Liver cancer is rising sharply. The biggest internal organ in the human body, and one of the most important to life, is being threatened by the increase in unhealthy lifestyles being observed across the world. In the US, Europe and even in developing countries in the Middle East and Asia, unhealthy life choices, partly blamed on globalization, are on the up.1
Speaking to the Pulse this week, Professor Valérie Vilgrain, Professor of Radiology, Chair of the department of diagnostic and interventional radiology at the Beaujon Hospital (Assistance Publique-Hôpitaux de Paris, Paris Sorbonne Cité, France), helped us take stock of our battle against liver cancer so far. It seems science and technology have come a very long way, but in the face of ever-rising numbers of cases, we still have some way to go.
“The classic causes of liver cirrhosis (chronic liver disease known to lead to liver cancer) are alcoholism, hepatitis C and hepatitis B. But now, we are seeing more and more patients with liver diseases that are not related to these typical causes. Nonalcoholic steatohepatitis (fatty liver disease) can also lead to hepatocellular carcinoma (primary liver cancer), and this etiology is now the number one cause of hepatocellular carcinoma in the US and the UK. It is increasing everywhere.”
On World Cancer Day, efforts to raise awareness of the importance of healthy lifestyle choices are redoubled. In light of Prof Vilgrain’s observations about unhealthy lifestyles, this is clearly needed. But when patients with liver cancer come into hospital, the time for awareness is passed.
Liver cancers are notoriously difficult to treat. “Many patients cannot be operated on because of their poor condition or because the tumor characteristics are such that surgery is simply not feasible, especially with hepatocellular carcinoma” she said. But in cases where surgery may have been impossible years ago, doctors are now using the cutting edge of radiology and imaging to treat liver cancer better than ever. Indeed, the most appropriate treatment is chosen during a multidisciplinary session.
“Now, with interventional radiology, there are basically two different approaches: tumor ablation and intra-arterial treatment. Tumor ablation is mainly performed percutaneously (via needle puncture through the skin) rather than open surgery with heat, using radiofrequency or microwaves. Another option is cryotherapy, which is the reverse: ablating the tumor with cold. Intra-arterial treatment comprises administration of chemotherapy or radiation therapy delivered through the arteries that supply the liver. These treatments that were originally focused on hepatocellular carcinoma are now also applied to liver metastases in some patients.
The popularity of these image-guided ablation treatments is a testament to recent improvements in imaging technology. More powerful Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) techniques, paired with a better understanding of what exactly makes treatment effective, is yielding better outcomes for patients today.
“[Treatment] has changed a lot,” said Prof Vilgrain. “Now we can image more and more small liver tumors which, thanks to the increase in speed and resolution [of MRI and CT scanners], we could not have seen twenty or even ten years ago.”
“Today the challenge is to characterize these very small tumors. We sometimes call them TSTC: too small to characterize. Another challenge is to make the appropriate specific diagnosis; whether the tumor is cancerous or not, whether it looks like a primary cancer or a metastasis. Treatment would be very different for each of these scenarios.”
Prof Vilgrain says that these new challenges, rather than making the treatment of liver cancer more difficult, are making it more accurate and effective. By getting better at seeing the tiny details, doctors are getting better at picking the right course of action.
“We have tools, like Cone Beam CT and 3D CT, which enable us to optimize needle placement and see the arteries that supply tumors, in real time, in the intervention room.” she said. “We can combine tumor ablation with surgery to treat cases where surgery would not have otherwise been amenable, in particular for bilobar liver metastases (tumors that affect both lobes of the liver)”.
Speaking about the future of liver cancer care, Prof Vilgrain is upbeat. “Diagnosis will keep improving,” she said. “I think the field that is becoming most interesting is the field of biomarker imaging, using biomarkers to assess the prognosis of a tumor.” Biomarkers have been mentioned on the Pulse before; they are mostly analyzed using MRI and allow to assess function and metabolism in the liver.
“So I think imaging will be used more and more to predict and choose the most appropriate treatment,” Prof Vilgrain continued. “This is the concept of personalized medicine. We are not yet at a stage where we can use a specific biomarker and decide on one specific course of action for each patient. It’s a bit too early. But this is exactly what I think the future will bring.”