Tumors of Liver

Essential Information

Summarize

Liver function and anatomy

        The liver is the largest and heaviest solid organ in the human body, and it is the only organ capable of regeneration. In infancy, a baby's liver weighs more than half of their body weight (11/18)! As children grow, the liver's weight increases more rapidly than their body weight, causing this ratio to gradually decrease. In adults, the liver typically makes up about 1.5% to 2.5% of body weight, and its size and shape can vary from person to person.

 

 

        The liver, which is normally reddish-brown, is located in the upper right side of the abdominal cavity and is mostly covered by the costal arch. The liver is primarily divided into two main lobes, which we distinguish by their positions on either side of the body. The larger, more prominent right lobe is on the right side, while the smaller left lobe is on the left side. The larger right lobe is bordered by the right pleura and the base of the right lung above, the colon in front, and the right adrenal gland and kidney behind. The smaller left lobe is connected to the heart above, with a small part adhering to the anterior abdominal wall, and the stomach below (Figure 1: Medical Illustration). If the liver is flipped over, two additional lobes can be seen between the two main lobes: the higher caudate lobe and the lower quadrate lobe.

 

 

        Figure 1. Schematic diagram of liver anatomy: The liver is located in the upper abdomen near the stomach, intestines, gallbladder, and pancreas, and is divided into left and right lobes. Each lobe is further divided into two parts (not shown in the figure). Bile is produced in the liver and flows through the common hepatic duct and cystic duct to the gallbladder, where it is stored.

 

 

        The liver is mainly functioned by hepatocytes, which occupy 80% of the liver's volume, along with some fascia and other tissues. The liver plays a major role in detoxification and metabolism, so it is generally considered a digestive organ involved in the digestion of the three macronutrients.

Epidemiological

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Etiology & Risk Factors

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Classification & Staging

Types of liver cancer in children

The two main types of liver cancer in children are hepatoblastoma and hepatocellular carcinoma. See the corresponding chapter for details.

Clinical Manifestations

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Clinical Department

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Examination & Diagnosis

Common tests

        At present, the common liver tumor detection methods in clinical practice are as follows:

 

 

 

1. Blood biochemical indicators

 

        Serum alpha-fetoprotein is a common and important method for diagnosing liver cancer. β-HCG is recommended to be tested in children with hepatocellular carcinoma, because some children will show elevated levels of this index.

 

 

 

        Since the liver is involved in a number of metabolic functions and is an important organ for blood storage and filtration, when a tumor is produced in the liver, the chemical substances produced or increased by the tumor can enter the blood. By detecting the level of these chemical substances in the blood, it is possible to initially detect whether there is a possibility of liver tumor.

 

 

 

2. Imaging examination

 

Ultrasound examination: is the most commonly used liver imaging examination method in clinical practice.

 

 

Magnetic resonance imaging (MRI) ​: MRI is not radioactive, but can clearly distinguish the characteristics of different tissues, so MRI has become a common imaging technology for clinical detection, diagnosis and efficacy evaluation of liver cancer.

 

CT: The conventional method of plain scan + enhanced scan (commonly using iodine contrast agent) is generally slightly inferior to MAGNETIC resonance imaging in detecting and diagnosing small liver cancer. The diagnosis of liver cancer by MRI and CT needs to be combined with other signs (such as pseudocapsule) to improve the accuracy of liver cancer diagnosis.

 

 

Digital subtraction angiography (DSA): DSA is an invasive and traumatic examination. During the procedure, contrast agents are injected into the blood vessels, and images taken before and after the injection are compared using a computer. This technique is used for local treatment of liver cancer or for treating acute liver cancer rupture bleeding. DSA provides accurate and objective information about anatomical abnormalities in the blood vessels, the relationship between major blood vessels, and the extent to which the portal vein is infiltrated by liver tumors. It is crucial for assessing the feasibility and thoroughness of surgical resection and for determining the most appropriate treatment plan.

