Primary liver cancer

A cancer that starts in the liver is called primary liver cancer. There is more than one kind of primary liver cancer.

Hepatocellular carcinoma (HCC)

This is the most common form of liver cancer in adults. Doctors can classify several subtypes of HCC. Most often these subtypes do not affect treatment or prognosis (outlook). But one of these subtypes, fibrolamellar, is important to recognize. It is rare, making up less than 1% of HCCs and is most often seen in women younger than age 35. Often the rest of the liver is not diseased. This subtype tends to have a better outlook than other forms of HCC.

Intrahepatic cholangiocarcinoma (bile duct cancer)

About 10% to 20% of cancers that start in the liver are intrahepatic cholangiocarcinoma. These cancers start in the cells that line the small bile ducts (tubes that carry bile to the gallbladder) within the liver.

Angiosarcoma and hemangiosarcoma

These are rare cancers that begin in cells lining the blood vessels of the liver.

Hepatoblastoma

This is a very rare kind of cancer that develops in children, usually in those younger than 4 years old. The cells of hepatoblastoma are similar to fetal liver cells.

Secondary liver cancer (metastatic liver cancer)

Most of the time when cancer is found in the liver it did not start there but has spread (metastasized) from somewhere else in the body, such as the pancreas, colon, stomach, breast, or lung. Because this cancer has spread from its original (primary) site, it is called a secondary liver cancer. These tumors are named and treated based on their primary site (where they started).

Symptoms:

Most people don't have signs and symptoms in the early stages of primary liver cancer. When signs and symptoms do appear, they may include:

• Losing weight without trying
• Loss of appetite
• Upper abdominal pain
• Nausea and vomiting
• General weakness and fatigue
• Abdominal swelling
• Yellow discoloration of your skin and the whites of your eyes (jaundice)
• White, chalky stools
• Dark-colored urine.
• An enlarged liver, felt as fullness under the ribs on the right side

Risk factors:

Factors that increase the risk of primary liver cancer include:

• Chronic infection with HBV or HCV. Chronic infection with the hepatitis B virus (HBV) or hepatitis C virus (HCV) increases your risk of liver cancer.
• Cirrhosis. This progressive and irreversible condition causes scar tissue to form in your liver and increases your chances of developing liver cancer.
• Certain inherited liver diseases. Liver diseases that can increase the risk of liver cancer include hemochromatosis and Wilson's disease.
• Diabetes. People with this blood sugar disorder have a greater risk of liver cancer than those who don't have diabetes.
• Nonalcoholic fatty liver disease. An accumulation of fat in the liver increases the risk of liver cancer.
• Exposure to aflatoxins. Aflatoxins are poisons produced by molds that grow on crops that are stored poorly. Crops, such as grains and nuts, can become contaminated with aflatoxins, which can end up in foods made of these products.
• Excessive alcohol consumption. Consuming more than a moderate amount of alcohol daily over many years can lead to irreversible liver damage and increase your risk of liver cancer.

Diagnosis:

Your healthcare provider may suspect you have liver cancer if they find liver cancer signs and symptoms during your physical examination. They may order the following tests to learn more:

• Blood tests: Healthcare providers may do blood tests for cancer, such as a liver function test, to check on liver enzymes and liver functions. They may test for a tumor marker called alfa-fetoprotein (AFP). High AFP levels may indicate liver cancer.
• Ultrasound (sonography): This test provides pictures of your soft tissue structures. Healthcare providers use ultrasound to look for liver tumors.
• Computed tomography (CT) scan: This takes detailed images of your liver, providing information about liver tumor size and location.
• Magnetic resonance imaging (MRI): This test produces very clear images of your body using a large magnet, radio waves, and a computer.
• Biopsy: Healthcare providers remove liver tissue to look for signs of cancer. Biopsies are the most reliable way to confirm a liver cancer diagnosis. A biopsy is not always needed to diagnose liver cancer. Sometimes doctors can diagnose liver cancer based on the results of imaging tests such as CT scans and MRI.

