This information has been prepared to help you understand more about liver cancer.
Many people feel understandably shocked and upset when they are told they have liver cancer. This information is intended to help you understand the diagnosis and treatment of this type of cancer.
We cannot advise you about the best treatment for you. You need to discuss this with your doctors. However, we hope this information will answer some of your questions and help you think about the questions you want to ask your doctors or other health carers.
The liver is the largest organ inside the body. It is found on the right side of the abdomen under the ribs, just beneath the right lung and diaphragm.
The liver is made up of two sections called the right and left lobes. Blood from both the hepatic artery and the portal vein flows to the liver. The hepatic artery carries oxygen, while blood in the portal vein carries nutrients and waste products.
The liver performs several important functions including:
- producing bile to dissolve fat so it can be digested
- converting sugar and fat into energy
- storing nutrients
- making proteins for the blood
- helping the blood to clot
- making other chemicals the body needs
- breaking down harmful substances such as alcohol and drugs, and getting rid of waste products
Unlike other internal body organs, the liver can usually repair itself. It can function normally even if only a small part of it is working and it can grow back to normal size in a couple of weeks or months.
What is liver cancer?
Liver cancer occurs when cells in the liver become abnormal and grow uncontrollably. Primary liver cancer is cancer that starts in the liver. It is when a malignant tumour or tumours are found in the liver tissue.
Secondary cancer in the liver is cancer that started in another part of the body but has spread (metastasised) to the liver. Digestive cancers often spread to the liver because blood containing cancer cells from the digestive organs pass through the liver first and can lodge there. Cancers of the breast, ovary, kidney and lung can also metastasise to the liver.
Types of liver cancer
There are three major types of primary liver cancer:
Hepatocellular carcinoma (HCC): starts in the hepatocytes, the main cell type in the liver. HCC, also called hepatoma, is the most common type of primary liver cancer.
Cholangiocarcinoma: starts in the cells lining the bile ducts, which connect the liver to the bowel and gall bladder. It is also called bile duct cancer.
Angiosarcoma: a very rare type of liver cancer starting in the blood vessels. It usually occurs in people over 70.
The information presented here uses the term ‘secondary cancer in the liver’ to refer to any type of cancer that has spread to the liver.
How common is it?
If you would like to read any facts or statistics about liver cancer, please refer to the Cancer Institute NSW website:
What is the cause?
The exact cause of primary liver cancer is not known, but some factors may increase your risk:
- Gender – it is more than twice as common in men.
- Getting older – it is more common in people aged over 65.
- Infection with hepatitis B or C viruses.
- Having cirrhosis of the liver – often caused by excessive alcohol consumption or the progression of the hepatitis C virus.
- Being from South-East Asia – due to high rates of hepatitis B in that region.
- Having diabetes.
- Lifestyle factors – smoking, heavy drinking, high-fat diet, being overweight.
Secondary cancer in the liver is caused when another type of cancer grows and spreads to the liver. It occurs about 20 times more often than primary liver cancer.
What are the symptoms?
Primary liver cancer usually has no symptoms in the early stages. Symptoms often start to appear as the cancer grows and may include:
- weakness and tiredness (fatigue)
- pain in the upper right side of the abdomen
- severe abdominal pain if a primary liver tumour bleeds
- loss of appetite, feeling sick (nausea) and weight loss
- yellowing of the skin and eyes (jaundice)
- swelling of the abdomen (ascites)
You may have nothing to worry about if you experience these symptoms, as they can all be caused by many other non-cancerous conditions. However, if you notice one or more of these symptoms you should bring it to the attention of your doctor for further investigation.
Primary liver cancer and secondary cancer in the liver are diagnosed using a number of different tests, including blood tests, imaging tests and biopsies.
You will probably undergo blood tests to check how you liver is working (liver function), how well your blood clots, and whether you have hepatitis B or C. Your doctor will probably want to check the level of certain chemicals, known as tumour markers, which are produced by cancer cells. The tumour markers used to diagnose primary liver cancer include alpha-fetoprotein (AFP), cancer antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA).
In addition to blood tests, imaging tests will be used to diagnose liver cancer and/or determine the extent of the cancer and how far it has spread. You will probably have one or more of the following tests:
A CT scan is a type of X-ray that takes three-dimensional pictures of several organs at the same time. You will need to drink a liquid dye, or have it injected into a vein, before the scan. The dye helps to make the picture clearer. The scan usually takes 10-30 minutes and is painless.
