Liver Cancer (cont.)
What are the symptoms of liver cancer?
The initial symptoms (the clinical presentations) of liver cancer are variable. In
countries where liver cancer is very common, the cancer generally is discovered at a very
advanced stage of disease for several reasons. For one thing, areas where there
is a high frequency of liver cancer are generally developing countries where access to
healthcare is limited. For another, screening examinations for patients at risk
for developing liver cancer are not available in these areas. In addition, patients from
these regions actually have more aggressive liver cancer disease. In other words, the
tumor usually reaches an advanced stage and causes symptoms more rapidly. In
contrast, patients in areas of low liver cancer frequency tend to have liver
cancer tumors that
progress more slowly and, therefore, remain without symptoms longer.
Abdominal pain is the most common symptom of
liver cancer and usually signifies a very
large tumor or widespread involvement of the liver. Additionally, unexplained
weight loss or unexplained fevers are warning signs of liver cancer in patients with
cirrhosis. These symptoms are less common in individuals with liver cancer in the U.S.
because these patients are usually diagnosed at an earlier stage. However,
whenever the overall health of a patient with cirrhosis deteriorates, every
effort should be made to look for liver cancer.
A very common initial presentation of liver cancer in a patient with compensated
cirrhosis (no complications of liver disease) is the sudden onset of a
complication. For example, the sudden appearance of ascites (abdominal fluid and
swelling), jaundice (yellow color of the skin), or muscle wasting without
causative (precipitating) factors (for example, alcohol consumption) suggests the
possibility of liver cancer. What's more, the cancer can invade and block the portal
vein (a large vein that brings blood to the liver from the intestine and
spleen). When this happens, the blood will travel paths of less resistance, such
as through esophageal veins. This causes increased pressure in these veins,
which results in dilated (widened) veins called esophageal varices. The patient
then is at risk for hemorrhage from the rupture of the varices into the
gastrointestinal tract. Rarely, the cancer itself can rupture and bleed into the
abdominal cavity, resulting in bloody ascites.
On physical examination, an enlarged, sometimes tender, liver is the most
common finding. Liver cancers are very vascular (containing many blood vessels) tumors.
Thus, increased amounts of blood feed into the hepatic artery (artery to the
liver) and cause turbulent blood flow in the artery. The turbulence results in a
distinct sound in the liver (hepatic bruit) that can be heard with a stethoscope
in about one quarter to one half of patients with liver cancer. Any sign of advanced
liver disease (for example, ascites, jaundice, or muscle wasting) means a poor
prognosis. Rarely, a patient with liver cancer can become suddenly jaundiced when the
tumor erodes into the bile duct. The jaundice occurs in this situation because
both sloughing of the tumor into the duct and bleeding that clots in the duct
can block the duct.
In advanced liver cancer, the tumor can spread locally to neighboring tissues or,
through the blood vessels, to elsewhere in the body (distant metastasis).
Locally, liver cancer can invade the veins that drain the liver (hepatic veins). The
tumor can then block these veins, which results in congestion of the liver. The
congestion occurs because the blocked veins cannot drain the blood out of the
liver. (Normally, the blood in the hepatic veins leaving the liver flows through
the inferior vena cava, which is the largest vein that drains into the heart.)
In African patients, the tumor frequently blocks the inferior vena cava.
Blockage of either the hepatic veins or the inferior vena cava results in a very
swollen liver and massive formation of ascites. In some patients, as previously
mentioned, the tumor can invade the portal vein and lead to the rupture of
esophageal varices.
Regarding the distant metastases, liver cancer frequently spreads to the lungs,
presumably by way of the blood stream. Usually, patients do not have symptoms
from the lung metastases, which are diagnosed by radiologic (x-ray) studies.
Rarely, in very advanced cases, liver cancer can spread to the bone or brain.
Next: How is liver cancer diagnosed? »
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