eat moldy food and less pickled meat products, etc;
4, regular life, daily living, outdoor activities, diet and nutrition, physical exercise, regularization;
5.Avoid infection of hepatitis B and C. The prevention and treatment of liver cancer is a long way to go.
Warm tips.
1. Patients with history of hepatitis B and C should have regular review of blood AFP level and liver ultrasound to achieve early detection, early diagnosis and early treatment of liver cancer.
2. For patients with liver cancer developed on the basis of hepatitis, the importance of antiviral treatment should be emphasized, as early antiviral treatment can effectively control the progress of liver cancer.
Once liver cancer is diagnosed, a reasonable individualized treatment plan for liver cancer should be selected according to the size, location, presence or absence of metastasis inside and outside the liver and the 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.
4.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 controlled for advanced liver cancer.
5. Regular review after liver cancer surgery is very important, and imaging examination and dynamic detection of AFP changes should be performed regularly.