Liver Tumors: Causes, Diagnosis, and Treatment
Liver tumours and its implications and modalities of treatment. So basically, liver tumour means a tumour in the liver, where there are multiple causes for it, the most common causes now people are facing is fatty liver, fatty liver induced NASH or nonalcoholic steatohepatitis and leading to liver cirrhosis and liver tumours.
The first common cause is fatty liver, other causes also are there like alcohol-induced liver cirrhosis and liver tumours, hepatitis B, hepatitis C, or there are some idiopathic causes where nobody knows why the tumour comes in the lever. Where there is a damaged liver, they are more bound to form liver tumours or liver SOL in the background of a bad liver disease. Liver tumours can also form in a normal, healthy liver, so the causes are varied: alcohol, tobacco smoking, spicy oily diet, hereditary, genetic, environmental, some people working in chemical factories, there are multiple varied reasons for that. But mainly the thing which is happening is fatty liver or fatty liver induced liver damage which leads to N-A-S-H or NASH and liver tumour, these is sequence.
Second thing is alcohol is very rampant in lower and middle socioeconomic class where they drink binge of alcohol and therefore the liver gets damaged within a span of 20 years and then the liver becomes nodular, forms cirrhosis, and then the tumour starts popping in the liver. So these are the two main causes and there are multiple other causes, so how to diagnose them early, how to prevent this from happening because we know prevention is better than cure. So first thing we should do, whenever you have a fatty liver, don’t panic, there are other sides of the story also. “Fatty liver, fatty liver,” people come to me with reports of raised SGPTs, just fatty liver, panic, they say we have got fatty liver. I say, fatty liver is the first early stage of a liver disease but that’s not the only panicking point, so if we do a sonography of 100 people, 90% people will have fatty liver or maybe somewhere close to that figure. But it has implication only if some other factors are there, for example, obesity is there, patient has high lipid profile, diabetes, blood pressure, and raised SGOT, SGPT are there, then they have to bother about fatty liver, otherwise fatty liver is a very common sonography finding seen in all sonography done for multiple varied reasons, for health checkups or for non-health checkups or for when the patient has pain in the abdomen, we do sonography and find fatty liver, so fatty liver is just a diagnosis on paper but implications may or may not be there for that person.
So if the patient has fatty liver and if the LFTs are normal, if there are no symptoms, you can just ignore fatty liver. Just what you can do is cut down on cholesterol and fat in the diet, go on more fibre and protein diet, fatty liver will be reduced with the reduction in tummy fat and reduction in weight. But if the SGOT-SGPT are high and there is significant grade 2 or grade 3 fatty liver then there are issues that fatty liver can lead to liver cirrhosis over a period of 10, 15 or 20 years and then lead to liver tumour in that, so that is the implication of a fatty liver.
Secondly, alcohol, if you keep drinking/binging alcohol, what happens the liver damages, liver cells damage because of constant injury to the liver because of the alcohol. So you will always find that the SGOT-SGPT, they are always higher than normal and then the patient will start developing giddiness, weakness, not eating well, there is severe acidity because of alcohol. So first thing is to stop alcohol and if the patient also has other factors like obesity, raised cholesterol, raised BP, definitely stop alcohol and also reduce some weight, so that liver damage can halt or some liver can come back or liver regeneration. There is only one organ in the body which can regenerate is the liver. So if you stop alcohol, the liver can regenerate and come back to at least near normal, if not normal. So these two are the primary factors, fatty liver and alcohol induced liver disease which can lead to liver cirrhosis and in the long run can lead to liver tumours.
So as we say “prevention is better than cure“, always treat at the early stage, don’t treat when it is already a liver tumour there. So when you find a sonography report which says there is something in the liver, some mass in the liver, some SOL in the liver, always investigate further by doing a triphasic liver CT scan, where you can actually know whether it is a liver haemangioma, it is a benign liver adenoma or benign liver tumour, or it is a hepatocellular carcinoma or a cancer of the liver. So when you get that, don’t stop at sonography, get your all basic blood tests done: CBC, liver function tests, creatinine level, and go for a triphasic liver CT scan which is done in a very good CT scan 64-Slice CT or a 128-Slice CT Scan Centre. Once we have diagnosed that then we have to treat that, so we have to do some tumour markers called alpha-fetoprotein, CA19-9, where we come to know the nature of the liver tumour. If it is a haemangioma, lot of people come with the report of small 2-3 centimetre haemangioma in the liver, they panic, they say “We have a liver tumour,” it’s not so. A haemangioma is a congenital condition where there was a blood swelling in the liver and you panic. So, haemangioma should not be treated unless they grow large in size, suppose they grow more than 10 cm then there is a small chance of bleeding internal or it can rupture and therefore haemangiomas more than 10 centimetres should be operated, especially if there is pain associated with the haemangioma. So, treatment is removing that haemangioma, removing that part of the liver which carries the haemangioma, so it’s called a benign lesion and not a tumour. Benign tumour is a hepatic adenoma, especially happens in those who are consuming oily, which an lead to do surgery and removing that tumour.
