Liver cancer

Primary liver cancer: etiology and clinical presentation

Primary malignant lesions of the liver tissue have a clear, traceable link to preceding pathologies. In 60–75% of cases, the tumor develops against the background of pre-existing liver cirrhosis. The key etiological factors are viral hepatitis and alcohol abuse. The combined effect of viral infection and chronic alcoholism presents a particular danger and the highest risk of oncological progression.

The clinical presentation features so-called "red flags" indicating a malignant process:

• Progressive general weakness.
• Pronounced and rapid weight loss in the patient, up to the development of cachexia.
• Rapid formation of ascites that is refractory (resistant) to ongoing therapy.

Examination of the ascitic fluid often reveals its hemorrhagic nature (presence of erythrocytes), while cytological analysis detects atypical tumor cells.

Physical examination findings are also highly specific. The patient exhibits hepatomegaly (enlargement of the liver). Upon palpation, the organ is tender, its surface is often nodular, and its consistency becomes abnormally dense, acquiring a characteristic "stony" structure.

Laboratory and instrumental diagnostics

Laboratory parameters in primary liver cancer demonstrate several characteristic shifts. Blood biochemistry shows a rapid increase in alkaline phosphatase (ALP) levels. A complete blood count may show the presence of anemia and leukocytosis. In some cases, systemic (paraneoplastic) manifestations develop: polycythemia, hypoglycemia, hypercalcemia, and dysglobulinemia. Determining tumor markers plays a critical role: $\alpha$-fetoprotein is a key indicator and is detected in 50–90% of patients with hepatomas.

A wide range of instrumental methods is used for visualization and diagnosis confirmation:

1. Ultrasound and CT — allow the detection of focal changes in the liver tissue, assessing their density and contours.
2. Scintigraphy (with $^{99}Tc$) — used to further confirm the presence of a pathological lesion.
3. Arteriography — a highly informative method for studying the vascular bed of the tumor itself.
4. Laparoscopy with targeted biopsy — the gold standard, providing definitive morphological verification of the diagnosis.

Diagnostic challenges in cirrhosis

Timely detection of malignant transformation against the background of ongoing cirrhosis presents significant difficulty, as the symptoms of tumor growth overlap with the manifestations of the underlying disease.

The physician must pay close attention to the following warning signs:

• Sudden and sharp escalation of general symptoms (increased weakness, rapid weight loss, unexplained fever, and pain).
• Rapid change in physical examination findings: abrupt enlargement of the liver and a change in its consistency to "stony".
• Laboratory "spike": sudden appearance of leukocytosis, hyperenzymemia, elevated bilirubin, development of hypergammaglobulinemia, and a significant acceleration of ESR.

Metastatic liver tumors

Secondary (metastatic) liver involvement is much more common than primary tumors. According to autopsy data, liver metastases are found in 30–50% of all cancer patients. Such high frequency is explained by the intensive vascularization of the organ, which creates ideal conditions for the settlement of circulating cancer cells. The source of metastasis can be virtually any neoplasm (except brain tumors), but malignant tumors of the gastrointestinal tract are the absolute leaders.

The clinical presentation of metastatic disease is most often determined by the dominant symptoms of the primary tumor located outside the liver. General non-specific symptoms include marked weakness, anorexia, weight loss, fever, and sweating.

Specific hepatic symptoms include:

• Pain in the right upper quadrant.
• Hepatomegaly (the liver is firm and nodular on palpation).
• Development of complications: appearance of ascites, obstructive jaundice, and signs of portal hypertension.

In laboratory diagnostics of metastases, signs of impaired liver function often remain mild. The most characteristic change is an increased alkaline phosphatase activity. Anemia, decreased albumin levels (hypoalbuminemia), and a moderate increase in transaminases may also be observed.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Mechanisms of paraneoplastic syndrome development (polycythemia, hypoglycemia, hypercalcemia)
• Interpretation of alkaline phosphatase and transaminase levels in oncological pathology
• Pathogenesis of refractory ascites and portal hypertension formation
• The role of viral hepatitis B and C in hepatocyte malignancy
• Technique of laparoscopy with targeted liver biopsy

Other topics in the section "Liver, Biliary Tract, and Spleen"

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