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. Still, 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, called hepatocellular carcinoma, is more common and is the type of primary liver cancer addressed in these treatment summaries.
Cancer that has started in the liver is different from cancer that has spread to the liver from another part of the body. If the cancer starts in another part of the body, such as the colon or breast, and then spreads to the liver, it is referred to as colon (or breast) cancer with liver metastases
. Treatments for other cancers that have spread to the liver are discussed in the summaries for those cancer types.
Liver cancer is a very serious disease that is often diagnosed late in its course. However, advances in treatments for liver cancer in the past several years have given many patients an improved outlook.
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
The liver is a large organ in the upper right side of the abdominal cavity. It is divided into four sections, called lobes, which differ in size and shape. The liver is the only organ in the body that can regenerate itself. All of the blood leaving the stomach and intestines passes through the liver.
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 often present before primary liver cancer begins to develop.
Liver cancer is a very serious disease that is often diagnosed late in its course. The NCCN Guidelines recommend that people who are at high risk for primary liver cancer, such as those with chronic hepatitis or cirrhosis, undergo certain screening tests at regular intervals, so that if primary liver cancer develops it can be identified and treated early.
If you are at high risk of for developing primary liver cancer, your doctor may recommend you undergo screening with a blood test for alpha-fetoprotein (AFP) and an ultrasound examination of your liver every 6 to 12 months. If your AFP level rises or the ultrasound examination shows a liver mass or nodule, your doctor will recommend additional imaging (see Diagnosing Liver Cancer). In some cases, contrast-enhanced ultrasound will be used, but it is not widely available in the U.S.
Diagnosing Liver Cancer
Although most people with liver cancer do not have symptoms, some 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 additional imaging tests to further characterize a nodule or mass found on the screening ultrasound examination. These tests can include contrast-enhanced CT, MRI, and ultrasound (if available).
If a nodule smaller than 1 cm is found on screening, the NCCN Clinical Practice Guidelines recommend you have imaging tests every 3 to 4 months for 18 months if the size of the nodule remains stable, and then gradually lengthen the time between tests to 6 to 12 months. If you have a small nodule that your doctor wants to monitor, it is very important that you keep these appointments so that any change in the nodule can be identified and treated.
For larger masses that are 1 to 2 cm in size, the NCCN Guidelines recommend that you have 2 types of contrast-enhanced imaging tests. Only one type of imaging is necessary to evaluate liver masses larger than 2 cm.
In some cases, cancer can be confirmed by imaging tests alone. In other cases, a biopsy is performed. The result of the biopsy can confirm the presence or absence of cancer or give an indeterminate result. An indeterminate result means that no clear evidence of cancer was found but that cancer cannot be ruled out. You may need to undergo additional imaging tests or other follow-up to monitor your condition.
If the mass or nodule is confirmed 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
If a biopsy of the liver is performed, it can indicate whether the mass is, in fact, cancer. The biopsy result can be cancer, not cancer, or indeterminate. An indeterminate result means that 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.
In general, the more localized the cancer is, the better the chance that it can be cured with treatment. If the cancer has spread to different parts of your body, it is unlikely that it can be cured; however, with appropriate management, it may be controlled and you may live a longer, higher-quality life.
Staging
There is a formal system for identifying how localized or widespread your cancer is. This system is called staging. 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; it is used both to help you and your doctors make treatment decisions and to provide information about what typically happens to patients with cancers most like yours (e.g., your prognosis).
For a more detailed discussion of staging, see the Cancer Staging Guide.
Treatment of Liver Cancer
Management of 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. Treatment for liver cancer involves several specialists who plan and work together to coordinate your care, and it often involves a combination of several approaches.
In general, the lower the stage of disease, the better the chance that your cancer can be cured. The effectiveness of your treatment depends on factors such as how localized your cancer is, whether or how far it has spread in your body, and whether you have underlying liver disease and its severity. Your treatment may involve several approaches, depending on the stage of your disease, the other factors discussed earlier, the characteristics of your tumor, and your age and general health.
For some patients with good liver function who have small tumors that have not spread beyond the liver, surgery may cure the disease. Liver transplant is also an option for some patients with early-stage liver cancer, even if liver cirrhosis is present. Patients for whom transplant is an option should be aware that there is frequently a considerable waiting period before a liver becomes available and that other treatments may be required to control the cancer during this time. If your cancer is localized but you cannot have surgery, local therapies such as ablation, embolization, or radiation therapy may be recommended.
More often, the cancer is too advanced for surgery or the presence of noncancerous liver disease makes surgical treatment impossible. Localized disease that cannot be surgically treated or disease that has spread beyond the liver may be treated with local or systemic (drug) therapy. These treatments are designed to slow the progression of the disease and reduce symptoms to provide you with the longest, best possible quality of life. In addition, you will be given treatment to reduce the symptoms associated with the disease. In some cases, your doctor may recommend that you participate in a clinical trial testing a new treatment.
Talk with your doctor about what to expect from your treatment and how 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 affect the effectiveness of 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 may 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.
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:
- Can vary widely with each liver cancer stage
- 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 overall health, including other diseases you have
- The stage of your liver cancer
- Your response to the treatment(s) being used
New therapies and combinations of therapies 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 therapies are used and may be compared with standard treatments.
Life After Treatment
If you underwent curative treatment for primary liver cancer, you will begin a period called follow-up once your treatment is complete. 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.