• Endoscopic retrograde cholangiopancreatography (ERCP): ERCP uses an endoscope and a catheter (thin, flexible tubes) to examine your bile ducts.
• PET scan: This procedure is used to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.

Treatment:

Treatments for primary liver cancer depend on the extent (stage) of the disease as well as your age, overall health and personal preferences.

Surgery:

Operations used to treat liver cancer include:

• Surgery to remove the tumor. In certain situations, your doctor may recommend an operation to remove the liver cancer and a small portion of healthy liver tissue that surrounds it if your tumor is small and your liver function is good. Whether this is an option for you also depends on the location of your cancer within the liver, how well your liver functions and your overall health.
• Liver transplant surgery. During liver transplant surgery, your diseased liver is removed and replaced with a healthy liver from a donor. Liver transplant surgery is only an option for a small percentage of people with early-stage liver cancer.

Localized treatments:

Localized treatments for liver cancer are those that are administered directly to the cancer cells or the area surrounding the cancer cells. Localized treatment options for liver cancer include:

• Radiofrequency ablation uses electric current to heat and destroy cancer cells. Using an imaging test as a guide, such as ultrasound, the doctor inserts one or more thin needles into small incisions in your abdomen. When the needles reach the tumor, they're heated with an electric current, destroying the cancer cells. Other procedures to heat the cancer cells might use microwaves or lasers.
• Cryoablation uses extreme cold to destroy cancer cells. During the procedure, your doctor places an instrument (cryoprobe) containing liquid nitrogen directly onto liver tumors. Ultrasound images are used to guide the cryoprobe and monitor the freezing of the cells.
• Injecting alcohol into the tumor. During alcohol injection, pure alcohol is injected directly into tumors, either through the skin or during an operation. Alcohol causes the tumor cells to die.
• Injecting chemotherapy drugs into the liver. Chemoembolization is a type of chemotherapy treatment that supplies strong anti-cancer drugs directly to the liver.
• Placing beads filled with radiation in the liver. Tiny spheres that contain radiation may be placed directly in the liver where they can deliver radiation directly to the tumor.

Radiation therapy:

• This treatment uses high-powered energy from sources such as X-rays and protons to destroy cancer cells and shrink tumors. Doctors carefully direct the energy to the liver, while sparing the surrounding healthy tissue.
• Radiation therapy might be an option if other treatments aren't possible or if they haven't helped. For advanced liver cancer, radiation therapy might help control symptoms.

Targeted therapy:

• Targeted drug treatments focus on specific abnormalities present within cancer cells. By blocking these abnormalities, targeted drug treatments can cause cancer cells to die.
• Many targeted drugs are available for treating advanced liver cancer.
• Some targeted therapies only work in people whose cancer cells have certain genetic mutations. Your cancer cells may be tested in a laboratory to see if these drugs might help you.

Immunotherapy:

Immunotherapy uses your immune system to fight cancer. Your body's disease-fighting immune system may not attack your cancer because the cancer cells produce proteins that blind the immune system cells. Immunotherapy works by interfering with that process.

Immunotherapy treatments are generally reserved for people with advanced liver cancer.

Chemotherapy:

Chemotherapy uses drugs to kill rapidly growing cells, including cancer cells. Chemotherapy can be administered through a vein in your arm, in pill form or both. Chemotherapy is sometimes used to treat advanced liver cancer.

Palliative care:

Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness. Palliative care specialists work with you, your family and your other doctors to provide an extra layer of support that complements your ongoing care. Palliative care can be used while undergoing other aggressive treatments, such as surgery, chemotherapy or radiation therapy.

When palliative care is used along with all of the other appropriate treatments, people with cancer may feel better and live longer.

Palliative care is provided by a team of doctors, nurses and other specially trained professionals. Palliative care teams aim to improve the quality of life for people with cancer and their families. This form of care is offered alongside curative or other treatments you may be receiving.