An MRI scan uses magnetism and radio waves to take detailed cross-sectional pictures of the body. These show the extent of the tumour and whether it is affecting the main blood vessels around the liver.
An MRI is painless but some people find lying in the scanner noisy and may feel claustrophobic.
A PET scan combined with a CT scan is a type of imaging test available at some major metropolitan hospitals. A PET scan uses the emissions from a mild, radioactive glucose solution to create images that explain how certain organs or systems in the body are functioning. The solution circulates throughout the body and is taken up by actively dividing cells, such as cancer cells.
An ultrasound uses soundwaves to create a picture of a part of your body. It is a quick and painless test that can show the size of location of abnormal tissue in your liver.
During the scan, a small device called a transducer will be moved over your abdomen. It creates soundwaves that echo when they meet something dense, like an organ or tumour. The soundwaves are sent to a computer and turned into a picture.
The diagnosis of liver cancer often requires tissue sampling (biopsy), in which tissue or cells are taken and examined under a microscope. Tissues or cells can be obtained in several ways, including:
This procedure involves passing a fine needle through the skin and into the suspected tumour. An ultrasound or CT scan will be done at the same time to help the doctor guide the needle to the right place. Cells are drawn into the needle, removed and examined under a microscope.
Laparoscopy (often referred to as keyhole surgery) allows the doctor to look at the liver and surrounding organs using a thin tube containing a light and a camera (a laparoscope). It is often done if the doctor suspects that the cancer has spread to other areas besides the liver.
You will be given a general anaesthetic for the procedure. A small cut is made in your lower abdomen and the laparoscope is inserted. If necessary, the surgeon will take tissue samples.
If initial testing shows that you have secondary cancer in the liver, you may need further tests to find out where the primary cancer started. The further tests may include a colonoscopy, endoscopy and/or a mammogram.
Staging refers to how far your cancer has spread. It can help your doctors work out what treatment is best and what your prognosis (or expected outcome) is.
The different stages of cancer are based on how far away from the original tumour site the cancer is found. Different types of cancer have different staging systems. In primary liver cancer, generally stage 1 and stage 2 tumours are confined to the liver. Usually, stage 3 and stage 4 describes cancer that has spread away from the liver.
Prognosis means the expected outcome of a disease. You may want to discuss your prognosis with your doctor. It is important to understand that it is not possible for any doctor to predict the exact course of your disease. However, your doctor will be able to discuss your likely prognosis with you based on the stage and location of the cancer and other factors including your age, fitness and medical history.
The sooner liver cancer is diagnosed, the better the prognosis. If surgery or transplant is an option for primary liver cancer, these treatments usually offer a good chance of cure. Other treatments for primary liver cancer or secondary cancer of the liver may enable you to live for much longer than if you were to have no treatment.
Which health professionals will I see?
You will be cared for by a range of health professionals who specialise in different aspects of your treatment. Health professionals who may care for you include:
- General practitioner (GP) – arranges the first tests to investigate your symptoms and refers you to specialists.
- Gastroenterologist – specialises in diagnosing and treating diseases of the digestive system.
- Hepatobiliary surgeon – a doctor who specialises in surgery of the liver and its surrounding organs.
- Hepatologist – a gastroenterologist who has further specialised in diseases of the liver and gall bladder.
- Medical oncologist – prescribes and coordinates chemotherapy.
- Cancer nurse coordinators and nurses – help administer drugs, including chemotherapy, and support and assist you through all stages of your illness.
- Dietician – recommends the best eating plan to follow while you are in treatment and recovery.
- Social worker, physiotherapist and occupational therapist – link you to support services and help you to get back to normal activities.
The treatment(s) you receive will depend on whether you have primary liver cancer or secondary cancer in the liver and whether you have any other diseases that affect your liver.
If you have primary liver cancer, you may undergo surgery, including a transplant. However, this is not an option in all cases. The most common treatments are tumour ablation using heat (radiofrequency ablation) and chemotherapy delivered directly into the cancer, known as transarterial chemoembolisation (TACE).
The main treatments for secondary cancer in the liver are chemotherapy and a combination of surgery and chemotherapy. If you have secondary cancer in the liver, surgery will only be possible if there is enough healthy liver remaining and the cancer hasn’t spread to other parts of the body where it can’t be removed (such as the bones).