HCC or adenocarcinoma is called cancer of the liver or adenocarcinoma of the liver or hepatocellular carcinoma, to be very specific, so that is what is liver cancer, which can be alarming. So they can develop in a normal liver, then treatment is remove that part of the liver, question is over. But in a cirrhotic liver, we cannot remove that big portion of the liver, so anything more than 5 cm, 6 cm in the liver cirrhosis cannot be removed surgically, we have to use alternative methods of treatment like trans-arterial chemoembolization or RFA of the tumour, where we burn the tumour and cause less injury to the liver because this liver will fail if you go for operation. Other treatment for a liver tumour with liver cirrhosis is to change the liver, so that the patient doesn’t get another liver tumour in the damaged liver later, so liver transplantation is done when there is a liver HCC and there is a background of liver cirrhosis because of hepatitis B, C, alcohol, or NASH. Treatment is liver transplantation where we change the liver, remove the tumour and remove the bad liver and we get a new lease of life for the patient, very less likely there is a chance that the patient get another liver cancer later in your life.
So this is basically a protocol where we find a liver tumour, diagnose the liver tumour early and treat the liver tumour. Sometimes the patients comes so late, they are full of ascites, the liver tumour of size 20 cms, 30 cms, we cannot do anything, just we have to give some symptomatic treatment, and the normal life span of such a patient who has liver cirrhosis and a big liver tumour with metastases everywhere is 3-4 months or maximum 6 months. So always you should diagnose early, come to the consultant early, diagnose the things early, and then immediately go for the treatment.
Now treatment based of a liver tumour, it depends on, they require a fitter patient. surgically, so you should have maybe more also 70-80 years of age also. So looking at the patient profile and what the patient has and is the patient really fit for surgery, we subject the patient for surgical removal of a liver tumour. Liver transplantation can be done roughly up to the age of 65-70 years of age, beyond 70 years of age, it’s pointless doing a liver transplantation because the morbidity/mortality increases significantly after the age of 70 because they cannot tolerate such a morbid procedure of 24 hrs, but of course results are there, even patients have been operated for liver tumours in background even after the age of 70 and they have survived. So the family also has to take a major decision whether you are willing to push the patient for such a big surgery where they may be 1% or 2% chance of mortality and therefore we have to take a wiser decision dealing with the liver tumour.
So no point talking about treatment but you should always prevent than cure, so prevention is better than cure, this is always a gold standard treatment. So how will you prevent a liver tumour? I told you the factors are fatty liver, alcohol, obesity, so best is to avoid all these and you should always have more of fibre and protein in diet so that you don’t get a fatty liver. You should obviously not take alcohol, all the vices should be stopped, smoking and tobacco are as dangerous as alcohol, so if you control all these factors, your liver will always remain healthy. Liver has a very good capacity of regeneration, out of 100% liver we have, 30% is good enough for survival but that doesn’t mean that you damage the rest of the 70%. So 30% liver is good for survival.
Therefore, if you are taking alcohol, you have got liver cirrhosis don’t get disheartened, you can just stop alcohol, you may get up to 45 to 50% which is good enough for your survival for your whole life. So cut down all the factors which cause fatty liver, and therefore, you can prevent fatty liver induced liver cirrhosis, induced liver tumour. Just cut down on the cholesterol, cut down on the spicy, oily food, cut down on milk which is high, which is rich in cholesterol. Eat lot of protein and fibre in diet, egg whites or protein shakes are okay, but you have to have a healthy protein fibre diet, so that will prevent NASH and induced liver cirrhosis and liver tumours.
There are other factors like hepatitis B and C which can induce liver cirrhosis, so diagnose this conditions early. Normally, hepatitis B and C tests are done whenever you go for any surgical procedure and these patients normally come with a report that they had gone for some check-up and they found that they are Hep B or Hep C positive. So, Hep B and Hep C are blood borne diseases, they can come to you only when some contaminated blood has entered your body or from intercourse, so you have to be sure that you are vaccinated, so now we have available Hepatitis B Vaccine. So if you are on a field where you are getting touch with blood products daily like paramedics or medical field or doctors, they should be vaccinated ideally. Hepatitis B vaccination is a norm now in children when they are newborn. Incidents of hepatitis B and C is coming down drastically now because the blood that is transfused from one person to another is always checked and we see that there is no hepatitis B or C virus in that. So the incidents of hepatitis B and C is decreasing but still it is prevalent and therefore you should be very careful about hepatitis B and C because once diagnosed, they never will leave your system and you should be careful in treating them at the right time, so that they don’t cause liver cirrhosis in the future.
So this was all about liver tumours, the causes and the treatment options available. At Currae Hospital, we have all the facilities of doing a liver surgery and treatment of a liver tumour, be it liver resection or be it RFA or microwave of a liver tumour. Normally, we require a very good ICU setup to deal with liver tumours for which the facilities are available. This was all about liver tumours, haemangiomas, HCC, liver cirrhosis, treatment of fatty liver, diagnosis of fatty liver and alcoholic hepatitis.
Dr. Sachin Wani
Consultant – Gastroenterologist, Currae Hospitals