Liver cancer care at Shefa-El Orman Hospital:

Shefa-El Orman experts have the knowledge, experience and resources to provide you with a personalized treatment plan that takes all of your concerns into consideration.

At Shefa-El Orman, experts in oncology, hepatology, surgery, radiology, pathology, radiation oncology and transplant work together to form a team of specialists to provide comprehensive care for those with liver cancer. Pediatric experts provide care for children with liver cancer. Other professionals are included as needed.

Shefa-El Orman Hospital equips its doctors with the latest technology and specialized techniques to improve care.

The range of treatments offered to people with liver cancer includes surgery, such as liver transplant, and ablative therapies, such as radiofrequency ablation and cryoablation. Other treatments include chemotherapy, radiation therapy, and biological therapy.

 Shefa-El Orman doctors have extensive experience caring for people with hepatocellular carcinoma and other, rarer types of liver cancer. Each year, Shefa-El Orman doctors care for more than 1,500 people with primary liver cancer.

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• Diagnosis:

The program includes:

• Initial presentation in the clinic
• clinical history taking
• physical examination
• laboratory tests:
• complete blood count
• general urine analysis
• biochemical analysis of blood
• tumor markers (AFP, CA 19.9, CEA).
• inflammation markers (CRP, ESR)
• blood coagulation analysis (aPTT, PT, INR)
• ultrasound of the abdomen, CT/MRI scans (if clinically indicated)
• FNA liver biopsy under CT or ultrasound control (if clinically indicated)
• Histopathological examination and immunohistochemistry.
• nursing services
• services of all leading experts
• explanation of individual treatment plan

Required documents

• Medical records
• MRI/CT scan (not older than 3 months)
• Biopsy results (if available)

Price from: On request

Type of program: Outpatient

Expected duration of the program: 5 days

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• Chemotherapy, targeted therapy and immunotherapy:

The program includes:

• Initial presentation in the clinic
• case history collection
• general clinical examination
• laboratory tests:
• complete blood count
• biochemical analysis of blood
• tumor markers
• indicators of inflammation
• indicators of blood coagulation
• abdominal ultrasound, CT / MRI of chest and abdomen (if indicated clinically )
• 1 course of chemotherapy
• consultations of related specialists
• symptomatic and specific treatment
• the cost of essential medicines and materials
• nursing services
• control examinations
• full hospital accommodation (if indicated according to treatment protocol and patient general condition)
• developing further treatment plan

How program is carried out

During the first visit, the doctor will conduct a clinical examination and go through the results of previous laboratory tests and instrumental examinations. After that, you will undergo an additional examination, including laboratory assessment of liver and kidney function, ultrasound scan. Based on the received results, the doctor will elaborate the chemotherapy regimen. If necessary, related medical specialists will be involved in the elaboration of a treatment regimen (tumor board).

Chemotherapy is carried out as the inpatient procedure, with mandatory admission to the hospital. After the placement of a venous catheter, you will stay in a comfortable ward. An infusion system will be connected to the catheter, through which the required drug or a drug combination will be administered. All drugs are administered by intravenous drip, slowly, so the total duration of the infusion can be up to several hours. All this time, doctors and nurses will monitor your health condition closely.

After the course of chemotherapy, you will stay under medical supervision in the ward for a few more hours. After the completion of the chemotherapy course and control examinations you will receive the medical report with detailed recommendations regarding further treatment. In the future, you will be able to have a distant consultation with your attending physician and schedule the next course of chemotherapy, if necessary.

Required documents

• Medical records
• MRI/CT scan (not older than 3 months)
• Biopsy results (if available)

Price from: 

Type of program: Inpatient

Expected duration of the program: 5 days

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• Surgery:

The type of the operation will be explained by your treating physician depending on your medical condition.

