Cancer that starts in the liver is called primary liver cancer. It is relatively uncommon in the United States, but very common in other parts of the world. However, approximately 20,000 cases of primary liver cancer have been diagnosed in the United States each year over the past several years, and the number has increased with each subsequent year.
Primary liver cancer occurs when cancerous tumors grow within liver tissue or in the bile ducts within the liver. The first type of primary liver cancer, called hepatocellular carcinoma, is more common and is the type of liver cancer discussed in this summary. Although liver cancer is a serious disease that is often diagnosed late in its course, advances in treatments in the past several years have given many patients an improved outlook.
Cancer that has started in the liver is different from cancer that has spread to the liver from another part of the body.
If you have been diagnosed with liver cancer, you probably have many questions and concerns about your disease, how it is likely to be treated, and what happens when treatment is completed. This summary for patients, which is based on the NCCN Clinical Practice Guidelines in Oncology, will help you understand the best available treatments for the form of liver cancer called hepatocellular carcinoma. Talk to your doctor about these options so that together you can decide on a treatment plan that is right for you.
Background of Early-Stage Liver Cancer
The liver has many functions. Some of these functions are to produce bile, which helps in the digestion of fat; to store sugar as an energy reserve in a form called glycogen; to manufacture some of the building blocks of proteins; to store certain vitamins and minerals (vitamins A, D, K, and B12, and iron); and to produce cholesterol. The liver also helps break down certain harmful substances that then pass into the bile or blood and are eliminated from the body in the stool or urine.
There are several risk factors for developing primary liver cancer. Liver cirrhosis is a major risk factor and can be caused by chronic viral hepatitis infection (e.g., hepatitis B or C), alcohol abuse, and other causes. In some cases, chronic hepatitis virus infection can lead to the development of primary liver cancer even without liver cirrhosis. However, some type of chronic liver disease is usually present before primary liver cancer begins to develop.
Diagnosing Early-Stage Liver Cancer
Most people with early-stage liver cancer do not have symptoms. However, some people may have symptoms that lead them to contact their doctors. These symptoms can include a hard lump on the right side just below the rib cage, discomfort in the upper abdomen on the right side, pain around the right shoulder blade, unexplained weight loss, jaundice (yellowing of the skin and whites of the eyes), unusual tiredness, nausea, or loss of appetite. These symptoms can also be related to other causes. If you have any of these symptoms, you should discuss them with your doctor.
To diagnose primary liver cancer, your doctor will perform imaging tests either to look for a nodule or mass in the liver or to further characterize a nodule or mass found on the screening ultrasound examination. These additional imaging tests can include contrast-enhanced CT, MRI, and ultrasound, although contrast-enhanced ultrasound is not widely available in the United States.
If the mass or nodule is found to be liver cancer, your doctor will recommend another series of tests, including various blood tests and/or chest imaging, to determine how advanced the cancer is, how good your liver function is, and which treatments might be best for you.
The Pathology Report
The results of the biopsy can indicate whether the mass is, in fact, cancer. The biopsy results can be cancer, not cancer, indeterminate. An indeterminate result means no clear evidence of cancer was found, but you will still need to be re-evaluated at frequent intervals. Your doctor will recommend repeat imaging and follow-up as long as the size of the mass remains the same. If the nodule or mass gets larger, your doctor will recommend more imaging and/or another biopsy.
The pathology report will also assign the tumor a grade from 1 to 4 indicating how aggressive the tumor is based on how similar it is to normal liver tissue. A grade 1 tumor is likely to be less aggressive and a grade 4 is likely to be very aggressive.
Staging of Liver Cancer
Staging is a formal system for identifying how localized or widespread your cancer is. For primary liver cancer, the stages range from stage I (most localized) to stage IV (spread to distant organs in your body). A number of staging systems are available that may be used by your treatment team. Some factors included in some of these systems are how well your liver is functioning (as determined by blood tests and a physical examination) and your overall health.
Staging is an important part of developing the best treatment plan for you. In general, the lower the stage of disease, the better the chance that your cancer can be cured. Staging is used both to help you and your doctors make the most appropriate treatment decisions and to provide information about what typically happens to patients with cancers most like yours (e.g., your prognosis).
Treatment of Early Stage Liver Cancer
Management of early stage liver cancer requires excellent coordination of a team of doctors, including a hepatologist (specialist in liver disease), medical oncologist, interventional radiologist, surgeon, and transplant team. Many people with liver cancer also have other serious medical conditions, especially other diseases of the liver. The team of doctors caring for you must work together to make a treatment plan that is safe and most likely to be effective for you.
Your health care team must decide whether you are able to have surgery, whether you are a candidate for a liver transplant, whether a type of locoregional therapy can be used to destroy the liver tumor or tumors, or whether systemic drug therapy is right for you. These choices depend on the size and position of the tumor or tumors in your liver, the condition of your liver, and your overall health.
Each of these treatments has side effects. Talk with your doctor about what to expect from your treatment and how these side effects can be prevented, reduced, managed, or eliminated. Some side effects can be anticipated, and you can receive treatment to reduce their severity. Generally, reducing side effects does not change the effectiveness of treatment; it simply makes you feel better while you are in treatment.
Your doctor should provide you with a written care plan explaining what treatments you will have, when and how often (if you will have targeted therapy) they will occur, and what side effects you may experience.