 

 

Nuclear medicine imaging examinations, including Positron Emission Tomography (PET/CT) and Single Photon Emission Computed Tomography (SPECT-CT), involve labeling essential substances in biological metabolism, such as glucose, proteins, nucleic acids, and fatty acids, with short-lived radionuclides like fluorine-18 and carbon-11. After these substances are injected into the body, their distribution during metabolism is monitored to reflect metabolic activity, aiding in diagnosis. SPECT/CT has gradually replaced SPECT as the primary equipment for single-photon imaging in nuclear medicine. By selecting lesions identified through whole-body planar imaging and performing local SPECT/CT fusion imaging, both SPECT and diagnostic CT images of the lesion can be obtained simultaneously, significantly enhancing diagnostic accuracy.

 

 

3. Liver biopsy

 

        A liver biopsy involves using a hollow needle to puncture the liver and obtain tissue samples for histological analysis. Alternatively, fine-needle aspiration can be used for cytological diagnosis. This procedure is typically performed under ultrasound or CT guidance. The primary risks of liver biopsy include bleeding and needle tract seeding. Therefore, it is important to check platelet counts and coagulation function before the procedure. Patients with severe bleeding tendencies, heart and lung diseases, brain disorders, kidney issues, or systemic failure should avoid liver biopsy.

Clinical Management

 tumors of liver

       

 

        The liver is one of the few organs in the human body capable of self-renewal. Liver cells grow very actively, but when this growth becomes excessive and out of control, it can lead to the formation of lumps or even liver tumors. Once a liver tumor develops, symptoms such as a palpable mass in the abdomen, an enlarged and protruding liver area, abdominal pain, and jaundice may occur. However, due to the liver's large size and complex functions, some early-stage liver tumors can be difficult to detect through medical imaging.

 

 

 

Liver tumors can be classified as benign or malignant based on their severity. Benign liver tumors, such as hemangiomas, focal nodular hyperplasia, and hepatic adenomas, typically do not become cancerous; however, malignant liver tumors can develop into liver cancer. Primary liver cancer is caused by the malignant transformation of benign liver tumors, while secondary liver cancer occurs when a tumor first develops in another organ and then spreads to the liver.

 

 

 

        What are the symptoms of liver tumors? How should they be treated after they occur? There is a big difference between adults and children, and it is more worrying when they occur in children.

 

 

 

        Liver tumors in children are rare and mostly malignant, with only about one-third of liver tumors in children being benign. However, because most liver cancer in children lack obvious clinical symptoms and manifestations, and children have poor ability to report, it often leads to missed diagnosis or delay, which may lead to missing the best time for treatment.

 

 

 

        When your child has the following symptoms, parents need to pay attention and go to medical institutions for examination in time.

 

 

 

A painless mass in the abdomen

Abdominal swelling or pain

Unexplained weight loss

 anorexia

 N&V

 

 

        Therefore, it is of great value to make timely and accurate judgment on the nature, location, benign and malignant degree of liver tumors.

 

 

 

 therapeutic method

 

        There are many different treatments available for children with liver cancer, including conventional treatments and some that are currently in clinical trials. Because the number of children with cancer is small, participation in clinical trials requires special attention, and some clinical trials are only open to patients who have not yet received any treatment.

 

 

 

 

1. Surgery

 

        1.1 Common types of surgery

 

 

 

        1.1.1 Cryosurgery

 

        Abnormal tissues and cells are very sensitive to temperature. Cryosurgery uses the characteristics of tissues and cells to destroy and remove abnormal tissues and cells by freezing them locally through instruments. This method is also known as cryotherapy, in which doctors use ultrasound to control the instruments.

 

 

 

        1.1.2 Partial hepatectomy

 

        Remove part of the liver tissue found to be cancerous. This may be a wedge section, or a whole lobe of the liver, or a large portion of the liver along with surrounding normal tissue.

 

 

 

        1.1.3 Total hepatectomy and liver transplantation

 

        When the cancer has not spread beyond the liver, a complete liver removal and transplant can remove the lesion. But while waiting for an organ donor, other treatments may be necessary.

