A team of doctors led by Dr Ramcharan Thiagarajan, Consultant Surgical Gastroenterology & Hepato Pancreatic Biliary Surgery, Fortis Hospitals, Bangalore recently performed a high risk surgery on a 60 year old Nigerian to remove a perilous tumor weighing 4 kilos surrounding his liver.

Mr. Giddy Ejeng was suffering from acute abdomen pain and had symptoms of anemia for almost about a year. While consulting with doctors in Nigeria he had got a CT scan done which revealed the giant sized liver tumor. Sensing the high risk involved, doctors at Nigeria referred the case to Fortis Hospitals Bangalore who has the expertise to perform such high risk surgeries. “The surgery performed is called “Trisegmentectomy” where major part of the liver is resected to remove the cancer leaving behind small portion of the normal liver. This surgery is possible because we all know liver regenerates quite fast. Had the surgery not being performed in time, the situation could turn fatal” explained Dr. Ramcharan Thiagarajan.

This was a case of a massive liver resection where two third of his liver was removed due to a gigantic tumor sitting on his tumor. The size of the tumor was unusually big and was impinging on the IVC (inferior vena cava) the large vein that carries de-oxygenated blood from the lower half of the body to the right atrium of the heart. The patient presented with severe abdominal pain and fatigue for four preceding months and loss of appetite. Examination revealed a large mass 20 cm x 15 cm occupying almost the whole of the liver.

“After adequate general anesthesia, the abdomen was opened in layers with an inverted T-shaped incision, detailed inspection of the liver and other abdominal organ was performed. The liver was mobilised to facilitate resection of the mass. A careful dissection of the tumor was performed thereby minimizing collateral tissue damage and blood loss” added Dr. Ramcharan Thiagarajan.

“I believe we should never give up hope even if sometimes everything seems to come to an end. We believed Giddy will be fine and cured completely. So when our doctor in Nigeria told us to take Giddy to India we knew they surely have the expertise to handle the case. May be this faith and conviction helped us in going through the difficult times. Since the surgery there has been a tremendous improvement in my husband’s health. I would like to thank the doctors at Fortis Hospitals for their support and warmth extended to us. They have treated my husband with utmost care” said Mrs. Giddy.

Know about Liver Cancer by – Dr. Ramcharan Thiagrajan, Consultant Gastroenterology & Hepato Pancreatic Biliary Surgery, Fortis Hospitals, Bangalore

What is Liver Cancer?

Liver cancer or hepatic cancer is properly considered to be a cancer which starts in the liver, as opposed to a cancer which originates in another organ and migrates to the liver, known as a liver metastasis, implies uncontrolled transformation and growth of the cells in the liver. The liver is made up of different cell types (for example, bile ducts, blood vessels, and fat-storing cells) and cancerous change can happen to any one of the cell types. However, liver cells (hepatocytes) make up 80% of the liver tissue. Thus, the majority of primary liver cancers (over 90 to 95%) arises from liver cells and is called hepatocellular cancer or carcinoma. Liver cancer can also be classified as primary or secondary. Primary liver cancer is cancer that has originated in the liver such as hepatocellular cancer, cholangiocancinoma. Secondary liver cancer is cancer that has spread to the liver from another location in the body.

Types of Liver Cancer:

There are many forms of liver cancer, although many cancers found in the liver are metastases from other tumors, frequently of the GI tract (like colon cancer, carcinoid tumors mainly of the appendix, etc.), but also from breast cancer, ovarian cancer, lung cancer, renal cancer, prostate cancer, etc. The most frequent, liver cancer is hepatocellular carcinoma (HCC) (also named hepatoma, which is a misnomer because adenomas are usually benign). Patients who develop this cancer normally are in the younger population.

Symptoms of Liver Cancer:

Liver cancers are seen commonly in people who have end stage liver disease or cirrhosis. Liver cancer on such population should be considered if there is sudden deterioration of function over a short period of time. Otherwise liver cancer is detected accidently at the time of another scan and at the time of work-up for elevated liver function tests. Abdominal pain is the most common symptom of liver cancer and usually signifies a very large tumor or widespread involvement of the liver. Additionally, unexplained weight loss or unexplained fevers are warning signs of liver cancer in patients with cirrhosis. Other common symptoms are Anemia

• Back pain
• Jaundice
• Itching
• Weight loss
• Fever

Causes of Liver Cancer

Researchers have identified several known risk factors for liver cancer. Cirrhosis, a condition marked by scarring of the liver, is a major risk factor for liver cancer. It has several causes, with excessive, long-term alcohol consumption being a primary cause. Asia is endemic for hepatitis B and hepatitis B infection confers a hundred time predisposition of liver cancer compared to non-hepatitis B population. Liver fluke infection seen in East Asia and primary sclerosing cholangitis seen commonly in West causes inflammation of bile ducts which predisposes to cholangiocarcinoma. Other conditions causing cirrhosis can also cause liver cancer by the same pathway

Complications associated with liver Cancer:

The following are complications associated with liver cancer:

Internal Bleeding: A growing tumor may block the portal vein, which carries blood from the intestines into the liver. Blood in the vein backs up and tries to return to the heart through smaller blood vessels in the esophagus and stomach. These smaller vessels cannot handle such large amounts of blood and may rupture, causing dangerous internal bleeding in the upper gastrointestinal tract. More rarely, internal bleeding can occur if the tumor itself ruptures, flooding the abdominal cavity with blood.