You will also be asked to sign an informed consent document indicating that you have been told about your treatment and what to expect.
It is very important that you ask your doctor or nurse every question you have. Liver cancer and its treatment are complicated, and most patients have questions.
Surgery and Transplant
Liver surgery and transplantation are potentially curative treatments for early-stage liver cancer. The size and location of the tumor or tumors and the condition of your liver aside from the cancer are the most important factors in determining whether surgery or liver transplantation are possible treatment options for you.
For liver surgery or transplant be an option, the tumor or tumors must not invade the large blood vessels leading to and from the liver, and there must be no spread of the tumor beyond the liver.
In general, surgical removal of liver cancer is only an option if only one tumor is present in the liver, your liver is functioning well, the tumor is located in a part of the liver from which it can be safely removed, and your surgeon estimates that enough healthy liver will remain after the surgery to allow your liver to function properly. Surgery for liver cancer is major surgery, and you must be in good overall health.
Some people with a small number of limited-size tumors and who have impaired liver function may be candidates for liver transplantation. One disadvantage of a liver transplant is that fewer donor livers are available than people who need them. Sometimes there is a significant waiting period before a liver that is a good match becomes available.
Several “bridge” therapies that can be used to slow the progression of the disease while a person with liver cancer is waiting for a new liver. These therapies include several locoregional treatments called ablation and embolization, which are described below.
Locoregional Therapy
Ablation and Embolization Therapy
If you have early-stage liver cancer, you should first be evaluated to see if you are eligible for liver surgery or transplantation. If those options are not possible or if there is a significant delay in obtaining an appropriate liver for transplant, a form of locoregional therapy (i.e., therapy that treats the liver only) called ablation may be an option for you. These are treatments that destroy the tumor using radiofrequency ablation, cryoablation, or chemoablation, chemoembolization, or radioablation. Ablative treatments may be used instead of surgery in some circumstances.
Ablation destroys the tumor by focusing the treatment directly in it. This treatment is usually reserved for small tumors (≤ 3 cm). It is usually not a substitute for surgery unless a patient’s health is not good enough for surgery; however, it can be a very effective measure for reducing the tumor while awaiting a transplant.
Some types of ablation use changes in temperature to destroy the tumor. For example, radiofrequency ablation uses radiowaves to heat the tumor, and cryoablation freezes the tumor. Chemoablation involves injection of a chemical substance, usually ethanol or acetic acid, directly into the tumor.
Chemoembolization uses chemotherapy drugs injected into the artery that supplies blood to the specific location of the tumor in the liver to kill the tumor cells. After the chemotherapy, a substance may be put into the artery to block blood flow to the tumor, starving it of oxygen and nourishment. Radioembolization uses the same principle of delivering radioisotopes directly to the tumor through the artery that supplies blood to it to destroy it.
Radiation therapy, using high-energy beams to destroy the cancer, is another option for people who are not in good enough health to undergo surgery. Because the liver and blood vessels that supply it with nourishment are delicate structures that must be protected, specific very-targeted radiation therapy techniques are used for liver cancer.
Systemic Therapy
Although systemic therapy is typically reserved for advanced liver cancer, if your general health is not good enough to undergo surgery, your doctor may recommend either the locoregional therapy options described earlier or systemic therapy using sorafenib, a drug that both reduces tumor growth and restricts blood supply to the tumor. This treatment is only an option if you have relatively good liver function.
Managing Symptoms
People with liver cancer often are quite ill apart from their cancer. If after discussion with your doctor, you and your doctor agree that you are too sick to undergo treatment for the liver cancer, your doctor still may be able to treat your symptoms and improve the quality of your life. Common symptoms are pain, fatigue, and loss of appetite. Each of these can be helped with proper care. There is no reason to suffer needlessly. Let your doctor or nurse know if you have troublesome symptoms and together make decisions about how you would like them to be addressed.
Prognosis
In determining a prognosis—the likely course or outcome of a disease and its treatment—your doctor may look at survival statistics taken from studies of large groups of liver cancer patients. However, such statistics:
- Are estimates only and cannot be use to predict outcomes for a particular person
- Can vary widely with each stage of liver cancer
- Are sometimes based on older data that do not reflect recent advances in early detection and treatment options
- Cannot be used to precisely predict your survival
Your individual prognosis will be affected by many factors, including:
- Your age
- Your overall health, including other diseases you have
- The stage and grade of your liver cancer
- Your response to the treatment(s) being used
Ask your doctor which treatment(s), in his or her judgment, will give you the best life expectancy and quality of life.
New treatments are enabling people with liver cancer to live longer, with better-quality lives than ever before. You may want to find out whether you are eligible to participate in a clinical trial, in which new and experimental treatments are used and may be compared with standard treatments. More information is available in the Guide to Clinical Trials and Demystifying Common Clinical Trial Myths.
Life After Treatment for Early-Stage Liver Cancer
After completion of your treatment, you will begin a period called follow-up. During this period, you will visit your doctor at regular intervals. Your doctor will perform a physical exam, ask you how you are feeling, and order tests to make sure you remain healthy and that any long-term effects of your liver cancer or its treatment can be addressed. If your cancer recurs (comes back after treatment), these visits will allow your doctor to begin effective treatment as soon as possible.