 

 

 

        1.1.4 Resection of metastatic lesions

 

        For those that have spread from the liver to surrounding tissues, such as the lungs or brain, surgical resection of the metastases can be used.

 

 

 

        1.2 Factors affecting the type of surgery

 

 

 

Cancer clinical stage (which stage of cancer the patient is at before surgery)

Size of primary lesion

There is more than one tumor in the liver

Whether it has been transferred into the bloodstream

The level of alpha-fetoprotein (AFP) in the blood

Whether the tumor can be reduced by chemotherapy so that it can be removed surgically

Whether a liver transplant is needed

 

 

        Before surgery, chemotherapy is sometimes administered to reduce the size of the tumor, making it easier to remove. This approach is known as neoadjuvant therapy. On the other hand, even if all visible tumors are removed during surgery, some patients may still need to undergo chemotherapy or radiotherapy post-surgery to eliminate any remaining cancer cells. This treatment, aimed at reducing the risk of recurrence after surgery, is referred to as adjuvant therapy.

 

 

 

 

2. Observation therapy

 

        Observation therapy involves closely monitoring the patient's condition until certain indicators or symptoms appear before treatment is given. In hepatoblastoma, this therapy is usually used in patients with small tumors that do not require surgical removal.

 

 

 

 

3. Chemotherapy

 

        Chemotherapy involves using drugs to control the growth of tumor cells, directly kill cancer cells, or prevent their further division. Chemotherapy drugs are administered orally, intravenously, or by intramuscular injection, entering the bloodstream and reaching cancer cells throughout the body (systemic chemotherapy). If the drugs are placed directly into the cerebrospinal fluid, organs, or body cavities (such as the abdominal cavity), they primarily target cancer cells in the surrounding tissues (local chemotherapy). When more than one anticancer drug is used, it is referred to as combination chemotherapy. The type and stage of cancer determine which chemotherapy method is used.

 

 

 

        Chemoembolization of the hepatic artery, which supplies blood to the liver, is a local chemotherapy method used to treat pediatric liver cancer. Anti-cancer drugs are injected into the hepatic artery through a catheter (a long, thin tube). The drugs are mixed with substances that can block the artery, thereby cutting off the blood flow to the tumor. Most anti-cancer drugs remain near the tumor, while only a small portion reaches other parts of the body. The embolization can be temporary or permanent, depending on the substance used to block the artery. This blocks the tumor's access to oxygen and nutrients from the bloodstream, effectively starving the cancer cells to death. Meanwhile, normal liver tissue continues to receive blood from the portal vein, which comes from the stomach and small intestine.

 

 

 

        The chemotherapy regimen used will vary depending on the type and stage of the tumor.

 

 

 

 

4. Radiotherapy

 

External beam radiation therapy: the use of an external instrument to deliver radiation to cancer tissue;

 

Internal radiation therapy: the radioactive material is enclosed in a needle, ball, particle, wire or catheter and placed directly into or near the tumor so that the high-energy rays can reach the tumor tissue and destroy it.

        The choice of radiotherapy treatment plans also takes into account the patient's tumor type and stage. Hepatic artery radioembolization is a form of in vivo radiotherapy used to treat pediatric liver cancer, similar to the aforementioned' hepatic artery chemoembolization.' The key difference is that it uses microspheres containing a very small amount of radioactive material, which are injected into the hepatic artery via a catheter. These microspheres are mixed with substances that block the artery, cutting off blood flow to the tumor. Most of the radioactive material remains near the tumor to kill cancer cells. This method is typically used to alleviate symptoms and improve quality of life for patients with hepatocellular carcinoma. External beam radiotherapy is usually recommended for patients with hepatoblastoma who cannot be surgically removed or have already spread to other parts of the body.

 

 

 

 

5. Ablation therapy

 

        Ablation therapy can remove or destroy tumor tissue. There are two main types of ablation therapy for liver cancer.

