Liver Cancer

Liver cancer begins in the cells of the liver. The liver is the body's largest internal organ, and it plays several vital roles: breaking down and storing nutrients, producing and excreting bile, regulating clotting factors and detoxifying harmful substances.

Liver cancer is one of the most common causes of cancer death worldwide, contributing to over 700,000 deaths each year. The American Cancer Society estimated that in 2020 there would be about 42,810 new cases of primary liver cancer and intrahepatic bile duct cancer in the United States, and about 30,160 deaths from these cancers.

Types of liver cancer

The main types of liver cancer are:

• Hepatocellular carcinoma (HCC): the most common type, which starts in the hepatocytes (the main type of liver cell).
• Cholangiocarcinoma (bile duct cancer): starts in the bile ducts, the thin tubes that carry bile from the liver to the gallbladder and small intestine.
• Angiosarcoma or haemangiosarcoma: a rare, fast-growing cancer that starts in the blood vessels of the liver.
• Hepatoblastoma: a very rare cancer that occurs in children, usually those younger than four.
• Secondary (metastatic) liver cancer: a cancer that starts in another part of the body — commonly the colon — and spreads (metastasises) to the liver.

Risk factors

Several factors can increase the risk of developing liver cancer:

• Gender: men are more likely to develop liver cancer than women, with both incidence and death rates higher in men.
• Race/ethnicity: liver cancer is more common in sub-Saharan Africa and Southeast Asia.
• Chronic viral hepatitis: chronic infection with hepatitis B (HBV) or hepatitis C (HCV) raises the risk.
• Cirrhosis: irreversible scarring of the liver also increases the risk.
• Inherited metabolic diseases: conditions such as haemochromatosis and Wilson's disease raise the risk of both cirrhosis and liver cancer.
• Diabetes: people with diabetes are at higher risk.
• Non-alcoholic fatty liver disease: a build-up of fat in the liver, common in people who are obese, which increases the risk of cirrhosis and liver cancer.
• Aflatoxins: cancer-causing substances made by a fungus that grows on crops; long-term exposure is a major risk factor.
• Overconsumption of alcohol: prolonged heavy drinking can cause irreversible liver damage and raise the risk.
• Smoking: smokers and ex-smokers are more likely to develop liver cancer.
• Obesity: people who are very overweight are at higher risk.

Signs and symptoms

Signs and symptoms of liver cancer may include:

• unintentional weight loss
• loss of appetite, or feeling full after a small meal
• persistent weakness or fatigue
• nausea and vomiting
• an enlarged liver (hepatomegaly)
• upper abdominal pain, or pain near the right shoulder blade
• swelling or fluid build-up in the abdomen (ascites)
• yellowing of the skin and eyes (jaundice)

How liver cancer is diagnosed

Several tests may be used to diagnose liver cancer and find out whether it has spread:

• Imaging tests: ultrasound, CT and MRI scans, and angiogram. A bone scan may be used to check whether the cancer has spread to the bones, and a PET/CT scan to find out whether it has spread to other parts of the body.
• Liver biopsy: taking a sample of tissue, which may be done by needle, laparoscopically or surgically.
• Blood tests: to detect any liver abnormalities.

Treatment options

After diagnosis, your doctor will establish the stage of the disease. Taking into account your current health, medical history and the results of staging, they will discuss the most suitable treatment options with you. Regular follow-up and periodic monitoring with tests and investigations are strongly recommended.

Treatment options include:

• Surgery: removing the tumour through surgical resection with a partial hepatectomy, or a liver transplant.
• Ablation destroys liver cancer cells without removing the tumour. Methods include:
• radiofrequency ablation (RFA): high-energy radio waves heat the tumour and destroy the cancer cells.
• microwave ablation (MWA): energy from electromagnetic waves heats the tumour and destroys the cancer cells.
• cryoablation (cryotherapy): cold gases freeze the tumour and kill the cancer cells.
• ethanol (alcohol) ablation: concentrated alcohol is injected into the tumour to damage the cancer cells.
• Embolization therapy reduces the tumour's blood supply by injecting substances directly into an artery in the liver. Types include trans-arterial embolization (TAE), trans-arterial chemoembolization (TACE), drug-eluting bead chemoembolization (DEB-TACE) and radioembolization (RE).
• Radiotherapy uses high-powered energy beams to kill cancer cells. It is not recommended for people with severe liver damage.
• Targeted therapy uses drugs that act on specific abnormalities within cancer cells.
• Immunotherapy uses immune cells, or drugs that prompt the immune system, to kill cancer cells.
• Chemotherapy destroys cancer cells either systemically, with drugs given intravenously or orally, or regionally, with drugs delivered directly into the hepatic artery.
• Alternative treatments use other science-based approaches to attack cancer cells.

Reducing your risk

Steps that may help reduce the risk of liver cancer include:

• preventing and treating hepatitis B and C infections
• limiting smoking and alcohol
• maintaining a healthy weight
• limiting exposure to cancer-causing substances
• treating conditions that increase the risk of liver cancer