An Overview of Liver Cancer

Liver cancer is uncommon in the United States but is common worldwide due to risk factors such as chronic hepatitis B and hepatitis C infections and aflatoxin exposure. Symptoms may include jaundice (a yellowing of the skin), pain in the upper abdomen, right shoulder blade pain, and weight loss. Doctors diagnose the condition using a combination of imaging tests and blood tests. Depending on the size of the tumor, treatment options may include removal of the tumor, liver transplantation, targeted therapies, chemotherapy, and sometimes radiation therapy.

Liver cancer arises in the liver, an organ located beneath your lower ribs on the right side of your abdomen. It's important to distinguish primary liver cancer (hepatocellular carcinoma) and bile duct cancer (cholangiocarcinoma) from tumors which begin in other places of the body and spread to the liver (liver metastases). Liver metastases are much more common than primary liver cancers and are treated in the way that a primary cancer (such as lung cancer or breast cancer) are treated, instead of the way that primary liver cancer is treated.

The functions of the liver are important to know as you look at the possible symptoms of the disease. The liver play roles in detoxifying substances, secreting bile to aid in digestion and making hormones that are important in the production of red blood cells.

In addition to the cancers mentioned above, there are less common types of liver cancer. A few of these include hepatoblastoma, a rare form of childhood cancer, and angiosarcoma of the liver. This review will focus primarily on primary liver cancer and bile duct cancer.

Symptoms

Liver cancer symptoms are uncommon in the early stages of the disease unless the tumor lies near one of the bile ducts and causes an obstruction (with symptoms similar to a gallbladder attack). Early stages include stage 1, where the tumor hasn't yet spread. In stage 2 liver cancer, several small tumors may be present and may spread to nearby blood vessels. As the tumor spreads to nearby organs it becomes categorized as stage 3 liver cancer. Stage 4 means that the cancer has spread to distant organs and sites, such as the lungs, bones, and adrenal glands.

Generally, symptoms may include:

  • Pain in the right upper abdomen
  • A mass in the right abdomen (just under your ribs or potentially lower)
  • Right shoulder blade pain
  • Jaundice, a yellowish discoloration of the skin and the whites of the eyes
  • Pale or white stool
  • Dark urine
  • Intense itching
  • Ascites, the build-up fluid in the abdomen
  • Fever (101 degrees or higher that lasts for several days without obvious signs of infection)
  • Unintentional weight loss without a significant change in diet or exercise
  • Nonspecific symptoms such as loss of appetite, fatigue, and a general sense of being unwell

Causes and Risk Factors

We aren't certain exactly what causes the disease, though we know of several risk factors for liver cancer. Most of these risk factors result in scarring (cirrhosis) of the liver, though liver cancer may also develop without cirrhosis.

The most common risk factor for liver cancer is one of the forms of hepatitis. Together, hepatitis B and hepatitis C are thought to be the cause of around 85 percent of liver cancers worldwide. Some of the risk factors include:

  • Alcohol use and smoking: Long-term heavy alcohol use (more than 3 drinks per day) is clearly associated with the development of cirrhosis, and can also raise the risk of liver cancer. Smoking also appears to raise the risk, especially when combined with other risk factors, such as hepatitis B.
  • Family history and genetic diseases: If you have a family member who has liver cancer, your risk is higher than average. The risk is also increased for those who have genetic diseases such as hemochromatosis and Wilson's disease.
  • Medical conditions: Medical conditions that increase the risk of liver cancer include primary sclerosing cholangitis, primary biliary cirrhosis, non-alcoholic fatty liver disease, and diabetes.
  • Aflatoxin exposure: Uncommon in the United States, but common worldwide, exposure to aflatoxins—toxins released by fungi that grow on improperly stored grains and nuts—is a significant cause of liver cancer.

Diagnosis

Those who have any symptoms of liver cancer or risk factors for developing the disease should see their doctor. A physician can take a careful history and perform a physical exam. For some, screening tests may be considered. Depending on the evaluation, a combination of blood tests and imaging studies may also be done to form a diagnosis.

  • Labs and tests: Blood work (such as liver function tests), a hepatitis panel, and tumor markers are often the first steps in diagnosing liver cancer. One specific test, the alpha-fetoprotein tumor marker test (AFP), may be ordered to screen for liver diseases.
  • Imaging: The first imaging test that is usually done is an ultrasound. Other tests that may be helpful in diagnosis include MRI and CT scans. An angiogram of the liver may also be recommended.
  • Biopsy: Unlike many cancers, the diagnosis of liver cancer is often made based on imaging findings rather than biopsy. A biopsy may not be needed unless it is important to understand the molecular characteristics of the tumor, such as in a clinical trial.

Treatment

The treatment options available for liver cancer depend on the stage of the disease, your general health, and much more. Treatment options fall into two camps:

Systemic Treatments

These treat cancer cells wherever they happen to be and are the main option for advanced liver cancers.