 

 

 

Radiofrequency ablation: A special needle is inserted directly into the skin or through an abdominal incision to reach the tumor site. High-energy radio waves heat the needle and the tumor to kill cancer cells. Radiofrequency ablation is often used to treat recurrent hepatoblastoma.

 

 

Transdermal ethanol injection: Ethanol (pure alcohol) is injected directly into the tumor with a small needle to kill cancer cells. This method may require several treatments in combination. Transdermal ethanol injection is often used in the treatment of recurrent hepatoblastoma.

 

 

 

6. Antiviral therapy

 

        Hepatocellular carcinoma associated with viruses is uncommon in children and adolescents. Studies have shown that the replication level of hepatitis B virus (HBV), the duration of persistent infection, and the degree of liver damage are all positively correlated with the risk of developing hepatocellular carcinoma (https://aasldpubs.onlinelibrary.wiley.com/doi/full/10.1002/hep.28278). Therefore, in treating this type of liver cancer, HBV vaccines (https://www.sciencedirect.com/science/article/pii/S1521691815001249) or antiviral drugs can be used.

 

 

 

Targeted therapy

 

        Targeted therapy is a treatment that uses drugs or other substances to attack specific cancer cells. Compared with chemotherapy or radiotherapy, targeted therapy causes less damage to normal cells. Targeted therapy is being studied more deeply for the treatment of all types of childhood liver cancer.

 

Prognosis

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Follow-up & Review

It is important to have a follow-up after treatment!

 

 

 

        Some tests used to diagnose cancer stages may need to be repeated; tests used to determine whether a treatment is working also need to be repeated. Some clinical trials require regular follow-up after treatment, and the results of these tests will tell you if your child's condition has changed or if the cancer has returned. This is called a follow-up.

 

 

 

        It is important to note that some cured children may develop side effects months or even years after treatment. These side effects are often caused by delayed reactions to damage to tissues and organs caused by surgery or radiotherapy and chemotherapy, and are therefore also called delayed side effects.

 

 

 

        Although most delayed side effects are not life-threatening, they can have a very negative impact on children's health and quality of life. Delayed side effects can be controlled through regular follow-up after treatment and the development of good living habits, so it is important to communicate with your child's doctor about possible side effects of treatment in a timely manner.

 

 

 

        For more information on delayed side effects, see long-term effects of childhood cancer treatment.

Daily Care

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Cutting-edge therapeutic and clinical Trials

Consider participating in a clinical trial

 

        Most of the conventional cancer treatments used today are based on clinical trials that have shown whether new cancer treatments are safe, effective, and superior to existing conventional treatments.

 

 

 

        Clinical trials are conducted in many areas. These can be found in the NCI (National Cancer Institute) Clinical Trials List: http://www.cancer.gov/clinicaltrials, see the Treatment Options section (Treatment Options) for information on ongoing clinical trials.

 

 

 

        Participation in a clinical trial does not necessarily mean that a new approach will be performed. Depending on the study method, participants may be assigned to receive conventional treatment (which has been shown to be safe and effective) or to the new approach group. For some people, participation in a clinical trial may be the optimal treatment option.

 

 

 

        From a broader perspective, patients participating in clinical trials can also help to better develop future cancer treatments. Even if clinical trials do not lead to effective new treatments, they can answer many important questions and help advance cancer research.

References 

 reference material ：

 

1. https://www.cancer.gov/types/liver

 

50.  https://en.wikipedia.org/wiki/Liver

 

 reference material ：

 

1. https://en.wikipedia.org/wiki/Liver_tumor

 

2. https://www.cancer.gov/types/liver/patient/about-adult-liver-cancer-pdq

 

3. http://www.seattlechildrens.org/medical-conditions/cancers-tumors/liver-tumors

 

4.  https://wenku.baidu.com/view/102d5e83e45c3b3566ec8b09.html?rec_flag=default

 

 reference material ：

 

Guidelines for diagnosis and treatment of primary liver cancer 2017

 

 

 

Audit specialists

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