Introduction

Hepatoma or hepatocellular carcinoma is a type of cancer originating from the liver. It is also commonly referred as liver cancer. This is not the same as cancer originating from the other organs and are spread to the liver. Hepatoma or Hepatocellular carcinoma is one of the most common cancer known today due to an effective health screening program held worldwide. Globally hepatoma results in between 250,000 to 1,000,000 deaths yearly and it is the third leading cause for cancer- related death in the world.

The main causes for hepatoma are chronic viral infections of the liver ie chronic hepatitis B and C which account for about 80 % of hepatoma cases. The highest prevalence are in the East Asian region such as China, Taiwan, and Hong Kong. Malaysia is included in the mid-range prevalence together with Indonesia and Thailand. Statistic from the National Cancer Registry of Malaysia, 2004 edition revealed that liver cancer was identified in 2.8/100,000 population of the peninsular Malaysia making it one of the top ten main cancer among men.

It has been estimated that 5.24% of the Malaysian population are Hepatitis B-Antigen-positive while 2 % of the population are the Hepatitis C-antibody-positive. Both of hepatitis B and C individuals are at risk of getting hepatoma. The following groups of individuals are at risk of developing hepatoma :

• Chronic hepatitis B (the risk increases with age).
• Chronic hepatitis C with severe fibrosis(scarring)/cirrhosis.
• Liver cirrhosis (liver hardening due to severe scarring or fibrosis)from any cause.

Symptoms and signs

Patients with hepatoma may be asymptomatic in the early stage. Symptoms tend to occur late, therefore individuals who are at risk need to undergo screening.

The symptoms and signs of possible hepatoma :

• Right-sided abdominal pain.
• Lethargy, loss of weight and frequent attack of fever.
• Enlarged liver upon inspection (palpation).
• Jaundice (yellowish discolouration of eyes or skin).
• Bone pain due to cancer spread onto the skeletal system.
• Bleeding from ruptured hepatoma leading to bloody ascites (fluid accumulation in the abdomen due to liver cirrhosis).

In general, the appearance of the above symptoms may signify late stages of hepatoma so regular screening are important for those at risk.

The screening program for hepatoma consist of 6-12 monthly ultrasound of the abdomen and a blood test for the alphafeto protein level.

If the screening test is positive, further radiological test such as CT scan and MRI are needed to confirm the diagnosis and to plan the appropriate treatment.

Complications

Patient with hepatoma may develop the following complications :

• Hematemesis or vomiting of blood due to bleeding from the varices in the oesophagus (due to liver cirrhosis or blocked blood vessels secondary to cancer spread).
• Abdominal pain due to bleeding from hepatoma or enlargement of hepatoma causing pressure to the surrounding structures.
• Abdominal distension due to the enlargement of the hepatoma or ascites (accumulation of fluid in the abdominal cavity).
• Jaundice (yellowish discolouration of eyes or skin) due to failure of the liver in advance stage.
• Hepatic encephalopathy (state of coma due to liver failure) due to failure of the liver in advance stage

Figure 1 : Recent bleeding from Oesophageal varices

Figure 2 : Recent banding of oesophageal varices

Figure 3 : Abdominal distension

Figure 4 : Jaundice (yellowish discolouration of the eyes)

Treatment

There are different modalities to treat hepatoma. Hepatoma that are detected late for example after the onset of symptoms are usually too advanced for the treatment listed below. Early detection by screening before the onset of symptoms is crucial because effective treatment during early phase of hepatoma can lead to healing. The list of treatment options for hepatoma are below :

• Surgical option such as hepatectomy or removal part of liver which has been affected by hepatoma. This method has a high cure rate but sometimes limited by stages of hepatoma, the function of the remaining liver ,overall patient`s condition and the availability of expertise.
• Liver transplantation is considered to be the first line treatment option for patients with single tumours less than 5cm or less & equal to 3cm not suitable for resection
• Radio frequency ablation (RFA) – use a probe to deliver radio frequency directly to the hepatoma to burn the cancerous cells, The procedure is usually carried out by the radiologist.
• Percutaneuous Ethanol Injection (PEI)-direct injection of strong ethanol/alcohol to the hepatoma. The procedure is carried out by the radiologist.
• Transarterial chemoembolisation (TACE) is a form of chemotherapy but the active chemotherapy agents are injected to the blood vessels supplying the hepatoma close to the lesion itself. The procedure is carried out by interventional radiologist.
• Others are systemic chemotherapy, radiotherapy and targeted molecular therapy.

Prevention

Patients with hepatoma are usually those who have already been detected to suffer from chronic hepatitis B or liver cirrhosis. As for that reason, those with risk-factors such as hepatitis B carrier, alcoholic cirrhosis patient or from any other causes should be on follow-up or on proper treatment in a specialist clinic. The family members of hepatoma patient and those with chronic hepatitis B and C should also be screened as they are at risk in getting hepatoma.

Since we know what are the risk-factors for hepatoma, the risk can be reduced by preventing liver scarring (fibrosis) or hardening of the liver (cirrhosis) in those who already have chronic liver diseases. This is usually done by early detection of the liver condition and starting on the appropriate treatment. For example, on individuals with chronic hepatitis B/C treatment with anti-viral agents maybe needed to prevent liver scarring or hardening.

For hepatitis B infection, the infection can be prevented by hepatitis B vaccination.

Rehabilitation

Patients who had undergone hepatectomy or any procedure mentioned before will be subjected to a certain follow-up program. The rehabilitation program will depend on the type of procedure and the overall patient`s condition. All patients will continue to have serial investigations involving blood tests, xrays and doctors follow-up to detect recurrence.

References

1. Data from Malaysian Liver Foundation ( www.liver.org.my )
2. Data from Malaysian society of gastroenterology and hepatology ( www.msgh.org.my )
3. Mohamed R, et al. J Gastroenterol Hepatol 2004 : 19 : 958-969
4. Data from electronic publication ( www.uptodate.com )
5. Management of hepatocellular carcinoma : an update . Hepatology July 2010
6. Data from National Cancer Registry , Malaysia ( December 2004)
7. EASL-EORTC Clinical Practice Guidelines: Management of hepatocellular carcinoma : Journal of Hepatology 2012