Liver Cancer

At Brown Cancer Center, we customize your care for liver cancer. This means we treat you as an individual, not a statistic.

Your treatment plan is personalized to include the most advanced therapies while focusing on your quality of life. Liver cancer treatment options may include:

• New forms of chemotherapy
• Chemoembolization
• Hepatic artery infusion to deliver chemotherapy directly to the liver
• Proton therapy
• Targeted therapies to help your body fight liver cancer

A team of experts in our Multidisciplinary Gastrointestinal Cancer Clinic, including medical, surgical and radiation oncologists, specialized pathologists, as well as a specially trained support staff, collaborate and communicate frequently about your case. For you, this means comprehensive, but focused, care for liver cancer.

Our doctors have at their fingertips the most modern techniques and technology to diagnose and treat liver cancer,  and they use them with extraordinary skill.

Surgery for liver cancer often is complex and challenging. Your best chance for a successful outcome is with a surgeon who has a high degree of experience and skill in these highly specialized procedures. Our surgeons at Brown Cancer Center use the latest methods to perform a large number of delicate liver cancer surgeries each year, with a higher chance for successful treatment than many other cancer centers.

As a research center, we are able to offer clinical trials (need new link) of new treatments for liver cancer.

Facts

Liver cancer is a disease in which malignant (cancer) cells form in the tissues of the liver.

The liver is one of the largest organs in the body. It has four lobes and fills the upper right side of the abdomen inside the rib cage. Three of the many important functions of the liver are:

• To filter harmful substances from the blood so they can be passed from the body in stools and urine
• To make bile to help digest fats from food
• To store glycogen (sugar), which the body uses for energy

The liver is in the upper abdomen near the stomach, intestines, gallbladder, and pancreas. The liver has four lobes. Two lobes are on the front and two small lobes (not shown) are on the back of the liver.

Liver cancer is the fourth most common cancer and the third leading cause of cancer death in the world. In the United States, men, especially Asian/Pacific Islander men, have an increased risk of liver cancer. The number of new cases of liver cancer and the number of deaths from liver cancer continues to increase, especially among middle-aged Black, Hispanic, and white men. People are usually older than 40 years when they develop this cancer.

Finding and treating liver cancer early may prevent death from liver cancer.

Adult primary liver cancer

• Adult primary liver cancer is a disease in which malignant (cancer) cells form in the tissues of the liver.
• Having hepatitis or cirrhosis can affect the risk of adult primary liver cancer.
• Signs and symptoms of adult primary liver cancer include a lump or pain on the right side.
• Tests that examine the liver and the blood are used to detect (find) and diagnose adult primary liver cancer.
• Certain factors affect prognosis (chance of recovery) and treatment options.

The two types of adult primary liver cancer are:

• Hepatocellular carcinoma
• Cholangiocarcinoma (bile duct cancer)

The most common type of adult primary liver cancer is hepatocellular carcinoma. This type of liver cancer is the third leading cause of cancer-related deaths worldwide.

Primary liver cancer can occur in both adults and children. However, treatment for children is different than treatment for adults.

Risk factors

Anything that increases your chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn’t mean that you will not get cancer. Talk with your doctor if you think you may be at risk.

The following are risk factors for adult primary liver cancer:

• Having hepatitis B or hepatitis C. Having both hepatitis B and hepatitis C increases the risk even more.
• Having cirrhosis, which can be caused by:
  • Hepatitis (especially hepatitis C) 
  • Drinking large amounts of alcohol for many years or being an alcoholic.
• Having metabolic syndrome, a set of conditions that occur together, including extra fat around the abdomen, high blood sugar, high blood pressure, high levels of triglycerides and low levels of high-density lipoproteins in the blood.
• Having liver injury that is long-lasting, especially if it leads to cirrhosis.
• Having hemochromatosis, a condition in which the body takes up and stores more iron than it needs. The extra iron is stored in the liver, heart and pancreas
• Eating foods tainted with aflatoxin (poison from a fungus that can grow on foods, such as grains and nuts that have not been stored properly).

Hepatitis increases risk of liver cancer

Being infected with certain types of the hepatitis virus can cause hepatitis and increase the risk of liver cancer.

Hepatitis is most commonly caused by the hepatitis virus. Hepatitis is a disease that causes inflammation (swelling) of the liver. Damage to the liver from hepatitis that lasts a long time can increase the risk of liver cancer.

There are six types of the hepatitis virus. Hepatitis A (HAV), hepatitis B (HBV), and hepatitis C (HCV) are the three most common types. These three viruses cause similar symptoms, but the ways they spread and affect the liver are different.

The hepatitis A vaccine and the hepatitis B vaccine prevent infection with hepatitis A and hepatitis B. There is no vaccine to prevent infection with hepatitis C. If a person has had one type of hepatitis in the past, it is still possible to get the other types.

Hepatitis viruses include:

Hepatitis A

Hepatitis A is caused by eating food or drinking water infected with hepatitis A virus. It does not lead to chronic disease. People with hepatitis A usually get better without treatment.

