Introduction
Liver cancer refers to malignant tumors in the liver, including the two types of primary liver cancer and metastatic liver cancer. Primary liver cancer can be divided into hepatocellular carcinoma, intrahepatic cholangiocarcinoma, and mixed liver carcinoma based on cell typing. It can be divided into nodular, bulky, and diffuse liver cancers according to tumor morphology. Primary liver cancer is one of the most common malignant tumors clinically, ranking fifth among world malignancies. At present, the number of liver cancer patients in China accounts for about 55% of the world total. This cancer has become a major killer, seriously threatening the health and lives of people in China, and the danger cannot be overlooked or underestimated. Also, it is difficult to be discovered in the early stage; therefore, when newly diagnosed and initially treated most patients have already lost the chance for a successful operation.
Early symptoms of the disease are concealed. Clinical manifestation is mainly liver pain, which can radiate to the right shoulder. With the progress of the disease, there may be fever, fatigue, anorexia, diarrhea, weight loss, and so on.
Treatments
1.Surgery
Surgery is the preferred treatment for liver cancers. Patients with indications for surgery should grasp the earliest opportunity for surgery. Patients with a clear diagnosis that lesions are confined to a leaf or half of the liver; patients of stages I and II with good compensatory liver function; and patients with good heart, lung, and kidney function who can also tolerate surgery are key indications for surgery. Surgical resection is preferred for cases of local lesions and combined sclerosis that is not serious, especially in the early stages of small liver cancer. Chemotherapy pump is indwelled via the hepatic artery and portal vein during surgery. Chemotherapy drugs, vitamin C, and so on are locally infused through the pump after surgery. Combining chelation detoxification, medical ozone, TCM, hyperthermia, and other treatments can further improve the curative effect. For multinodular cancer patients who are not suitable for surgery, and with liver function of level Child A, TACE, cryopreservation, radio-frequency ablation, and other interventional therapies are preferred. For patients with unresectable medium-advanced hepatocellular carcinoma; patients with postoperative cancer recurrence, liver function discompensation, and excessively low WBCs and platelets, who are also not suitable for surgery or chemotherapy; as well as patients with small hepatocellular carcinomas that are located in specific unresectable sites, accurate cryosurgical methods can effectively and accurately destroy liver cancer cells to improve survival rates. For small hepatocellular carcinoma, liver transplantation can be considered. Preoperatively and postoperatively (including before and after the intervention), providing positive chelation detoxification, medical ozone, TCM, and other nontoxic integrative treatments can further inhibit cancer cell growth and proliferation and protect liver function. They can not only create favorable conditions for surgery or intervention and enhance the therapeutic effect but also reduce the damage of surgery or interventional therapies to the patient so as to promote wound healing as quickly as possible.
2.Radiotherapy
It was believed previously that liver cancer had poor sensitivity to surgery and the effect was not ideal. But now, with the development of modern radiotherapy techniques, early cases have been reported showing that if larger doses of radiotherapy can be tolerated efficacy can be significantly improved from that in the past. Many early-stage inoperable liver cancers can obtain radical treatment through modern radiotherapy with minor liver dysfunction.
3.Chemotherapy
For unresectable liver cancers, transcatheter arterial chemoembolization is preferred and is mainly applicable to multinodular cancer patients with liver function of level Child A. For multinodular hepatocellular carcinoma with tumor thrombus at the main portal vein, and if liver function is good and collateral circulation is rich, it can also be applied. For patients with systemic multiple metastases, if their general condition is good systemic chemotherapy can be considered. For patients in poor general condition, combined therapy that focuses on supportive care is appropriate.
4.Hyperthermia
Hyperthermia can inhibit or kill cancer cells. Because most liver cancer patients have deficiency of both qi and yin and whole-body hyperthermia can easily cause profuse sweating and impair yin, local hyperthermia is recommended. Appropriate whole-body hyperthermia can also be chosen in cases of clear indications for hyperthermia, and after TCM assessment; but before and after hyperthermia, herbal medicines should be adjusted to mitigate possible adverse effects. In 1987, the local high-temperature curing treatment of liver cancer was reported for the first time in China; based on this, research studies on high-temperature tumor-curing vaccines have been conducted and the immune effects of hyperthermia in cancer therapy were confirmed on an experimental basis. In recent years, domestic and overseas research aiming to seek minimally invasive or noninvasive treatments of liver cancer have found relatively effective ways of utilizing hyperthermia in clinical applications: microwave/RF local hyperthermia, arterial catheter, thermal coagulation therapy, radio-frequency ablation, percutaneous arterial catheter thermochemotherapy, percutaneous ultrasound-guided laser (simply thermal conductivity), microwave curing, degradable starch microspheres for hepatic arterial embolization thermochemotherapy, isolated liver perfusion, and high-intensity focused ultrasound.