Options include:

  • Chemotherapy: There are different combinations of chemotherapy drugs that may be given for liver cancer. Chemotherapy works by attacking rapidly dividing cells in the body. Unfortunately, there are normal cells in the body that divide rapidly as well, which gives rise to the well-known side effects of chemotherapy, such as hair loss and increased risk of infection. Chemoembolization is a procedure in which chemotherapy is given directly into a large artery (transarterial) that enters the liver. Chemoembolization may be used as the main treatment, but is also used to attempt to slow down the growth of a tumor while a person is awaiting a liver transplant.
  • Targeted Therapy: Targeted therapy drugs differ from chemotherapy in that they "target" a particular pathway in the growth of a cancer cell. Nexavar (sorafenib), Lenvima (lenvatinib), and Stivarga (regorafenib) all improve survival and are currently standard treatments for people with advanced liver cancer.

Local Therapies

These treat cancer where it originates. Options that may be considered include:

  • Partial hepatectomy: This is the surgical removal of the cancer and some surrounding normal tissue. This may be an option for smaller liver tumors (less than 5 cm in diameter), depending on their location.
  • Liver transplant: The diseased liver is removed and is replaced with a part or an entire healthy liver. This may be a good option for those with extensive disease or who have decompensated liver failure but are otherwise in reasonable health.
  • Radiation therapy: This may involve external beam radiation therapy (treating a large area of tumor, usually to reduce symptoms or extend life, not to cure a tumor); stereotactic body radiotherapy, or SBRT (using a high dose of radiation for a small area of tissue to eradicate a tumor); or brachytherapy (placing radioactive beads in the liver).
  • Radiofrequency ablation (RFA): This is the use of a probe that has tiny electrodes that destroy cancer cells. 
  • Cryotherapy: This involves freezing the cancerous tissue.
  • Percutaneous ethanol injection: This involves an injection of alcohol into the liver and is a relatively safe procedure for small tumors, but has been largely replaced by radiofrequency ablation in recent years.

    Regardless of what type of treatment plan you and your doctor choose, you should know all the options that are available. The National Cancer Institute also recommends considering the option of clinical trials. Many are in progress and are looking at combinations of the above therapies, as well as newer treatments such as angiogenesis inhibitorsimmunotherapy approaches, and more.

    Palliative Care

    Palliative care involves treating the symptoms of cancer and cancer treatments, rather than the cancer itself. Unlike hospice care, palliative care may be used even for people with highly curable cancers. In addition to improving quality of life, a 2018 study suggests that this type of care may improve outcomes for people with liver cancer as well.

    Prevention

    When it comes to preventing liver cancer, an ounce of prevention is worth a pound of cure—and preventing hepatitis B and C is especially important. If you can avoid developing these diseases, or receive treatment if you have them, you could potentially lower your risk of liver cancer by up to 90 percent. Even for those who carry these infections, there are treatments that can reduce the risk of developing related cirrhosis, and probably liver cancer.

    Limit your consumption of alcohol, and if you smoke, quit. Take time to learn about your family history of any medical conditions, especially those that result in liver problems. And practice caution with any chemicals you are exposed to at work, as some of these are known to cause liver cancer.

    Coping

    If you or a loved one have been diagnosed with liver cancer, you may feel like your world has been turned upside down. Yet, there are things you can do that may help you feel like you are at least able to breathe. Learn as much as you can about cancer, but be careful to look at the most recent up-to-date information. Treatments and survival rates are improving, and information that is even a few years old may not reflect those changes. The same goes for survival statistics. 

    Connecting with the liver cancer community can be helpful both from the standpoint of emotional support and as a way to learn about the latest research on liver cancer. People who are living with the disease are motivated and often know more than even some general oncologists about the latest treatments. You can look for a support group in your community, or find the liver cancer community online. To find the right people, try using the hashtags #livercancer and #livertumor.

    Reach out to family and friends and welcome the support they can offer. Coping with liver cancer truly takes a village. 

    Caregiving

    Few people experience cancer in isolation, and coping with liver cancer can be as challenging for family caregivers as for those living with the disease. One of the most difficult parts of caregiving for someone with liver cancer is the sense of helplessness you may feel, yet there are ways that you can both help your loved one and cope with this feeling. Learning more about the disease is a great place to start.

    Conflict is common when people with cancer and their loved ones differ on how they would approach treatment. Offer your thoughts, but keep in mind that this is your loved one's journey that she needs to travel in her own way.

    Finally, it's more important than ever to take care of yourself as a caregiver as well. This may seem impossible at times, but taking time to make sure your own needs are met will also help you stay as healthy as possible while you care for your loved one.

    A Word From Verywell

    If you are worried that you may have liver cancer, talk to your doctor. Treatments are most effective in the early stages of the disease, and catching these cancers early offers a chance for a cure.

    For those who have been diagnosed with liver cancer, there is still hope. Treatments are improving, and newer treatments are available in clinical trials. Make sure to be an active part of your cancer care. Learn how to be your own advocate, or find a friend or loved one who can be an advocate for you. Self-advocating, when you have cancer, has not only been found to reduce anxiety but at times may even improve outcomes.

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