Liver Cancer (Hepatocellular Carcinoma)
Liver cancer is a malignant, or cancerous, tumor that starts in the cells of the liver. The word “malignant” means that the tumor can spread (metastasize) to other parts of the body. When cancer first appears in the cells of the liver, it is called primary liver cancer.
The liver, which is part of the digestive system, is one of the largest organs in the body. It is located in the upper right part of the abdomen. The liver produces enzymes and bile, which aid in the digestion of food. It also synthesizes proteins that help blood to clot. In addition, the liver cleanses the blood by removing harmful substances.
Sometimes liver cells go through changes that make the way they grow or behave abnormally. These changes can lead to the formation of benign tumors, such as a hemangioma. Benign tumors are not cancerous, but in some cases changes in liver cells can cause cancer.
Liver cancer most often starts in the cells that make up most of the liver (called hepatocytes). This type of cancer is called hepatocellular carcinoma. Liver cancer can also start in the cells that line the bile ducts inside the liver. This type of cancer is called intrahepatic bile duct cancer. The term cholangiocarcinoma is also used to denote cancer of the intrahepatic bile ducts.
Other types of cancer can also occur in the liver, but they are rare. These include soft tissue sarcoma, neuroendocrine tumors, and non-Hodgkin lymphoma.
Other types of cancer can spread to the liver, but this is a different disease from primary liver cancer. When cancer that starts in another part of the body spreads to the liver, it is called liver metastasis. Liver metastases are treated differently from primary liver cancer.
Below, we outline the symptoms, stages, types, diagnosis, chances of surviving, and treatments for liver cancer:
Symptoms of liver cancer
Liver cancer may not cause any signs or symptoms in the early stages of the disease. The liver is a large organ that can function normally even if it contains a large tumor. Signs and symptoms appear when the tumor grows and causes changes in the body, such as if it blocks the bile ducts. Other medical conditions including cirrhosis (scarring of the liver) can cause the same symptoms as liver cancer.
See your doctor if you experience these signs and symptoms:
- abdominal pain, which may radiate to the right shoulder
- lump or mass under the ribs
- loss of appetite
- feeling full after a light meal (called early satiety)
- swelling of the abdomen caused by a buildup of fluid (called malignant ascites)
- swelling of the feet and legs caused by a buildup of fluid (called edema)
- general feeling of discomfort or illness (called malaise)
Hepatic encephalopathy occurs when the liver does not work properly and waste products build up in the blood.
This can cause the following symptoms:
- breath that smells sweet or musty
- memory loss
- change in personality or mood
- nervousness and anxiety
- speech disorders (difficulty speaking)
- change in sleep patterns
- tremors or difficulty controlling the movement of the hands and arms
Portal hypertension is an increase in blood pressure in the portal vein (the main vein that delivers blood to the liver). This can happen when a liver tumor blocks blood flow in that vein, or if there is cirrhosis (scarring of the liver). The increased blood pressure causes large veins (called varicose veins) to form in the stomach and esophagus to allow blood to bypass the blockage. Varicose veins are very fragile and can bleed easily.
Symptoms of portal hypertension include:
- lump on the left side of the abdomen (caused by swelling of the spleen)
- accumulation of fluid in the abdomen (called ascites)
- shortness of breath (caused by a buildup of fluid around the lungs called pleural effusion)
- blood in the stool, making it appear black and tarry
- vomiting blood
Types of liver cancer
- Hepatocellular carcinoma (HCC): the most frequent, since it constitutes 80 or 90% of all cases of liver cancer.
- Cancer Metastatic: originates elsewhere in the body, such as the lung, liver and passes.
- Hepatoblastoma: a liver cancer that is very common in childhood.
- Cholangiocarcinoma: a tumor originating from the bile ducts of the liver.
- Angiosarcoma: a tumor originating from the blood vessels.
- Hepatic leiomyosarcoma: is an extremely unusual tumor, slow evolution and insidious course. Most of them are diagnosed at a very advanced stage.
- Mixed hepatic adenoneuroendocrine carcinoma: this cancer is characterized by the simultaneous presence of an exocrine glandular component and a neuroendocrine component. Its presentation as a primary liver tumor is almost unusual.
Causes of liver cancer
The exact causes of liver cancer are not known, but certain factors that allow the appearance of the known cancer :
- Hepatitis is the main factor that causes more liver cancer.