5.Chelation Detoxification Therapy
Chelation and detoxification therapy can effectively remove toxins from the body. Vitamins has a better hepatoprotective effect. Therefore, vitamin therapy is the most recommended detoxification therapy in the treatment for liver cancer. Chelation therapy is usually applied once every other day, with 20 times as a course of treatment, with an infusion time of more than 2 hours. For patients with severe heart and lung function disorders, the amount of liquid should be appropriately reduced and the infusion rate should be slowed. Chelation detoxification should be combined with hyperthermia at the same time, or conducted before hyperthermia, which can produce a sensitizing effect. Preoperative chelation detoxification helps to control subclinical lesions or micrometastases, prevents cancer cell transition and diffusion during metastasis, as well as preventing recurrence caused by rapid proliferation of postoperative residual cancer cells. Postoperatively patients are low in immunity, and chelation detoxification is conducive to the recovery of immune functions. Chelation detoxification therapy is particularly needed after local infusion chemotherapy because chelation detoxification can reduce the side effects of chemotherapy drugs. At the same time, it can produce a sensitizing effect and prevent recurrence and metastasis caused by rapid proliferation of postoperative residual cancer cells. Chelation detoxification therapy can also inhibit the proliferation and metastasis of cancer cells in patients with medium-advanced hepatocellular carcinoma. The drug composition of chelation detoxification is vitamin C and reduced glutathione, which have good hepatoprotective effects, and combining with TCM syndrome differentiation it is preferred for patients with advanced hepatocellular carcinoma. It is recommended that dosage can reach twice the usual therapeutic amount, once every other day, until the condition is stable and then can be adjusted to one to two times a week. Chelation detoxification therapy for advanced hepatocellular carcinoma patients has no treatment restrictions.
6.Medical Ozone Therapy
It has significant effects in promoting liver functional recovery, inhibiting hepatitis virus replication, and promoting hepatitis B virus antigen negative conversion. At the same time, it has significant tumor inhibition and direct killing effects.
7.Traditional Chinese Medicine
Conduct syndrome differentiation according to the patient’s condition, stage of disease, complications, and variations in body responses. The syndrome of qi stagnation and blood stasis is commonly seen in the early stage. Prescriptions recommended are Xiaochaihu Decoction plus modified Dahuang Zhechong Pill. The syndrome of wetness heat of liver and gallbladder is commonly seen in the medium-advanced stage. Prescriptions recommended are Yinchenhao Decoction plus modified Gexia Zhuyu Decoction. For the syndrome of yin deficiency of liver and kidneys, the prescription recommended is modified Yiguan Decoction.
8.Acupuncture
The syndrome of liver qi depression mainly appears at the early stage of liver cancers. The therapeutic principle should focus on soothing the liver and regulating the circulation of qi, as well as softening and resolving hard mass.
The syndromes of wetness heat of liver and gallbladder as well as yin deficiency of liver and kidneys mainly appear at the advanced stage of liver cancer. The therapeutic principle should focus on clearing away heat and eliminating dampness, eliminating foot ulcers, reducing swelling and resolving mass, nourishing the liver and kidneys, and invigorating spleen for diuresis.
9.Medicated Diet, Nutrition, and so on
The liver is the body’s most important metabolic organ; the occurrence and development of liver cancer is closely related to the levels of the body’s nutrition and metabolism. Liver cancer patients must be given nutritional assessment and rational nutritional support. Patients able to eat normally are subject to nutritional medicated diet combined with infusion to supplement sugar, salt, vitamins, amino acids, and so on; patients with poor nutrition and poor intake are given total parenteral nutrition for maintaining normal energy metabolism. Medium-advanced hepatocellular carcinoma patients have poor nutrition and many have been complicated by hepatic decompensation, thus requiring higher nutritional support. Replenished daily amounts of protein and other nutrients need to be calculated cautiously; otherwise, they are not conducive to the rehabilitation of patients, will increase the burden on the liver, and can even induce hepatic failure and hepatic coma. Patients who can eat should focus on taking a medicated diet. Patients who eat less can combine oral administration or intravenous nutrition. Patients who cannot eat should receive total parenteral nutrition.
