Liver cancer is the sixth most common cancer and the second highest cause of cancer deaths in the world. While incidences of liver cancer can be found in every region, it is most common in Sub-Saharan Africa and Asia. Though it is primarily caused by hepatitis virus infections, liver cancer has various causes depending on the area in which it is originating. Due to the expensive nature of treatments, prevention and reduction of risk factors should be the primary methods of combating liver cancer. Prevalence of Liver Cancer Nearly 85% of cases occur in Southeast Asia, the Pacific, and Sub-Saharan Africa. Over half of these cases occur in China alone and the highest incidence rate is in Mongolia at 78.1 cases per every 100,000 people (Ferlay, et al., 2013). These are the results of infections with hepatitis viruses B (HBV), C (HCV) or a combination of infections with HBV and hepatitis D virus (HDV). Other countries with high levels of liver cancer (more than 20 cases per 100,000 people) include Taiwan, Korea, Laos, Thailand, Vietnam, The Gambia and Guinea (Ferlay, et al., 2013). Incidence of liver cancer is also much higher in men than in women. Incidence of liver cancer are nearly 2 to 3 fold higher in men in almost every country reporting liver cancer incidences.

Most symptoms of liver cancer are not apparent until the later stages of the disease. The most common liver cancer symptoms include: Weight loss Loss of appetite Feeling satiated Nausea or vomiting Enlarged liver Enlarged spleen Abdominal pain Abdominal swelling Itchiness Jaundice (a yellowing of the skin and eyes). Liver tumors may also produce hormones that influence other organs. Some of their effects include hypercalcemia (high blood calcium levels), hypoglycemia (low blood sugar levels), gynecomastia (breast enlargement) or testicle shrinkage, erythocyosis (high red blood cell count), and high cholesterol.  These secondary cancer outcomes can have severe side effects on the patient including confusion, constipation, weakness, muscle issues, fatigue, fainting, and blushing.

There are several risk factors for liver cancer. Interestingly, these risk factors vary based on prevelance. In areas where liver cancer is most common, the risk factors are primarily infections from food contaminated with mycotoxin aflatoxin B1 and hepatitis B. In areas where liver cancer is less common, the major risk factors are hepatitis C virus infection, excessive alcohol consumption, obesity and diabetes. Hepatitis B Virus Chronic infection with HBV infection is the number one cause of HCC in Asia and Africa. Hepatitis B infection results from infection with the Hepatitis B Virus, which is transmitted by blood and body fluids. Chronic infection with HBV can result in cirrhosis and even liver cancer. Of the two billion people that have been infected with HBV, about 18% are chronically infected. Development of liver cancer can occur within 5 to 75 years after infection. HBV is transmitted through bodily fluids such as blood, semen and vaginal fluids. HBV was labeled as a human carcinogen in 1994 by the International agency for Research on Cancer (IARC). The risk of a hepatitis B infection becoming chronic is highly influenced by the age of infection. People infected during infancy or their childhood are more likely to develop chronic hepatitis B.

According to the PDQ Adult Treatment board, patients with large liver lesions more than 1cm in diameter who are also at risk for HCC should undergo testing involving imaging, biopsy or both in order to generate a proper diagnosis. Lesions smaller than 1cm in high-risk patients will be closely monitored, but will not undergo further testing for diagnosis since it is likely a cirrhotic lesion. There are many negative predictors of survival from liver cancer. These include vascular invasion, or when the cancer cells escape into the blood vessels, fibrosis or the formation of excess connective tissue in an organ (in this case the liver) and cirrhosis. Tumor size is also a negative predictor. Imaging : Lesions are imaged using either triple-phase, contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI). Using CT or MRI, the liver is imaged in two different phases; the arterial phase and the venous phase. Prior to imaging, a contrast media is injected into the patient’s veins to enhance the contrast of various structures in the different phases. Because HCCs only contain blood from the arteries while the rest of the liver has arteries and veins, the contrast media is more highly concentrated in the HCC.

Early Stage Liver Cancer Treatment Early stage liver cancer (stages 0, A and B) consists of localized HCCs presenting as single masses in one area of the liver or multiple small tumors (3 tumors or less with diameters of 3cm or less). These tumors do not display any vascularization and make up 30% of HCC cases. Early stage liver cancer is typically treated by surgical resection, liver transplantation or ablation which is a minimally invasive treatment that destroys tumor tissue. Late Stage Liver Cancer Treatment Advanced stages of liver cancer (stages C and D) are typically treated with transarterial embolization (TAE), transcatheter arterial chemoembolization, targeted therapy and radiation therapy. Surgical Liver Resection Strategies used to treat liver cancer depends on multiple factors including liver function, the extent and location of the tumor, and the patients overall health. While no large studies have been done that compare treatment strategies for early stage liver cancer, the gold standard for treating HCC is surgical liver resection and liver transplantation. Patients with localized HCC that will still have sufficient liver functioning after its removal will usually undergo surgical resection. Liver Transplant For patients with extensive cirrhosis, multiple small (smaller than 3cm) lesions, or patients that would have severely impaired liver function if they underwent resection, liver transplantation may be the best option.