In the U.S.

, the highest frequency of liver cancer occurs in immigrants from Asian countries, where liver cancer is common. The frequency of liver cancer among Caucasians is the lowest, whereas among African-Americans and Hispanics, it is intermediate. The frequency of liver cancer is high among Asians because liver cancer is closely linked to chronic hepatitis B infection

In areas where liver cancer is more common and associated with hepatitis B, the cancer usually develops in people in their 30s and 40s, as opposed to other areas of the world, where they are in their 60s and 70s. Men are much more likely than women to have liver cancer, especially if they have hepatitis and cirrhosis.

 Cancer cells growing and dividing abnormally can originate in nearly any body part, organ or tissue. Cancer that starts in the liver is called primary liver cancer. Hepatocellular carcinoma (HCC) accounts for 70 percent to 85 percent of primary liver cancer cases.9 The next most common is primary cancer of bile duct cells (cholangiocarcinoma). Rare primary liver cancers include cancer of liver (hepatic) blood vessels (hemangioendothelioma), cancer of hepatic connective tissue (angiosarcoma) and cancer of other glands in the liver (adenocarcinoma).

 The cancerous cells lodge in the liver because of the role it plays in filtering the blood. Cancer that spreads to other tissues via the blood or lymphatic system is called secondary or metastatic cancer. Because metastatic cancer has characteristics of its tissue of origin, doctors may treat secondary liver cancer differently than primary liver cancer. This is important, because it means patients will have different treatment options open to them, depending on the type of cancer they have in the liver.

 Diagnosing liver cancer may begin with a blood test to measure the level of alpha fetoprotein (AFP), a protein produced by the liver. An elevated AFP level may be an indication of hepatocellular carcinoma, the most common type of primary liver cancer. If liver cancer is suspected, the doctor may order additional blood tests to measure liver function and determine whether surgery or other treatments are appropriate.

 Doctors first determine the extent of the disease through CT scanning, an accurate method of diagnosing and staging liver cancer. Triphasic CT provides images of the liver, gallbladder, bile ducts, and nearby lymph nodes during three different phases of blood flow through the liver.

 This technique, which may reveal the extent of tumor growth within the liver and surrounding organs and blood vessels, can help determine whether a tumor can be surgically removed.

 A small probe uses sound waves to identify the location and number of tumors, as well as tumor involvement with blood vessels (tumors located near blood vessels may be more difficult to remove). Ultrasound also can be used to distinguish a cancerous mass from a benign tumor.

 A small tissue sample may be obtained for microscopic examination through a technique called fine-needle aspiration (the removal of tissue or fluid for examination under a microscope).

 a thin, lighted tube with a camera on its tip is passed through a small incision in the abdominal wall to view the liver and surrounding organs, and remove tissue samples for biopsy. Laparoscopy can be used to avoid the need for exploratory surgery in some patients.

 Localized and Resectable (the tumor can be surgically removed) In this stage, the tumor, measuring 2 cm or less, is located in a single area of the liver and can be surgically removed.

 Localized and Possible resection In this stage, the cancer is present in one or more locations but did not spread to the adjacent lymph nodes or blood vessels. There are two situations that can occur: - A single tumor measuring either around 2 cm or less, or more than 2 cm is present . - Few tumors measuring 2 cm or less are present, but they are all confined to one liver lobe.

This stage is divided in two sub-stages:

 In this stage, the cancer has not spread to other organs or lymph nodes. However, there are two situations that can occur: - A single tumor larger than 2 cm is present and the blood vessels around the tumor are affected. - There are a few tumors measuring either around 2 cm or less, or more than 2 cm are present in the same liver lobe, and the adjacent blood vessels might be affected.

 In this stage, the tumors can have any size, the blood vessels may or may not be affected, and the cancer has spread to the adjacent lymph nodes without affecting other organs.

Disseminated (diffused) this stage is divided in two sub-stages:

 In this stage, the cancer is present in more than one liver lobes, it may have spread to adjacent lymph nodes, organs (but not the gallbladder) and structures (like peritoneum), and it grew into or around the main blood vessels (portal vein and hepatic artery).

 In this stage, the cancer has spread to distal (situated farthest from origin point) organs and lymph nodes.

 Using a multidisciplinary approach, each case is discussed by a Surgeon, Medical Oncologist, and Radiation Oncologist to develop a treatment plan that is tailored to the patient's individual condition. Treatment modalities that are available at our Liver Cancer Center include the following:

 gold standard in treating primary liver cancer.

 , is a minimally invasive treatment for cancer. It is an image-guided technique that heats and destroys cancer cells. In radiofrequency ablation, imaging techniques such as ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) are used to help guide a needle electrode into a cancerous tumor. High-frequency electrical currents are then passed through the electrode, creating heat that destroys the abnormal cells.