- Cirrhosis is the second leading factor in liver cancer.
- Hemochromatosis is a liver disease that can lead to cancer.
Other possible causes in adults
High-grade dysplatic nodules are precancerous lesions of the liver. Within 2 years, there is a 30-40% risk of developing cancer resulting from these nodules.
Obesity is believed to be a major risk factor as it can lead to steatohepatitis.
The diabetes increases the risk of liver cancer.
The smoke increases the risk of HCC compared with non-smokers and smokers who quit.
There is about a 5-10% lifetime risk of developing cholangiocarcinoma in patients with primary sclerosing cholangitis.
The fascioliasis increases the risk of cholangiocarcinoma and is the reason why Thailand present particularly high rates of this cancer.
Diagnosis of liver cancer
Usually, the diagnostic process for liver cancer begins when a routine exam reveals that there may be a problem with the liver. Your doctor will ask you about the symptoms you are experiencing and perform a physical exam. Based on this information, your doctor may refer you to a specialist or order tests to check for liver cancer or other health problems.
The diagnostic process can seem long and overwhelming. It’s okay to worry, but try to remember that other medical conditions can cause symptoms similar to those of liver cancer. It is important that the healthcare team rule out any other possible cause of the health problem before making a diagnosis of liver cancer.
The following tests are commonly used to rule out or confirm a diagnosis of liver cancer. Many tests that can diagnose cancer are also used to determine the stage, that is, the extent of progression of the disease. Your doctor may also order other tests to assess your general health and help plan your treatment.
Medical history and physical examination
A medical history is a history of symptoms, risk factors, and any medical events and conditions a person has had in the past. When checking your medical history, your doctor will ask you questions about your personal history of:
- symptoms that may indicate the presence of liver cancer
- scarring of the liver (cirrhosis)
- infection with hepatitis B virus or hepatitis C virus
- consuming a large amount of alcohol
Your doctor may also ask you about your family history of:
- liver cancer
- risk factors for liver cancer
- other cancers
The physical exam allows the doctor to look for any signs of liver cancer. During the physical examination, the doctor may:
- feel your abdomen to check for swollen organs or for fluid buildup
- observe your eyes or skin to see if they are yellow (jaundice)
- checks to see if your feet and legs are swollen due to a buildup of fluid (edema)
Blood biochemical analyzes
In blood chemistry tests, the level of certain chemicals in the blood is measured. They make it possible to evaluate the functioning of certain organs and to detect abnormalities.
To diagnose liver cancer, the following blood chemistry tests can be done.
Liver function tests
Liver function tests (or liver tests) are a set of blood chemistry tests that are often ordered together. Although they cannot diagnose liver cancer, they can tell the doctor that there might be a problem with the liver.
Albumin is a protein produced by the liver. If liver cells are damaged, they do not synthesize a normal amount of albumin. Low albumin levels may indicate the presence of liver damage.
Bilirubin is a product of the breakdown of used red blood cells. It is absorbed and metabolized by the liver. High levels of bilirubin can mean that the liver is not working normally and that it is damaged. The buildup of bilirubin in the body can cause jaundice.
Prothrombin time (PT), also called prothrombin time (PT) or international normalized ratio (INR), is a test that measures the time it takes for blood to clot. The INR is a standard way of communicating the results of this analysis. The liver makes proteins that are needed for blood to clot (called clotting factors). Doctors use blood clotting and bleeding factor assays to assess how well the blood is clotting. A longer than normal clotting time may be caused by liver damage or liver disease.
Other blood chemistry tests
Other blood chemistry tests, including the following, may be done to find out if there are problems with the liver.
Blood sugar is a measure of the amount of glucose (sugar) in the blood. The liver releases glucose into the blood to maintain normal blood sugar levels. A low level of glucose in the blood (hypoglycemia) may indicate that the liver is damaged.
Alkaline phosphatase (AP) is an enzyme, which is a protein that speeds up certain chemical reactions in the body. It is found in the liver as well as in other body tissues. High blood pressure can be a sign that the liver is damaged.
Aspartate transaminase (AST) is an enzyme found in cells of the liver, muscles and heart. When liver or heart cells are damaged, they release SGOT into the blood. A high level of SGOT in the blood may indicate the presence of liver damage or liver disease.
