Liver cancer (primary)

The liver has many important jobs. It breaks down harmful substances such as drugs and alcohol, stores sugars and fats so they can be used for energy, produces bile to help dissolve fat for digestion, and makes proteins that help blood clot and balance fluid in the body. Unlike most internal organs, a healthy liver may be able to repair itself if it is injured or if part of it is surgically removed during cancer treatment.

What liver cancer is#

Liver cancer begins when cells inside the liver change and grow out of control. It can be a primary cancer, meaning it started in the liver, or a secondary cancer, meaning it started somewhere else in the body and spread to the liver. Secondary cancer in the liver is much more common than primary liver cancer. Almost three times as many men as women are affected by primary liver cancer.

Symptoms#

Liver cancer often causes no symptoms in the early stages, but signs may appear as it grows or spreads. Possible symptoms include:

• weakness and tiredness (fatigue)
• pain in the abdomen, or in the right shoulder blade
• a hard lump on the right side of the abdomen
• appetite loss and feeling sick (nausea)
• unexplained weight loss
• yellowing of the skin and eyes (jaundice)
• dark urine and pale stools
• itchy skin
• a swollen abdomen caused by fluid build-up (ascites)

Not everyone with these symptoms has liver cancer, but if you have any of them or are worried, always see your doctor.

Risk factors#

Primary liver cancer most often develops in people with underlying liver disease, usually cirrhosis. In cirrhosis, healthy liver cells are replaced by scar tissue and benign (non-cancerous) nodules form throughout the liver. As it worsens, the liver stops working properly.

Risk factors include:

• long-term (chronic) infection with hepatitis B or hepatitis C
• drinking too much alcohol
• metabolic-associated fatty liver disease (MAFLD), linked to obesity and/or type 2 diabetes
• too much iron in the bloodstream (haemochromatosis)
• smoking tobacco
• a family history of hepatocellular carcinoma (HCC)

Some populations, including people from regions with higher rates of hepatitis B infection, are also at greater risk. Having risk factors does not mean you will develop liver cancer. If you are worried about your risk, ask your doctor for advice.

How liver cancer is diagnosed#

Several tests may be used:

• Blood tests help doctors work out what type of liver cancer may be present and how well the liver is working.
• Imaging scans are used to look for liver cancer. An ultrasound is usually the first scan and is also used to monitor people with cirrhosis, but it cannot confirm a diagnosis on its own, so one or more other scans are usually needed.
• Biopsy removes a small sample of liver tissue to be checked for cancer cells. The sample is usually collected with a core biopsy: the doctor numbs the area with a local anaesthetic, then passes a needle through the skin of the abdomen to take a sample from the tumour.

If the tests show secondary cancer in the liver, further tests may be needed to find out where the cancer started.

Types of liver cancer#

The most common type of primary liver cancer in adults is hepatocellular carcinoma (HCC), which starts in the hepatocytes, the main type of cell in the liver. Less common types include:

• cholangiocarcinoma (bile duct cancer), which can start in the bile ducts connecting the liver to the bowel and gall bladder
• hepatoblastoma, a rare form that affects only young children
• angiosarcoma, a very rare type that starts in the blood vessels

Staging#

The stage of a cancer describes how large it is, where it is and whether it has spread. Primary liver cancer is staged using the Barcelona Clinic Liver Cancer (BCLC) system, which has five stages: 0 (very early), A (early), B (intermediate), C (advanced) and D (end-stage).

To work out the stage, your doctor considers the size and number of tumours, whether the cancer has spread to blood vessels, lymph nodes or other organs, how well you are functioning in daily life, and how well the liver is working. Liver function is measured using a Child-Pugh score, which ranks it as A (some damage but working normally), B (moderate damage affecting how well it works) or C (very damaged and not working well). A severely damaged liver may not be able to cope with some treatments.

Prognosis#

Prognosis means the expected outcome of a disease. The prognosis for liver cancer tends to be better when it is found early, but it is often found later. To estimate prognosis, your doctor considers your test results, the type of liver cancer and how fast it is growing, whether you have cirrhosis and how well the liver is working, how well you respond to treatment, and other factors such as your age, fitness and overall health.

