Liver Metastases

The liver is the third most common site for breast cancer to spread to after bone and lung. Studies show that first metastases go to the liver in approximately 10 percent of cases. Two-thirds of women with metastatic breast cancer eventually have it spread to the liver. Because blood from all parts of the body must pass through the liver for filtration, cancer cells from other organs and tissues easily reach the liver, where they can lodge and grow into secondary tumors.

Liver metastases are often difficult to detect. Symptoms of liver metastases are subtle at first but become increasing intense over time. The long period between the beginning of the tumor's growth and the first signs of illness is the major reason why the disease has a high mortality rate. Weight loss, loss of appetite, fever, and gastrointestinal disorders may indicate liver metastases. Liver blood tests may first detect cancer in the liver. However, a liver biopsy is necessary to distinguish between cancerous tumors and other abnormalities.

Symptoms of liver metastasis may include:

• Abdominal pain or bloating that continues an extended time without any obvious cause
• ache on the right side below the rib cage
• occasional sharp pain in the right side
• Yellowing of the skin or eyes (jaundice)
• Abnormal liver function blood tests

Imaging studies

Imaging studies are useful in locating specific areas of abnormal tissue in the liver. Liver tumors as small as an inch across can now be detected by ultrasound or computed tomography scan (CT scan). Imaging studies, however, cannot tell the difference between a hepatoma and other abnormal masses or lumps of tissue (nodules) in the liver. A sample of liver tissue for biopsy is needed to make the definitive diagnosis of a primary liver cancer. CT or ultrasound can be used to guide the doctor in selecting the best location for obtaining the biopsy sample.

Chest x rays may be used to see whether the liver tumor is primary or has metastasized from a primary tumor in the lungs.

Liver biopsy

Liver biopsy is considered to provide the definite diagnosis of liver cancer. A sample of the liver or tissue fluid is removed with a fine needle and is checked under a microscope for the presence of cancer cells. In about 70% of cases, the biopsy is positive for cancer. In most cases, there is little risk to the patient from the biopsy procedure. In about 0.4% of cases, however, the patient develops a fatal hemorrhage from the biopsy because some tumors are supplied with a large number of blood vessels and bleed very easily.

Laparoscopy

The doctor may also perform a laparoscopy to help in the diagnosis of liver cancer. First, the doctor makes a small cut in the patient's abdomen and inserts a small, lighted tube called a laparoscope to view the area. A small piece of liver tissue is removed and examined under a microscope for the presence of cancer cells.

Treatment

Treatment of liver cancer is based on several factors, including the type of cancer (primary or metastatic); stage (early or advanced); the location of other primary cancers or metastases in the patient's body; the patient's age; and other coexisting diseases, including cirrhosis. For many patients, treatment of liver cancer is primarily intended to relieve the pain caused by the cancer but cannot cure it.

Surgery

Few liver cancers in adults can be cured by surgery because they are usually too advanced by the time they are discovered. If the cancer is contained within one lobe of the liver, and if the patient does not have either cirrhosis, jaundice, or ascites, surgery is the best treatment option. Patients who can have their entire tumor removed have the best chance for survival. If the entire visible tumor can be removed, about 25% of patients will be cured. The operation that is performed is called a partial hepatectomy, or partial removal of the liver. The surgeon will remove either an entire lobe of the liver (a lobectomy) or cut out the area around the tumor (a wedge resection).

Chemotherapy

Some patients with metastatic cancer of the liver can have their lives prolonged for a few months by chemotherapy, although cure is not possible. If the tumor cannot be removed by surgery, a tube (catheter) can be placed in the main artery of the liver and an implantable infusion pump can be installed. The pump allows much higher concentrations of the cancer drug to be carried to the tumor than is possible with chemotherapy carried through the bloodstream. The drug that is used for infusion pump therapy is usually floxuridine(FUDR), given for 14-day periods alternating with 14-day rests. Systemic chemotherapy can also be used to treat liver cancer. The medications usually used are 5-fluorouracil (Adrucil,Efudex) or methotrexate (MTX, Mexate). Systemic chemotherapy does not, however, significantly lengthen the patient's survival time.

Radiation therapy

Radiation therapy is the use of high-energy rays or x rays to kill cancer cells or to shrink tumors. Its use in liver cancer, however, is only to give short-term relief from some of the symptoms. Liver cancers are not sensitive to radiation, and radiation therapy will not prolong the patient's life.

Liver transplantation

Removal of the entire liver (total hepatectomy) and liver transplantation can be used to treat liver cancer. However, there is a high risk of tumor recurrence and metastases after transplantation.

Other Therapies

Other therapeutic approaches include:

• Hepatic artery embolization with chemotherapy (chemoembolization).
• Alcohol ablation via ultrasound-guided percutaneous injection.
• Ultrasound-guided cryoablation.
• Immunotherapy with monoclonal antibodies tagged with cytotoxic agents.
• Gene therapy with retroviral vectors containing genes expressing cytotoxic agents.

Clinical trials

There are many clinical trials in place studying new types of radiation therapy and chemotherapy, new drugs and drug combinations, biological therapies, ways of combining various types of treatment for liver cancer, side effect reduction, and quality of life. Information on clinical trials can be acquired from the National Cancer Institute at http://www.nci.nih.gov or (800) 4-CANCER