Hepatitis B

Hepatitis B is caused by contact with the blood, semen or other body fluid of a person infected with hepatitis B virus. It is a serious infection that may become chronic and cause scarring of the liver (cirrhosis). This may lead to liver cancer. Blood banks test all donated blood for hepatitis B, which greatly lowers the risk of getting the virus from blood transfusions.

Hepatitis C

Hepatitis C is caused by contact with the blood of a person infected with hepatitis C virus. Hepatitis C may range from a mild illness that lasts a few weeks to a serious, lifelong illness. Most people who have hepatitis C develop a chronic infection that may cause scarring of the liver (cirrhosis). This may lead to liver cancer. Blood banks test all donated blood for hepatitis C, which greatly lowers the risk of getting the virus from blood transfusions.

Hepatitis D

Hepatitis D develops in people already infected with hepatitis B. It is caused by hepatitis D virus (HDV) and is spread through contact with infected blood or dirty needles, or by having unprotected sex with a person infected with HDV. Hepatitis D causes acute hepatitis.

Hepatitis E

Hepatitis E is caused by hepatitis E virus (HEV). Hepatitis E can be spread through oral-anal contact or by drinking infected water. Hepatitis E is rare in the United States.

Hepatitis G

Being infected with hepatitis G virus (HGV) has not been shown to cause liver cancer.

Symptoms

Signs and symptoms of adult primary liver cancer include a lump or pain on the right side.

These and other signs and symptoms may be caused by adult primary liver cancer or by other conditions. Check with your doctor if you have any of the following:

• A hard lump on the right side just below the rib cage
• Discomfort in the upper abdomen on the right side
• A swollen abdomen
• Pain near the right shoulder blade or in the back
• Jaundice (yellowing of the skin and whites of the eyes)
• Easy bruising or bleeding
• Unusual tiredness or weakness
• Nausea and vomiting
• Loss of appetite or feelings of fullness after eating a small meal
• Weight loss for no known reason
• Pale, chalky bowel movements and dark urine

Diagnosis

Screening

There is no standard or routine screening test for liver cancer.

Although there are no standard or routine screening tests for liver cancer, the following tests are being used or studied to screen for it:

Physical exam and history

An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.

Serum tumor marker test

A procedure in which a sample of blood is examined to measure the amounts of certain substances released into the blood by organs, tissues or tumor cells in the body. Certain substances are linked to specific types of cancer when found in increased levels in the blood. These are called tumor markers. An increased level of alpha-fetoprotein (AFP) in the blood may be a sign of liver cancer. Other cancers and certain noncancerous conditions, including cirrhosis and hepatitis, may also increase AFP levels. Sometimes the AFP level is normal even when there is liver cancer.

Liver function tests

A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by the liver. A higher than normal amount of a substance can be a sign of liver cancer.

CT scan (CAT scan)

A procedure that makes a series of detailed pictures of areas inside the body, such as the abdomen, taken from different angles. The pictures are made by a computer linked to an X-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography or computerized axial tomography. Images may be taken at three different times after the dye is injected, to get the best picture of abnormal areas in the liver. This is called triple-phase CT. A spiral or helical CT scan makes a series of very detailed pictures of areas inside the body using an X-ray machine that scans the body in a spiral path.

MRI (magnetic resonance imaging)

A procedure that uses a magnet, radio waves and a computer to make a series of detailed pictures of areas inside the body, such as the liver. Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later.

Biopsy

The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. Procedures used to collect the sample of cells or tissues include the following:

• Fine-needle aspiration biopsy: The removal of cells, tissue or fluid using a thin needle.
• Core needle biopsy: The removal of cells or tissue using a slightly wider needle.
• Laparoscopy: A surgical procedure to look at the organs inside the abdomen to check for signs of disease. Small incisions (cuts) are made in the wall of the abdomen and a laparoscope (a thin, lighted tube) is inserted into one of the incisions. Another instrument is inserted through the same or another incision to remove the tissue samples.

A biopsy is not always needed to diagnose adult primary liver cancer.

Risks of liver cancer screening

The risks of liver cancer screening include the following:

False-negative test results can occur.

Screening test results may appear to be normal even though liver cancer is present. A person who receives a false-negative test result (one that shows there is no cancer when there really is) may delay seeking medical care even if there are symptoms.

False-positive test results can occur.

Screening test results may appear to be abnormal even though no cancer is present. A false-positive test result (one that shows there is cancer when there really isn't) can cause anxiety and is usually followed by diagnostic tests and procedures, such as a liver biopsy, which also have risks.

Side effects may be caused by procedures to diagnose liver cancer.

Abnormal screening results may lead to a liver biopsy to diagnose liver cancer. Liver biopsy may cause the following rare, but serious, side effects:

• Trouble breathing
• Leakage of bile, which can cause an infection of the lining of the abdomen
• A small puncture (hole) in an organ in the abdomen
• Spread of cancer cells along the needle path when the biopsy needle is inserted and withdrawn (taken out)

Your doctor can advise you about your risk for liver cancer and your need for screening tests.

Stages of adult primary liver cancer

After adult primary liver cancer has been diagnosed, tests are done to find out if cancer cells have spread within the liver or to other parts of the body.