The program includes:

• Initial presentation in the clinic
• clinical history taking
• physical examination
• laboratory tests:
• complete blood count
• biochemical analysis of blood
• TSH-basal, fT3, fT4
• tumor markers (AFP, CEA, CA 19.9)
• indicators of inflammation
• indicators blood coagulation
• ultrasound, CT/MRI scanners (if indicated clinically)
• guided biopsy and histopathology with immunohistochemistry (if indicated clinically)
• preoperative care
• operations:
• atypical or wedge liver resection
• unilateral hepatectomy.
• microbiological and histological examination
• symptomatic treatment
• cost of essential medicines
• nursing services
• stay in the hospital with full board 
• full hospital accommodation
• elaboration further recommendations

Required documents

• Medical records
• MRI/CT scan (not older than 3 months)
• Biopsy results (if available)

Service

• Interpreter up to 15 hours
• Translation up to 10 pages
• Visa support

Price from: on request

Type of program: Inpatient

Expected duration of the program: 10 days

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• Intervention radiology:

The program includes:

• Initial presentation in the clinic
• clinical history taking
• review of medical records
• physical examination
• laboratory tests:
• complete blood count
• biochemical analysis of blood
• TSH-basal, fT3, fT4
• tumor markers (AFP, CEA, СА-19-9)
• inflammation indicators (CRP, ESR)
• indicators of blood coagulation
• abdominal ultrasound scan, CT/MRI scans (if indicated clinically).
• preoperative care
• operative: the selection between the different types of operations according to your clinical conditions and well be explained by the treating physician.
• Percutaneous embolization (coiling) or chemoembolization (for one session).
• Using beads or microspheres (for one session).
• Alcohol or radiofrequency tumor ablation (for one session).
• Microwave tumor ablation (for one session).
• symptomatic treatment
• cost of essential medicines
• nursing services
• elaboration of further recommendations

How program is carried out

During the first visit, the doctor will conduct a clinical examination and go through the results of the available diagnostic tests. After that, you will undergo the necessary additional examination, such as the assessment of liver and kidney function, ultrasound scan, CT scan and MRI. This will allow the doctor to determine which vessels are feeding the tumor and its metastases, as well as determine how well you will tolerate the procedure.

Chemoembolization begins with local anesthesia and catheterization of the femoral artery. The thin catheter is inserted through a few centimeters long incision of the blood vessel. The doctor gradually moves the catheter to the vessel feeding the primary tumor or its metastases. The procedure is carried out under visual control, an angiographic device is used for this. The vascular bed and the position of the catheter in it are displayed on the screen of the angiograph.

When the catheter reaches a suspected artery, a contrast agent is injected through it. Due to the introduction of the contrast agent, the doctor clearly sees the smallest vessels of the tumor and the surrounding healthy tissues on the screen of the angiograph. After that, he injects emboli into the tumor vessels through the same catheter.

Emboli are the spirals or the liquid microspheres. The type of embolus is selected individually, taking into account the diameter of the target vessel. When carrying out chemoembolization, a solution of a chemotherapy drug is additionally injected into the tumor vessel. Due to the subsequent closure of the vessel lumen with an embolus, the chemotherapy drug influences the tumor for a long time. In addition, the drug does not enter the systemic circulation, which allows doctors to use high doses of chemotherapeutic agents without the development of serious side effects. Chemoembolization leads to the destruction of the tumor or slowing down its progression.

After that, the catheter is removed from the artery. The doctor puts a vascular suture on the femoral artery and closes it with a sterile dressing. During chemoembolization, you will be awake. General anesthesia is not used, which significantly reduces the risks of the procedure and allows performing it on an outpatient basis, avoiding long hospital stay.

After the first procedure, you will stay under the supervision of an interventional oncologist and general practitioner. If necessary, you will receive symptomatic treatment. As a rule, a second chemoembolization procedure is performed in 3-5 days after the first one in order to consolidate the therapeutic effect. After that, you will receive recommendations for further follow-up and treatment.

Required documents

• Medical records
• MRI/CT scan (not older than 3 months)
• Biopsy results (if available)

Price from: on request (per session)

Type of program: Outpatient

Expected duration of the program: 6 days