Alanine aminotransferase (ALT) is an enzyme found in the liver and kidneys. A high level of ALT is often seen in the blood before symptoms of liver damage, such as jaundice, appear.
Partial thromboplastin time (CT) is a measure of the time it takes for a blood sample to form a clot in a test tube when certain chemicals are added to it.
In an ultrasound, high-frequency sound waves are used to produce images of body structures. It is used to check if the liver is larger than normal or has thickened, or to see if a lump in the liver is solid or filled with fluid (such as a cyst).
Doctors can also use ultrasound to guide them to specific areas of the liver during a biopsy.
Computed tomography (CT)
A computed tomography (CT) scan uses special x-ray machines to produce 3-dimensional and cross-sectional images of the body’s organs, tissues, bones and blood vessels. A computer assembles the photos into detailed images.
To diagnose hepatocellular carcinoma (HCC), 4 CT scans are done. This is called a 4-phase, or multi-phase, acquisition. First, a test without a contrast medium is performed, then, before doing the next 3 tests, a contrast medium is injected into a vein. The way the contrast medium travels through the liver lets doctors know if a liver tumor is HCC. If doctors determine a tumor to be HCC using CT, a liver biopsy is not necessary.
Doctors also use CT to get information about the size, shape and location of the tumor. They can also be used to check for signs of the cancer spreading to nearby lymph nodes, tissues or organs. CT can also help the doctor decide if the liver tumor can be removed with surgery.
Magnetic resonance imaging (MRI)
Magnetic resonance imaging (MRI) uses powerful magnetic forces and radio waves to produce cross-sectional images of the body’s organs, tissues, bones, and blood vessels. A computer assembles the photos into 3-dimensional images.
MRI can be used to check for signs of the primary cancer spreading from the liver to nearby lymph nodes, tissues or organs.
During a biopsy, the doctor removes tissues or cells from the body for analysis in the laboratory. The laboratory report confirms the presence or absence of cancer cells in the sample.
In most cases, doctors will use CT with 4-phase acquisition to diagnose liver cancer instead, but if the imaging tests do not allow them to confirm that there is a tumor in the liver , they can do a liver biopsy.
During a core biopsy, doctors use a large, sharp, hollow needle to take a cylinder-shaped sample of tissue (commonly called a “core”) from a tumor or abnormal mass. This is the most common type of biopsy used for liver cancer because it provides enough tissue for a diagnosis.
If doctors believe a person has liver cancer, they will order a blood test to see if they are infected with hepatitis viruses. Chronic infection with hepatitis B virus (HBV), hepatitis C virus (HCV), or both increases your risk of developing liver cancer.
Complete blood count (CBC)
The complete blood count (CBC) is used to assess the quantity and quality of white blood cells, red blood cells and platelets. CBC is done to get basic information about your general health before treatment begins.
In an x-ray, low doses of radiation are used to produce images of the body’s structures on film. A chest x-ray is done to see if the liver cancer has spread to the lungs.
Determination of tumor markers
Tumor markers are substances found in the blood, tissues and fluids taken from the body. An abnormal level of a tumor marker can mean a person has liver cancer. Tumor marker assay is usually done to assess response to cancer treatment. It can also be used to diagnose liver cancer.
In the past, the tumor marker used for liver cancer has been alpha-fetoprotein (AFP). Recent research has shown that AFP levels may also be higher than normal in the presence of other types of cancer, including cancer of the intrahepatic bile ducts. Since this test does not specifically detect hepatocellular carcinoma, doctors no longer recommend it as a diagnostic test for liver cancer.
If liver cancer spreads
Cancer cells can spread from the liver to other parts of the body. This spread is called metastasis.
Understanding how a type of cancer tends to grow and spread helps your healthcare team plan for your treatment and future care. If liver cancer spreads, it can spread to the following structures:
- liver veins
- lining of the abdomen (called peritoneum)
- lymph nodes in the abdomen
- lungs (remote location most often affected)
Treatments for liver cancer
If you have liver cancer, your healthcare team will create a treatment plan just for you. It will be based on your health and specific information about the cancer. When deciding which treatments to offer for liver cancer, your healthcare team will consider:
- the stage of liver cancer
- how well your liver is working (liver function)
- the amount of scarring in the liver (called cirrhosis)
- whether or not the cancer can be completely removed by surgery
- your overall health
You may be offered one or a combination of the following treatments for liver cancer. Liver cancer is often at an advanced stage when it is diagnosed, so treatment options may be limited.