Metastasis: Metastases occur when cancerous cells travel through the bloodstream and contaminate other organs. Metastasis usually occurs at advanced stages of hepatic cancer and treatment options are severely limited at this stage.

Liver Failure: Once a tumor causes so much damage that the liver can no longer perform its basic functions, liver failure occurs. As the ability to produce many of the body’s essential chemicals, enzymes and nutrients are lost with the onset of liver failure, the condition often proves to be fatal.

Diagnosis of Liver Cancer:

Blood work (such as liver function tests), a hepatitis panel, and tumor markers are often the first steps in diagnosing liver cancer. One specific test, the alpha-fetoprotein tumor maker test (AFP), may be ordered for screening liver diseases. A tumor marker test measures the amount of substances in the body released by cells and organs. Many times, an increase in the level of these substances can indicate certain diseases. The AFP test can indicate liver cancer if there is a spike beyond the accepted range.

Other imaging tests that help diagnose liver cancer include: Ultrasound, MRI and CT Scan. Liver biopsy is not absolutely essential but may be required in certain scenarios. A typical mass seen by CT/MRI with specific pattern on a background of liver cirrhosis or with someone with elevated alpha feto protein is Liver cancer. As explained above sometimes liver biopsy may be required for confirmation. During a liver biopsy, a fine needle in inserted in to the liver through a small incision made in the skin. The biopsy needle retrieves a small sample of liver tissue, and the needle is removed. You are given a local anesthetic for the procedure

Liver Cancer Treatment:

How liver cancer is treated differs, depending on the stage of the disease and the presence of cirrhosis. Surgery is the best option for cure of Liver cancer and everything else is for palliative benefit. Some treatment plans may include standard treatments, such as chemotherapy, while some plans will include clinical trials of new drugs and treatment methods. Regardless of what type of treatment plan you and your doctor choose, you should know all the options that are available.

There are a couple of different options for treating liver cancer surgically. These options include:

Partial hepatectomy: A partial hepatectomy is the surgical removal of the cancerous part of the liver. With advances in surgical techniques, equipments and knowledge the morbidity of liver surgery is negligible in selected centers.

Liver transplant: In this procedure, the diseased liver with the cancer is removed and is replaced with a part or entire healthy liver. A liver transplant is available for select patients, and liver donors can only be family members who meet specific criteria.

Radiofrequency ablation: This is the use of a probe that has tiny electrodes that destroy cancer cells. The probe is inserted through minimally invasive method under ultrasonic guidance and the cancer in the liver is dessicated and destroyed. There are several requirements for this to be effective. This method could be used primarily or as an adjunct to surgery.

Transarterial chemo embolization (TACE): Liver cancer is resistant to the conventional chemotherapy medications and therefore chemotherapeutic medications are selectively instilled into the liver tumour by the same technique used for angiogram. This could be done in one sitting or multiple sittings depending on the size of the tumour and clinical condition of the patient.

Radio active Therapy: Radioactive yttrium in the form of crystals are instilled to the artery supplying the liver tumour exactly the same way as TACE.

Radiation Therapy: Trials are on going on for using radiation in the form of IMRT for palliative benefit for liver cancers

Liver Cancer Prevention:

Some cases of liver cancer can’t be prevented. Factors, such as genetics and involuntary exposure to certain chemicals, are things we can’t really control. There are, however, some simple lifestyle changes we can make to help reduce our risk factor for liver cancer. These simple tips will lead you in the path of reducing your risk factor: Watch Your Alcohol Intake. Drinking excessive amounts of alcohol and alcohol abuse leads to a disease that causes cirrhosis. Having cirrhosis is a risk factor for liver cancer. If you do drink, do so in moderation. Get the Hepatitis B Vaccine for You and Your Children.

Practice Safe Sex. By having unprotected sex, you can contract many diseases, including hepatitis C. Being infected with hepatitis B or C is one of the major risk factors for liver cancer.

Don’t Share Needles. Shared tattoo and illegal drug needles are a source of infection of not only HIV, but also hepatitis C. If you are an IV drug user, never share needles.

Quit Smoking. If you are smoker, now is never a better time to quit. Smoking not only has been linked to liver cancer, it has also been connected with many other types of cancers and diseases as well.