Liver Cancer (Hepatocellular Carcinoma)

  • Medical Author: Venkatachala Mohan, MD
  • Medical Editor: John P. Cunha, DO, FACOEP
    John P. Cunha, DO, FACOEP

    John P. Cunha, DO, FACOEP

    John P. Cunha, DO, is a U.S. board-certified Emergency Medicine Physician. Dr. Cunha's educational background includes a BS in Biology from Rutgers, the State University of New Jersey, and a DO from the Kansas City University of Medicine and Biosciences in Kansas City, MO. He completed residency training in Emergency Medicine at Newark Beth Israel Medical Center in Newark, New Jersey.

Liver cancer facts

  • Most people who get liver cancer (hepatic cancer) get it in the setting of chronic liver disease.
  • Incidence rates of hepatocellular cancer are rising in the United States due to increasing prevalence of cirrhosis caused by chronic hepatitis C and nonalcoholic fatty liver disease.
  • There are many treatment alternatives for liver cancer. The treatment chosen depends upon how much the cancer has spread and the general health of the liver and the overall health of the patient.
  • The type of physician that treats liver cancer is a specialist called an oncologist, an internal medicine doctor with a board certification in oncology.

Where is the liver located?

The liver is the largest organ inside the body and is located under the right ribs and beneath the right lung. The liver has several functions. It secretes bile into the intestines to absorb fats, breaks down and stores nutrients, manufactures clotting factors needed to stop bleeding, and breaks down toxic agents, like alcohol and drugs. Once the toxic agents are broken down, they can be eliminated from the body through urine or stool. One of the causes of cirrhosis, the scarring of the liver, is alcoholism. A person cannot live without a liver, so liver shut down or liver failure is fatal.

Hepatitis is an inflammation of the liver, which can progress to scarring (fibrosis) or liver cancer. Hepatitis can be caused by toxic substances, infection, or autoimmune diseases. Common viruses that cause hepatitis are referred to as types A, B, C, D, and E. It's possible to prevent hepatitis with a vaccine available for types A, B, and E.

Quick GuidePancreatic Cancer Symptoms, Causes, and Treatment

Pancreatic Cancer Symptoms, Causes, and Treatment

Liver Cancer Symptoms and Signs

Malignant tumors of the liver are most commonly metastases, or areas of distant spread, from tumors that arise elsewhere in the body. These tumors are not true liver cancers; instead they are named by their site of origin, such as lung cancer metastatic to the liver. True liver cancers are malignancies that arise in the cells of the liver. Symptoms of liver cancer arise most commonly in the later stages of the disease and include

  • weight loss,
  • nausea,
  • vomiting,
  • loss of appetite,
  • fatigue, and
  • abdominal swelling.

These symptoms are fairly nonspecific and can occur with cancers in other locations as well as some chronic diseases. Other symptoms of liver cancer include a yellowish discoloration of the skin and whites of the eyes (jaundice), enlarged and tender liver, and chalky, white-colored stools.

What is liver cancer?

Liver cancer definition

Primary liver cancer is a condition or disease that happens when normal cells in the liver become abnormal in appearance and behavior. The cancer cells can then become destructive to adjacent normal tissues, and can spread both to other areas of the liver and to organs outside the liver. Liver cancer is also called hepatic cancer.

Malignant or cancerous cells that develop in the normal cells of the liver (hepatocytes) are called hepatocellular carcinoma. A cancer that arises in the ducts of the liver is called cholangiocarcinoma.

What is metastatic liver cancer?

Metastatic cancer is cancer that has spread from the place where it first started (the primary site) to another place in the body (secondary site). Metastatic cancer in the liver is a condition in which cancer from other organs has spread through the bloodstream to the liver. Here the liver cells are not what has become cancerous. The liver has become the site to which the cancer that started elsewhere has spread. Metastatic cancer has the same name and same type of cancer cells as the original cancer. The most common cancers that spread to the liver are breast, colon, bladder, kidney, ovary, pancreas, stomach, uterus, and lungs.

Metastatic liver cancer is a rare condition that occurs when cancer originates in the liver (primary) and spreads to other organs (secondary) in the body.

Some people with metastatic tumors do not have symptoms. Their metastases are found by X-rays, CT scans, ultrasounds, or other tests. Enlargement of the liver or jaundice (yellowing of the skin) can indicate cancer has spread to the liver.

What causes liver cancer?

Most people who get liver cancer get it in the setting of chronic liver disease (long-term liver damage called cirrhosis), which scars the liver and increases the risk for liver cancer. Conditions that cause cirrhosis are alcohol use/abuse, hepatitis B, and hepatitis C.