Surgery for liver cancer involves removing the part of the liver that contains cancer and is called a liver resection. If you are relatively healthy, you may be considered for a transplant, in which your whole liver is replaced.
Surgery to remove part of your liver is called a partial hepatectomy. The amount of your liver that is removed depends on your circumstances, including the size, number and position of the tumours. The gall bladder is also taken out during a partial hepatectomy, as it is attached to the liver.
Your liver will be able to repair itself easily if it is not damaged. It will usually grow back to its normal size within a few months of surgery.
If you have tumours in both sides of your liver you may have two operations, carried out in two stages. In the first operation, the tumours will be removed from one side of your liver. You will then be given some time to recover. Before the second operation, the size of your liver will be checked. If enough of your liver has regrown, the tumours in the second side will be removed in another partial hepatectomy.
If your tumours are small and near the surface of the liver, the surgeon may do a laparoscopy to remove the tumour. Small cuts will be made in your abdomen and a camera will be used to view your organs while the tumours are surgically removed.
Tumour ablation is treatment that destroys a tumour without removing it from the body. Ablation is often used when there are only one or two small tumours but surgery is not possible. This procedure is rarely used for secondary cancer in the liver.
In most cases, ablation treatments use radio waves or microwaves to heat and destroy cancer cells. This can be done with a needle inserted through the skin or with a surgical cut. The various methods of ablation are outlined below:
This procedure is done under local or general anaesthetic and takes about 1-3 hours. A fine needle is guided through the skin and into the tumour using an ultrasound or CT scan. Radio waves or microwaves are then passed through the needle and into the tumour to destroy it.
In this procedure, pure alcohol is injected directly into a tumour to destroy the cancer cells. The alcohol is administered through a needle which is guided into the tumour using an ultrasound.
If the tumours are close to the surface of your liver, you may have an operation to avoid damage to the diaphragm or nearby organs. Probes are inserted through a cut in the skin to access the liver.
In this procedure, a cut is made in your abdomen and a probe is inserted into the centre of the tumour through the opening. The probe releases liquid nitrogen which freezes and kills the cancer cells.
Chemotherapy is the use of drugs to kill, shrink or slow the growth of tumours. You may have chemotherapy that spreads throughout your body (systemically) or goes directly into the tumour (locally). Systemic chemotherapy will be given intravenously (through a drip) or orally (tablets). Local chemotherapy is delivered using chemoembolisation.
Systemic chemotherapy is usually used as a treatment for secondary cancer in the liver. Occasionally systemic chemotherapy can shrink a secondary cancer enough so that it can be operated on. It may also be given after other treatments, such as cryotherapy or surgery, to kill any remaining cancer cells.
Chemoembolisation is a way of delivering chemotherapy directly to a primary cancer. By targeting the tumour directly, stronger drugs can be used without causing many of the side effects of systemic chemotherapy. TACE involves injecting chemotherapy drugs through a thin tube that has been inserted into your hepatic artery. Tiny beads or sponges are then placed in the smaller arteries that lead to the tumour, keeping the chemotherapy in the tumour and starving the cancer of oxygen. TACE is rarely used for secondary cancers.
Biologic therapies work against cancer cells by either stopping their growth and the way they function, or by helping the body’s immune system to destroy them. These therapies may be used after or in conjunction with other treatments for primary liver cancer or secondary cancer of the liver.
Selective internal radiation therapy
Selective internal radiation therapy (SIRT) is a type of treatment that targets liver tumours directly with high doses of internal radiation placed in tiny radioactive pellets. SIRT is used for both primary and secondary cancers in the liver when the tumours can’t be removed with surgery. Typically, it is used when there are many small tumours spread throughout the liver.
Endoscopic stent placement
If cancer in your liver is obstructing your bile ducts, it may cause symptoms of jaundice, such as yellowish skin, itchiness, pale stools or dark urine. Your gastroenterologist or a surgeon may place a thin tube (stent) in your liver to drain the bile and ease your symptoms. The stent is put in via an endoscope, which is then removed.
Palliative treatment helps to improve your quality of life by easing symptoms of cancer when a cure may not be possible. It involves managing pain relief, physical and emotional symptoms, and may include radiotherapy, chemotherapy or other medications.