Depending on the stage of liver cancer, you may have one of the following types of surgery.
Liver resection, or partial hepatectomy, is used to remove the tumour along with a margin of healthy tissue around it. It is used as the main treatment if there is only 1 tumour less than 2 cm in size and the cancer has not spread to lymph nodes or blood vessels of the liver. It is offered only if tests show that the liver is healthy enough to work normally after surgery and there is no increased pressure in the portal vein.
Liver transplant is the main treatment for people who have severe cirrhosis and the rest of the liver would not work normally after surgery to remove a tumour. The cancer cannot have spread outside the liver to other parts of the body.
Transarterial chemoembolization (TACE)
TACE is used to shrink and control liver tumours. It is a treatment that blocks the blood supply to a liver tumour and delivers chemotherapy directly to the tumour.
TACE is offered when the tumour cannot be treated with surgery, but the cancer hasn’t spread to the major blood vessels in the liver, lymph nodes or other parts of the body. It can only be offered to people with good liver function who don’t have any fluid in their abdomen (called ascites) or problems with the main vein of the liver (called the portal vein).
Ablation therapies destroy liver cancer cells, while trying to avoid damaging as much of the surrounding liver tissue as possible. Ablation therapies are offered to people with liver cancer who can’t have surgery.
Radiofrequency ablation (RFA) uses a high-frequency electrical current to create heat to destroy cancer cells. It is the most commonly used ablation therapy for liver cancer. RFA works best for liver tumours that are 2.5 cm or less in size and when there are no more than 3 tumours.
Percutaneous ethanol injection (PEI) is a treatment that injects concentrated ethanol alcohol through a needle into a liver tumour. It works best on tumours that are smaller than 2 cm in size.
Targeted therapy uses drugs to target specific molecules (such as proteins) on the surface of cancer cells. These molecules help send signals that tell cells to grow or divide. By targeting these molecules, the drugs stop the growth and spread of cancer cells while limiting harm to normal cells. It is used to treat advanced liver cancer when the person can’t have surgery or when the cancer no longer responds to other therapies.
External beam radiation therapy may be used to treat liver cancer that has spread to bone. Find out more about bone metastases.
If you don’t want or can’t have treatment
You may want to consider a type of care to make you feel better rather than treat the cancer itself. This may be because the cancer treatments don’t work anymore, they’re not likely to improve your condition or they may cause side effects that are hard to cope with. There may also be other reasons why you can’t have or don’t want cancer treatment.
Talk to your healthcare team. They can help you choose care and treatment for advanced cancer.
Follow-up after treatment is an important part of cancer care. You will need to have regular follow-up visits, especially in the first 2 years after treatment has finished. These visits allow your healthcare team to monitor your progress and recovery from treatment. People who have a liver transplant will be followed by their transplant team.
- Hepatitis B and C vaccinations to reduce the risk of viral hepatitis, a major risk factor for liver cancer.
- Regular screening and early detection for individuals at higher risk of liver cancer.
- Maintaining a healthy lifestyle with a balanced diet, regular exercise, and avoiding excessive alcohol consumption.
Prognosis and survival for liver cancer
If you have liver cancer, you may be wondering about your prognosis. A prognosis is the act by which the doctor best assesses how cancer will affect a person and how they will respond to treatment. The prognosis and survival depend on many factors. Only the doctor who is familiar with the person’s medical history, the type of cancer they have, the stage and characteristics of the disease, the treatments chosen and the response to the treatment can look at all of this data together with the statistics of the patient. survival to arrive at a prognosis.
A prognostic factor is an aspect of the cancer or a characteristic of the person that the doctor takes into account when making a prognosis. A predictor factor influences how cancer responds to a certain treatment. Prognostic and predictor factors are often discussed together and both play a role in the choice of treatment plan and in establishing the prognosis.
The following are prognostic factors and predictors of liver cancer.
Stage is one of the most important prognostic factors in hepatocellular carcinoma. The prognosis of people with stage BCLC 0 or A liver cancer is more favorable than that of people with stage BCLC B, C or D liver cancer.