The causes of liver cancer may be linked to environmental, dietary, or lifestyle factors. For example, in November 2014, researchers at the University of California, San Diego School of Medicine, found that long-term exposure to triclosan, a common ingredient in soaps and detergents, causes liver fibrosis and cancer in laboratory mice. Although triclosan has not been proven to cause human liver cancer, it is currently under scrutiny by the FDA to determine whether it has negative health impacts.

What are the risk factors for liver cancer? Is liver cancer hereditary?

Incidence rates of hepatocellular cancer are rising in the United States due to increasing prevalence of cirrhosis caused by chronic hepatitis C and steatohepatitis (nonalcoholic fatty liver disease).

Cirrhosis of the liver due to any cause is a risk factor for liver cancer. The risk factors for liver cancer in cirrhosis are being male, age 55 years or older, Asian or Hispanic ethnicity, family history in a first-degree relative, obesity, hepatitis B and C, alcohol use, and elevated iron content in the blood due to hemochromatosis.

Chronic hepatitis B infection even without cirrhosis is a risk factor for liver cancer.

What are liver cancer symptoms and signs?

Liver cancer causes no symptoms of its own. As the tumor grows, it may cause symptoms of pain in the right side of the abdomen or feeling overly full after eating a little. Some patients may have worsening of symptoms of chronic liver disease or cirrhosis, which often precedes the development of cancer of the liver. For example, patients may complain of

How do health care professionals diagnose liver cancer?

The best way to detect liver cancer is through surveillance ultrasound of the liver done by an oncologist every six months in a patient with a diagnosis of cirrhosis. As with most forms of cancer, it is best to treat the liver cancer as soon as it is detected.

Once a suspicion of liver cancer arises, a physician will order one the following to confirm a diagnosis:

  1. Blood tests: alpha-fetoprotein (AFP), which may be elevated in 70% of patients with liver cancer. AFP levels could be normal in liver cancer. A rising level of AFP is suspicious for liver cancer. The AFP may be elevated with cirrhosis and chronic active hepatitis. Other labs tests include des-gamma-carboxy prothrombin, which can be elevated in most patients with liver cancer.
  2. Imaging studies: Multiphasic helical CT scan and MRI with contrast of the liver are the preferred imaging for detecting the location and extent of blood supply to the cancer. If any imaging study is inconclusive, then an alternative imaging study or follow-up imaging study should be performed to help clarify the diagnosis. Lesions smaller than 1 cm are usually difficult to characterize.
  3. Liver biopsy is performed to sample tissue from the lesion in the liver, which is analyzed by a pathologist to confirm the suspected diagnosis of liver cancer. Liver biopsy is not needed in every case, especially if the imaging study and lab markers are characteristic for liver cancer. Risks of liver biopsy are infection, bleeding, or seeding of the needle track with cancer. Seeding is when cancer cells get on the needle used for a biopsy and spread to other areas touched by the needle. Liver biopsy of suspected liver cancer carries the added risk of seeding the liver biopsy needle track in 1%-3% of cases. If a liver biopsy is inconclusive, then a repeat imaging study is recommended at three- to six-month intervals.

How is liver cancer staged?

According to the American Cancer Society, "The stage of cancer is a description of how widespread it is. The stage of a liver cancer is one of the most important factors in considering treatment options. A staging system is a standard way for the cancer care team to sum up information about how far a cancer has spread. Doctors use staging systems to get an idea about a patient's prognosis (outlook) and to help determine the most appropriate treatment. There are several staging systems for liver cancer, and not all doctors use the same system."

Liver biopsy as well as imaging studies help in classifying liver cancer stages as per the American Joint Committee on Cancer (AJCC) TNM system, the Barcelona Clinic Liver Cancer (BCLC) staging system, the Cancer of the Liver Italian Program (CLIP) system, or the Okuda system.

What are the types of liver cancer and liver tumors?

Benign liver tumors: This type of tumor can become large enough to cause problems but will not spread to other areas of the body. The treatment is usually surgery.

Hemangioma: A hemangioma is a blood vessel tumor that only requires treatment if it bleeds.

Hepatic adenoma: This is a type of benign liver tumor, which may cause abdominal pain or blood loss. Surgical removal is usually recommended.

Focal nodular hyperplasia (FNH): This tumor is made up of several different types of cells (liver, bile duct, and connective tissue cells).

Liver angiosarcoma (or hepatic angiosarcoma) and hemangiosarcoma are rare. This is a cancer of the inner lining of the blood vessels. Since the symptoms of liver angiosarcoma are nonspecific, usually this type of liver cancer is not discovered until it is too late to be treated effectively.