10.Others
Patients with liver disease often show irascibility and irritability. In particular, when patients enter the medium-advanced stage the majority of them are frustrated and depressed, and their moods are worsened because pain and other symptoms cannot be relieved. At this point of time, it is a must to encourage the practice of qigong and to apply music therapy, TCM therapy, or Western psychotherapy, and so on to keep the patients calm and peaceful, as well as with positive and optimistic attitudes in conjunction with other treatments, all of which can help in their rehabilitation.
Typical Cases
A male patient, 62 years old, was admitted to Clifford Hospital for “icteric skin and sclera for over 20 days, abdominal distension accompanied with lower extremity edema for 3 days.”. Patient was feeling fatigued, and diagnosed with hepatitis in a local clinic. Patient ignored his condition, refusing further examination and treatment. The patient found that he had lower extremity edema, poor appetite and abdominal distension 3 days before coming to the Outpatient Department of Clifford Hospital, seeking medical attention. When patient came to Clifford Hospital Outpatient, an abdominal ultrasound revealed right hepatic lobe multiple nodules, the largest being 4cm×5cm×5.5cm. Abdominal CT results suggested left hepatic lobe atrophy and abnormal low-density lesion in the upper segment of the right hepatic lobe with a cross-sectional area of about 5.4cm×6.2cm. A sublesion with a diameter of about 6 mm was evident behind the lesion, which was consistent with primary liver cancer, liver cirrhosis and ascites. Patient was admitted to hospital for further treatment.
Diagnosis: (1) primary liver cancer and (2) posthepatitic cirrhosis of chronic hepatitis B
Integrative treatment prescription: On admission, patient showed abnormal liver function, massive ascites, hypoproteinemia, and elevated blood ammonia. He was at risk of liver failure and even liver coma, hepatorenal syndrome, upper gastrointestinal hemorrhage. He underwent chelation detoxification to protect liver and lower transaminase, to eliminate jaundice, to reduce blood ammonia, to suppress acid production, to correct hypoproteinemia. Other relevant symptomatic treatment was given together with appropriate nutritional support.
TCM syndrome differentiation and treatment: the early symptoms were xanthochromia, icteric sclera, ascites, lower extremity edema, poor appetite, red tongue with yellow greasy fur, and wiry pulse. The syndrome is related to stagnation of Qi due to depression of the liver, as well as water and dampness retention. The therapeutic principle was focused on soothing the liver and regulating the circulation of Qi to remove dampness and eliminate jaundice.
Medications: Pericarpium Citri Reticulatae Viride, Radix Curcumae, Rhizoma Cyperi, Fructus aurantii, Angelica Sinensis, Panax Notoginseng, Nacre, Fructus Tritici Ievis, Radix Glycyrrhizae Preparate, Fructus Trichosanthis, Bulbus Allii Macrostemi, Acorus Calamus, Danshen, Gegen, Mentha Haplocalyx Briq Curcuma Longa, Radix Paeoniae Rubra, and Herba Artemisiae Scopariae.
Local hyperthermia was applied to the abdomen once every other day. After 2 consecutive weeks of treatment, xanthochromia and icteric sclera were significantly reduced and ascites and lower extremity edema disappeared. After 4 consecutive weeks of treatment, jaundice disappeared, patient’s appetite improved and his liver function was normal.
Treatment Outcome: the symptom of decompensated liver cirrhosis was serious when the patient was admitted to hospital. The treatment at that time focused on crisis management solution by resorting to Western medicine for hepatic protection, acid making, supplementation of albumin, and reducing aminopherase and blood ammonia. We waited until patient had improved from critical condition before gradually increasing the intensity of treatment. Patient’s mental state improved markedly with normal appetite, more energized, no evidence of abdominal distension, and with normal appearance of stool, and no lower extremity edema after 2 months of hospitalization. No icteric skin or mucous on the entire body was found. The lesion was 5.4cm×5.5 cm. No effusion and enlarged lymph nodes were found in the abdominal cavity. The space-occupying lesions of the liver were smaller than that before treatments. Liver function was normal. Patient’s condition improved and discharged when his condition remained stable. Regular follow-up indicated patient’s improved mental state, appetite and sleep. Patient returned to hospital every month for a 10-day course of treatment which included detoxification, medical ozone, acupuncture and herbal medicines. The treatment was revised to 1 week of inpatient treatment every month after 3 months and 3 days of inpatient treatment after half a year. We conducted one-and-a-half year of follow-up after discharge. The lesions remained relatively stable with no enlargement and no new lesions as confirmed by abdominal CT at Outpatient. Liver function and other indicators were normal.