 Embolization involves injecting tiny particles through a small tube, or catheter, threaded into the hepatic artery. The particles block the flow of blood to the tumor, depriving it of the nutrients and oxygen it needs to survive. Embolization also can be used to deliver particles that are laced with chemotherapy drugs, such as doxorubicin.

 This new therapy is called Selective Internal Radiation Therapy also known as SIRT. This technique uses millions of tiny polymer beads or microspheres which contain a radioactive element called yttrium-90 SIR-Spheres microspheres are very small, approximately 32 microns in size, and are about one-third the diameter of a strand of hair. SIRT is usually administered as an outpatient procedure by a specially trained physician known as an interventional radiologist

 to shrink a tumor that cannot be removed with surgery. The aim of the treatment is to try to slow the growth of the cancer and help control symptoms.

 blocking or embolizing the portal venous flow to the diseased segment of the liver and redirecting flow to the part of the liver that is expected to remain after surgery This blockage stimulates hypertrophy (growth) of the non-embolized healthy liver segment and causes the embolized diseased portion of the liver to start to shrink

 Reports about treatment of liver cancer have often included a statement that the disease has a "poor prognosis. Currently, prognosis for life-expectancy is based on statistical data for prior cases that have been documented, analyzed, and summarized In the case of cancer, survival time after the initial diagnosis is measured in median duration to death or in rate of survival past certain marker points, usually 1, 3, and 5 years. Median duration to death is the time at which 50% of patients have died; survival rate indicates the percent of patients surviving at a given time point after diagnosis of the disease

LIVER TRANSPLANT SURGERY During liver transplant surgery, your diseased liver is removed and replaced with a healthy liver from a donor. Liver transplant surgery may be an option for certain people with early-stage liver cancer.

FREEZING CANCER CELLS 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.

CRYOABLATION

LIVER TRANSPLANT

HEATING CANCER CELLS In a procedure called radiofrequency ablation, electric current is used to heat and destroy cancer cells. Using an ultrasound or CT scan as a guide, your surgeon 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.

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.

RADIATION THERAPY
This treatment uses highpowered energy beams to destroy cancer cells and shrink tumors. During radiation therapy treatment, you lie on a table and a machine directs the energy beams at a precise point on your body. Radiation therapy for liver cancer may involve a technique called stereotactic radiosurgery that simultaneously focuses many beams of radiation at one point in the body. Radiation side effects may include fatigue, nausea and vomiting.

TARGETED DRUG THERAPY Sorafenib (Nexavar) is a targeted drug designed to interfere with a tumor's ability to generate new blood vessels. Sorafenib has been shown to slow or stop advanced hepatocellular carcinoma from progressing for a few months longer than with no treatment.

Pain relievers are sometimes called for in liberal doses. Narcotics may have excessive side effects because they are metabolized by the liver, which may not be functioning properly. Non-steroidal anti-inflammatory drugs may be surprisingly effective even against the severe pain associated with liver cancer and may also be helpful if patients are having fevers and sweats related to the cancer. Frequent small meals may be necessary to provide enough nutrition, since an enlarged liver might reduce the capacity of the stomach.

The loss of appetite that frequently accompanies liver cancer may be relieved with a medication called Megace Water pills (diuretics) to relieve fluid in the abdomen or legs may cause significant imbalance in kidney function if not carefully monitored. Nausea can be treated with standard medications, including suppositories. Sleep disturbances are common. Most sleeping pills are metabolized by the liver, however, so they should be used carefully.

Give analgesics as ordered and encourage the patient to identify care measures that promote comfort. Provide patient with a special diet that restricts sodium, fluids, and protein and that prohibits alcohol. To increase venous return and prevent edema, elevate the patients legs whenever possible. Keep the patients fever down. Provide meticulous skin care.

Turn the patient frequently and keep his skin clean to prevent pressure ulcers. Prepare the patient for surgery, if indicated. Provide comprehensive care and emotional assistance. Monitor the patient for fluid retention and ascites. Monitor respiratory function. Explain the treatments to the patient and his family, including adverse reactions the patient may experience

Budd-Chiari syndrome- blockage of the veins that drain blood from the liver, caused by blood clots that form within the veins. Budd-Chiari's syndrome is very rare, and causes liver enlargement, jaundice and liver failure. The onset of Budd-Chiari may be sudden, but is most often occurs more slowly with liver failure occurring over months to years Cancer spread to other organs Internal bleeding: Gastrointestinal bleeding Liver failure Tumor rupture

There is decrease in liver volume, decrease in drug metabolism and altered hepatobiliary function There is decrease ability of the liver to respond to injury Transplanted livers take longer to regenerate in the older than younger adult

Are particularly vulnerable to drug induced hepatitis Decrease in liver functions caused by decrease liver blood flow and enzyme activity result in decrease drug metabolism Decrease ability of the liver to recover from drug-induced injury