Hepatocellular carcinoma: This is the most common form of primary cancer. Primary liver cancer is cancer that began in the liver. It can occur as a single tumor or many small cancer nodules throughout the liver. Primary liver cancer will commonly spread to the lungs, the portal vein (kidney), and portal lymph nodes.

Intrahepatic cholangiocarcinoma (bile duct cancer): As described by its name, this cancer starts where the bile duct connects to the liver. Between 10%-15% of liver cancers are of this type. This type of cancer commonly spreads (metastasis) to the lymph nodes, lung, and bone marrow.

Hepatoblastoma: This is a rare cancer found in children, usually under age 4. This cancer is treated, successfully in most cases, with surgery and chemotherapy.

Secondary cancer: This is a cancer that started elsewhere in the body and spread to the liver. This spread of cancer from a primary site to other parts of the body is called metastasis. Secondary liver cancer is more common in the United States than primary liver cancer. A secondary cancer will be treated by the techniques that have been successful for the primary type of cancer. For example, lung cancer that has spread to the liver will be treated using lung cancer protocols, which are the standards of medical care that have been effective for lung cancer.

Lymphoma, a cancer of the immune system including the lymph nodes, also commonly spreads to the liver. Pancreatic cancer may also spread to the liver.

Is liver cancer curable?

Liver cancer is difficult to cure, as it is most often not caught in the early stage. When successfully treated, Liver cancer may never go away completely, so follow-up is very important. Blood tests and imaging tests may be part of a patient's survivorship plan. Statistics for liver cancer are difficult to apply to a specific patient, as the forms, stages and responses to treatment vary per individual. The statistics for deaths due to liver cancer in 2017 are estimated at 19,610 men and 9,310 women.

What is the medical treatment for liver cancer?

The medical treatment chosen depends upon how much the cancer has spread and the general health of the liver. For example, the extent of cirrhosis (scarring) of the liver can determine the treatment options for the cancer. Similarly, the spread and extent of spread of cancer beyond the liver tissue plays an important part in the types of treatment options that may be most effective.

Surgery: Liver cancer can be treated sometimes with surgery to remove the part of liver with cancer. Surgical options are reserved for the smaller sizes of cancer tumors. Complications from surgery may include bleeding (which can be severe), infection, pneumonia, or side effects of anesthesia.

Liver transplant: The doctor replaces the cancerous liver with a healthy liver from another person. It is usually used in very small unresectable (inoperable or not able to be removed) liver tumors in patients with advanced cirrhosis. Liver transplantation surgery may have the same complications as noted above for surgery. Also, complications from medications related to a liver transplant may include possible rejection of the liver transplant, infection due to suppression of the immune system, high blood pressure, high cholesterol, diabetes, weakening of the kidneys and bones, and an increase in body hair.

Ablation therapy: This is a procedure that can kill cancer cells in the liver without any surgery. The doctor can kill cancer cells using heat, laser, or by injecting a special alcohol or acid directly into the cancer. This technique also may be used in palliative care when the cancer is unresectable.

Embolization: Blocking the blood supply to the cancer can be done using a procedure called embolization. This technique uses a catheter to inject particles or beads that can block blood vessels that feed the cancer. Starving the cancer of the blood supply prevents the growth of the cancer. When this technique uses chemotherapy and synthetic material, it is sometimes called chemoembolization, as it blocks off the blood supply and traps the chemotherapy agent in a tumor. This technique is usually used on patients with large liver cancer for palliation. Complications of embolization include fever, abdominal pain, nausea, and vomiting.

Radiation therapy: Radiation uses high-energy rays directed to the cancer to kill cancer cells. Normal liver cells are also very sensitive to radiation. Complications of radiation therapy include skin irritation near the treatment site, fatigue, nausea, and vomiting.

Chemotherapy: Chemotherapy uses a medicine that kills cancer cells. The medicine can be given by mouth or by injecting it into a vein or artery feeding the liver. People can have a variety of side effects from chemotherapy, depending on the medications used and the patient's individual response. Complications of chemotherapy include fatigue, easy bruising, hair loss, nausea and vomiting, swollen legs, diarrhea, and mouth sores. These side effects are usually temporary.

Targeted agent: Sorafenib (Nexavar) is an oral medication that can prolong survival (up to three months) in patients with advanced liver cancer. Side effects of sorafenib (Nexavar) include fatigue, rash, high blood pressure, sores on the hands and feet, and loss of appetite.