Although statistics for liver cancer can be frightening, they are based on an average of many cases and may not apply to your situation. No one can predict the exact course of the disease, so talk to your doctor about how to interpret any statistics you come across.

Treatment#

Treatment depends on whether the cancer is primary or secondary, its size, whether it is contained in one part of the liver, whether major blood vessels are involved, whether you have cirrhosis, and your age and general health. It is fine to ask your treatment team to explain things more than once, and to take time over your decisions.

Surgery. The aim of surgery is to remove all the cancer along with a margin of healthy tissue. This is called a liver resection or partial hepatectomy. It is usually done in a specialist centre and is suitable for only a small number of people. Because the liver must repair itself afterwards, resection is only an option when the liver is working well. The remaining liver starts to grow back even if up to three-quarters has been removed, usually returning to its normal size within a few months, though its shape may change slightly. If too much liver would be removed for the remaining part to recover, you may have a portal vein embolisation (PVE) about 4 to 8 weeks before the resection.

Liver transplant. A transplant removes the whole liver and replaces it with a healthy liver from a donor. It is generally used only in people with a single tumour or several small tumours. To be considered you need to be reasonably fit, not smoke or take illegal drugs, and have stopped drinking alcohol. Donor livers are scarce, and waiting may take many months or even years, during which the cancer may keep growing. Most people have other treatment to control the cancer while they wait.

Tumour ablation. For tumours smaller than 3 cm, ablation destroys the tumour without removing it and may be the best option if you cannot have surgery or are waiting for a transplant. Types include thermal ablation, which uses heat from radio waves (radiofrequency ablation) or microwaves (microwave ablation); alcohol injection, which injects pure alcohol (ethanol) into the tumour and is used occasionally where other methods are not possible; and cryotherapy (cryosurgery), which kills cancer cells by freezing them and is offered occasionally.

Radiation therapy. Liver cancer is sensitive to radiation, but so are healthy liver cells. Selective internal radiation therapy (SIRT) and stereotactic body radiation therapy (SBRT) can deliver radiation directly to the tumour while limiting damage to the healthy part of the liver.

Chemotherapy. Traditional chemotherapy may be used for secondary cancer in the liver but is rarely used for primary liver cancer. Instead, transarterial chemoembolisation (TACE) delivers high doses of chemotherapy directly to the tumour, usually for people who cannot have surgery or are waiting for a transplant.

Drug therapies. These travel through the body to reach cancer cells wherever they may have spread. Two types are used for primary liver cancer: immunotherapy and targeted therapy. Drug treatment for advanced liver cancer is changing quickly, and new treatments may become available. Ask your doctor about the latest developments and whether any clinical trials are suitable for you.

All cancer treatments can have side effects. Your treatment team will discuss these before you start, and you should tell your doctor or nurse about any side effects you experience.

Managing symptoms and advanced cancer#

Liver cancer can cause symptoms such as jaundice, pain, poor appetite and weight loss, fluid build-up, fatigue and confusion, and there are ways to manage each of these.

With advanced cancer, a palliative care team may help with symptom management. Advanced cancer usually means cancer that is unlikely to be cured, but some people live for many months or years with it. Many people assume palliative care is only for those who are dying, but it is for any stage of advanced cancer. Doctors, nurses and others specialise in this care, which may include chemotherapy, radiation therapy or other treatment to help you live more comfortably by managing symptoms such as pain. Most people continue to have treatment for advanced cancer as part of palliative care, because it helps manage the disease and improve daily life.

Caring for someone with cancer can be difficult at times. Ask your doctor about treatment and palliative care services that may help, and about support for carers, family and friends.

Key points#

• The liver does many vital jobs, including breaking down harmful substances such as drugs and alcohol, and a healthy liver can often repair itself.
• Secondary cancer in the liver is much more common than primary liver cancer.
• Liver cancer often causes no symptoms early on, but signs such as fatigue, abdominal pain, jaundice and a swollen abdomen (ascites) may appear as it grows or spreads.
• Primary liver cancer most often develops in people with cirrhosis; many other risk factors, including chronic hepatitis B or C and heavy alcohol use, also increase risk.
• Treatment options include surgery, transplant, tumour ablation, radiation therapy, chemotherapy and drug therapies, chosen according to the cancer and your overall health.

Where to get help#