The prognosis for a person with reduced liver function due to the tumor, scarring of the liver (cirrhosis), or hepatitis is less favorable.
The Functional Index measures how well a person is able to perform common tasks and daily activities. The prognosis of people with a low functional index is less favorable than that of people with a good or acceptable functional index.
Characteristics of the tumor
The prognosis for people with multiple tumors is less favorable than for people with only one tumor. If the tumors are in both lobes of the liver, the prognosis is poorer than if they are all in one lobe.
A tumor that has invaded the blood vessels has a poor prognosis.
A tumor that grows inside a blood vessel has a poor prognosis.
A tumor measuring more than 5 cm has a less favorable prognosis than a smaller tumor.
Fibrolamellar carcinoma has a better prognosis than other types of liver cancer. This type of tumor does not invade the surrounding tissue very deeply, so doctors are usually able to remove it completely during surgery.
The Child-Pugh score is used to determine when it is safe to perform surgery. The Child-Pugh classification measures the degree of liver damage or failure due to cirrhosis (an abnormal condition where healthy liver tissue is replaced by scar tissue). It takes into account the following factors (between 1 and 3 points are assigned to each factor):
- presence of fluid buildup in the abdomen (called ascites)
- have symptoms of hepatic encephalopathy (a condition that occurs when the liver does not work properly and waste products build up in the blood)
- bilirubin level
- albumin level
- time it takes for the blood to clot (called prothrombin time, PT, or prothrombin time, PT)
|Number of points given
|grade 1 – mild
some changes to mental and physical function
grade 2 – moderate
many changes to mental and physical function
|grade 3 – poor
significant changes to mental and physical function
grade 4 – severe
significant changes to mental and physical function or coma
|less than 2
|between 2 and 3
|greater than 3
|greater than 3.5
|between 2.8 and 3.4
|less than 2.8
|prolongation of prothrombin time (seconds)
|between 1 and 3
|between 4 and 6
|greater than 6
The total number of points across the categories are added together to get the Child-Pugh score:
- A = 5–6 points
- B = 7–9 points
- C = 10–15 points
A high Child-Pugh score means that surgery is not safe to do and should not be performed. People who can’t have surgery have a less favourable prognosis than people who can have surgery to remove liver cancer.
Survival statistics for liver cancer
Survival statistics for liver cancer are very general estimates and must be interpreted very carefully. Because these statistics are based on the experience of groups of people, they cannot be used to predict a particular person’s chances of survival.
There are many different ways to measure and report cancer survival statistics. Your doctor can explain the statistics for liver cancer and what they mean to you.
Net survival represents the probability of surviving cancer in the absence of other causes of death. It is used to give an estimate of the percentage of people who will survive their cancer.
In Canada, the 5-year net survival for liver cancer is 19%. This means that, on average, about 19% of people diagnosed with liver cancer will survive for at least 5 years.
Survival by stage
Survival varies with each stage of liver cancer. The following factors can also affect survival for liver cancer.
- Liver cancer is not often found until it is at an advanced stage, when it can no longer be removed by surgery.
- Having liver disease, such as cirrhosis, can affect survival.
- Survival by stage of liver cancer is usually reported as a median survival. Median survival is the period of time (usually months or years) after diagnosis or treatment at which half of the people with a given disease will live longer and the other half will live less than this amount of time.
There are no specific Canadian statistics available for the median survival of different stages of liver cancer. The following information comes from a variety of sources and may include statistics from other countries.
|0 or A
|Median 5-year survival is 40%–70%, if treated with liver resection, radiofrequency ablation, or RFA, (for tumours 2 cm or less) or liver transplant.
|Median survival is 16 months. It may increase to 20 months with transarterial chemoembolization (TACE).
|Median survival is 8 months. It may increase to 11 months with targeted therapy.
|Median survival is 3 months.
Questions about survival
Talk to your doctor about your prognosis. A prognosis depends on many factors, including:
- your health history
- the type of cancer
- the stage
- certain characteristics of the cancer
- the treatments chosen
- how the cancer responds to treatment
Only a doctor familiar with these factors can put all of this information together with survival statistics to arrive at a prognosis.
Information: Cleverly Smart is not a substitute for a doctor. Always consult a doctor to treat your health condition.
Photo credit: Wikimedia Commons
Photo explainations: human liver carcinoma.