Clinical trial: A clinical trial is a way to receive specific treatments in a carefully controlled way to determine whether a new therapy approach is safe, effective, and better than existing therapies. A new treatment may be a drug, a device, a different way to do a surgery, a combination of two or more drugs, or methods of treatment or even diet. The government maintains a web site at ClinicalTrials.gov where more information on trials related to liver cancer can be found. The research from clinical trials, including the statistics supporting the effectiveness of the intervention being tested, is important in the introduction of new treatment methods and ways to change the standard of medical care for all types of liver cancer.

What is the follow-up after treatment for liver cancer?

Patients are advised to follow up with the doctor for lab tests and office visits. Patients with chronic liver disease should avoid alcohol and any drugs that can harm the liver. Patients with liver transplants will need to take anti-rejection drugs for the rest of their life to prevent their body from rejecting the new liver.

What is the prognosis of liver cancer? What are the survival rates for liver cancer?

The prognosis for liver cancer depends on multiple factors such as the size of the liver cancer, the number of lesions, the presence of spread beyond the liver, the health of the surrounding liver tissue, and the general health of the patient. Life expectancy depends on many factors that impact whether a cancer is curable.

The American Cancer Society states the overall five-year survival rate for all stages of liver cancer is 15%. One of the reasons for this low survival rate is that many people with liver cancer also have other underlying medical conditions such as cirrhosis. However, the five-year survival rate can vary depending on how much the liver cancer has spread.

If the liver cancer is localized (confined to the liver), the five-year survival rate is 28%. If the liver cancer is regional (has grown into nearby organs), the five-year survival rate is 7%. Once the liver cancer is distant (spread to distant organs or tissues), the survival time is as low as two years.

Survival rate can also be affected by the available treatments. Liver cancers that can be surgically removed have an improved five-year survival rate of over 50%. When caught in the earliest stages, and the liver is transplanted, the five-year survival rate can be as high as 70%.

Primary liver cancer deaths are usually from liver failure, bleeding, or advanced cancer.

Quick GuidePancreatic Cancer Symptoms, Causes, and Treatment

Pancreatic Cancer Symptoms, Causes, and Treatment

Are there alternative and complementary therapies for liver cancer?

Currently, there are no specifically approved alternative or complementary treatment options for liver cancer. Clinical research on the use of complementary and alternative medicine for liver cancer is limited. Studies suggest that certain alternative therapies may offer benefits for people being treated for all types of cancer, including liver cancer. Some alternative treatments have been found to alleviate unwanted side effects of conventional cancer treatments such as nausea and vomiting.

Acupuncture: Studies have shown acupuncture can help with nausea and vomiting among people with cancer.

Herbal therapy: Milk thistle has been used for centuries to treat liver problems. Mistletoe may also show promise in liver cancer in experimental studies.

Some herbal preparations, such as those mentioned above, may be helpful in treating symptoms associated with liver cancer. Even so, people who have liver cancer need to take extra precautions before taking an herbal remedy.

A person with cancer of the liver may have a harder time processing alcohol than people without liver disease and should avoid alcohol-containing products. Since many herbal preparations in extract form are alcohol-based, people with liver cancer should always check the ingredients for the presence of any alcohol before taking these herbs.

Additionally, some herbal supplements, such as gingko biloba, can cause excess bleeding. Because the liver releases important substances that help the blood to clot, liver cancer can decrease the body's ability to stave off bleeding. People with liver cancer should discuss any new medications, including herbal supplements, with their doctor before taking them.

Subscribe to MedicineNet's Cancer Report Newsletter

By clicking "Submit," I agree to the MedicineNet Terms and Conditions and Privacy Policy. I also agree to receive emails from MedicineNet and I understand that I may opt out of MedicineNet subscriptions at any time.

Is it possible to prevent liver cancer?

Prevention of cirrhosis, which is the underlying cause of liver cancer, will help in preventing the development of liver cancer.

Routine surveillance for liver cancer by performing ultrasound of the liver every six months in patients with a cirrhotic liver will detect early liver cancer.

Where can you learn more about liver cancer?

Patients can find many resources to learn more about cancer. A popular source is the American Cancer Society. Another is the National Comprehensive Cancer Network, which has a lot of information for consumers on resources and support groups.

Medically Reviewed on 10/26/2017
References
REFERENCES:

American Cancer Society. "Liver Cancer: Early Detection, Diagnosis, and Staging Topics." Dec. 5, 2014. <http://www.cancer.org/cancer/livercancer/detailedguide/liver-cancer-staging>.

American Association for Study of Liver Diseases
CONTINUE SCROLLING FOR RELATED SLIDESHOW

Health Solutions From Our Sponsors