The process used to find out if cancer has spread within the liver or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:

• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, such as the chest, abdomen and pelvis taken from different angles. The pictures are made by a computer linked to an X-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography or computerized axial tomography.
• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves and a computer to make a series of detailed pictures of areas inside the bodyPET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.

Treatment

Certain factors affect prognosis and treatment options.

• The stage of the cancer (the size of the tumor, whether it affects part or all of the liver, or has spread to other places in the body)
• How well the liver is working
• The patient’s general health, including whether or not there is cirrhosis of the liver

Different types of treatments are available for patients with adult primary liver cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Patients with liver cancer are treated by a team of specialists who are experts in treating liver cancer.

The patient's treatment will be overseen by a medical oncologist, a doctor who specializes in treating people with cancer. The medical oncologist may refer the patient to other health professionals who have special training in treating patients with liver cancer. These may include the following specialists:

• Hepatologist (specialist in liver disease)
• Surgical oncologist
• Transplant surgeon
• Radiation oncologist
• Interventional radiologist (a specialist who diagnoses and treats diseases using imaging and the smallest incisions possible)

Types of treatment

Seven types of standard treatment are used:

Surveillance

Surveillance for lesions smaller than 1 centimeter found during screening. Follow-up every three months is common.

Surgery

A partial hepatectomy (surgery to remove the part of the liver where cancer is found) may be done. A wedge of tissue, an entire lobe, or a larger part of the liver, along with some of the healthy tissue around it is removed. The remaining liver tissue takes over the functions of the liver and may regrow.

Liver transplant

In a liver transplant, the entire liver is removed and replaced with a healthy donated liver. A liver transplant may be done when the disease is in the liver only and a donated liver can be found. If the patient has to wait for a donated liver, other treatment is given as needed.

Ablation therapy

Ablation therapy removes or destroys tissue. Different types of ablation therapy are used for liver cancer.

Radiofrequency ablation: The use of special needles that are inserted directly through the skin or through an incision in the abdomen to reach the tumor. High-energy radio waves heat the needles and tumor which kills cancer cells.

Microwave therapy: A type of treatment in which the tumor is exposed to high temperatures created by microwaves. This can damage and kill cancer cells or make them more sensitive to the effects of radiation and certain anticancer drugs.

Embolization therapy

Embolization therapy is the use of substances to block or decrease the flow of blood through the hepatic artery to the tumor. When the tumor does not get the oxygen and nutrients it needs, it will not continue to grow. Embolization therapy is used for patients who cannot have surgery to remove the tumor or ablation therapy and whose tumor has not spread outside the liver.

The liver receives blood from the hepatic portal vein and the hepatic artery. Blood that comes into the liver from the hepatic portal vein usually goes to the healthy liver tissue. Blood that comes from the hepatic artery usually goes to the tumor. When the hepatic artery is blocked during embolization therapy, the healthy liver tissue continues to receive blood from the hepatic portal vein.

There are two main types of embolization therapy:

Transarterial embolization (TAE): A small incision (cut) is made in the inner thigh and a catheter (thin, flexible tube) is inserted and threaded up into the hepatic artery. Once the catheter is in place, a substance that blocks the hepatic artery and stops blood flow to the tumor is injected.

Transarterial chemoembolization (TACE): This procedure is like TAE except an anticancer drug is also given. The procedure can be done by attaching the anticancer drug to small beads that are injected into the hepatic artery or by injecting the anticancer drug through the catheter into the hepatic artery and then injecting the substance to block the hepatic artery. Most of the anticancer drug is trapped near the tumor and only a small amount of the drug reaches other parts of the body. This type of treatment is also called chemoembolization.

Targeted therapy

Targeted therapy is a treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells. Adult liver cancer may be treated with a targeted therapy drug that stops cells from dividing and prevents the growth of new blood vessels that tumors need to grow.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy X-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy, external and internal. 

External radiation therapy uses a machine outside the body to send radiation toward the cancer. Certain ways of giving radiation therapy can help keep radiation from damaging nearby healthy tissue. These types of external radiation therapy include the following:

• Conformal radiation therapy: Conformal radiation therapy is a type of external radiation therapy that uses a computer to make a 3-dimensional (3-D) picture of the tumor and shapes the radiation beams to fit the tumor. This allows a high dose of radiation to reach the tumor and causes less damage to nearby healthy tissue.
• Stereotactic body radiation therapy: Stereotactic body radiation therapy is a type of external radiation therapy. Special equipment is used to place the patient in the same position for each radiation treatment. Once a day for several days, a radiation machine aims a larger than usual dose of radiation directly at the tumor. By having the patient in the same position for each treatment, there is less damage to nearby healthy tissue. This procedure is also called stereotactic external-beam radiation therapy and stereotaxic radiation therapy.
• Cyberknife radiosurgery, which is not really surgery. The CyberKnife’s robotic arm will position itself around your body, delivering radiation with pinpoint precision.

Selective internal radiation therapy, also called radioembolization, uses radioactive beads delivered directly to the cancer in the liver through blood vessels that go to the liver.