Liver Cancer

What is liver cancer?

The liver is one of the largest organs in the body.  It is just beneath the right rib cage and consists of two lobes.  Liver cancer is cancer of the liver.  Hepatocellular carcinoma, also called hepatoma, is the most common form of primary adult liver cancer.  It accounts for approximately 75% of adult liver cancer.  In the United States, primary adult liver cancer is rare.  The majority of liver cancers in the United States are secondary liver cancers.  These are cancers that originated in another part of the body, such as lung, pancreas, colon, stomach and metastasize or spread to the liver.  If the cancer originated in another part of the body, such as the lung, but has metastasized to the liver, it is considered  cancer of the originating cancer site, such as the lung, that has metastasized to the liver.  This document will focus on adult primary liver cancer.

What are risk factors for liver cancer?

Risk factors increase the chance of getting liver cancer, but not everyone with a risk factor gets liver cancer. 

• Hepatitis B and C – These viruses are transmitted through the blood and have a high rate of leading to cirrhosis of the liver. 
• Cirrhosis – This is a permanent scarring of the liver tissue.  Most cases of cirrhosis of liver in the United States are due to excessive alcohol use.
• Hereditary conditions – Those with certain inherited conditions such as hemochromatosis, have an increased risk of cirrhosis and liver cancer.
• Aflatoxins – Exposure to these highly toxic carcinogens increase the risk of liver cancer.  Aflaxotins are formed from fungas that contaminate certain foods, such as nuts, corn, rice, soybeans.  The FDA has mechanisms in place to regulate the afloxatins in foods.
• Arsenic – Long term exposure to drinking water with arsenic, which can occur in natural water supplies, can increase the risk of liver cancer.
• Chemical exposure – Exposure to Vinyl chloride and thorium dioxide increases the risk of liver cancer.  Vinyl chloride is a chemical used in plastic manufacturing.  Thorium dioxide was given in the past to people under going X-ray testing.  This chemical is no longer used for medical purposes.
• Tobacco use – Smoking increases the risk for many cancers including liver cancer.
• Alcohol Abuse – This leads to cirrhosis of the liver and increases the risk for liver cancer.
  

What are prevention strategies for liver cancers?

While it’s not always possible to prevent liver cancer, there are steps to reduce risk factors for liver cancer.

• Protect against Hepatitis B and C viruses – There is a vaccine for Hepatitis B, but there is no vaccine currently available for Hepatitis C.  Both these viruses are transmitted through the blood.  It is important not to engage in unprotected sex unless you’re in a monogamous relationship with a partner you know is not infected with any sexually transmitted disease.  For those who inject drugs, it is important to seek treatment to quit this addiction.  If injecting drugs, the needles need to be clean.  Many communities offer needle exchange programs as well as addiction centers to help drug users quit their habit.  Not all counties screen their blood supply as the United States does.  So if you need to receive blood in another country, you should get screened for Hepatitis B and C when returning home.
• Avoid Exposure to chemicals – The liver filters toxins in the body, so its important to avoid harmful substances in food and products.
• Medications – Certain medications are harmful to the liver.  It is important to discuss risk factors of medicines you take.  Avoid mixing alcohol with acetaminophen as it can cause damage to the liver.
• Alcohol - Avoiding alcohol or limiting to no more than one drink daily reduces the risk of cirrhosis of the liver and liver cancer.
• Tobacco – Do not smoke or if you smoke, quit smoking (link to tobacco document under prevention). 
  

Is screening available?

There are no established national guidelines for liver screening.  It is important if a person is at high risk to discuss options with their healthcare provider.

What are the symptoms of liver cancer?

There may not be any symptoms in the early stages of liver cancer.  These symptoms may be signs of other conditions.  It is important to see your doctor if you have any of the following.

• Enlarged liver, hard lump under the right rib cage
• Discomfort in the abdomen on the right side
• Unexplained weight loss
• Loss of appetite
• Unusual fatigue
• Nausea
• Jaundice, which is evident through yellowing of the skin and the whites of the eyes
  

How is liver cancer diagnosed?

• History and physical examination – to assess risk factors, family history and gather information gathering on things such as weight, pain, symptoms, and medical condition.
• Alpha-fetaprotein (AFP) – Elevated AFP levels in the blood may indicate liver cancer or other conditions.
• Computed tomography (CT) scan – This is used in making initial diagnosis and is helpful in staging the cancer.
• Magnetic resonance imaging (MRI) – Like the CT scan, it is helpful with diagnosis and staging.
• Ultrasound - Ultrasound uses sound waves to create an image on a video screen.  Tumors and normal tissue reflect sound waves differently.
• Biopsy – This removes tissue to check for cancer.
• Laproscopy – A laparoscope, a thin lighted tube, is inserted into an incision in the abdomen .  A biopsy may be performed at this time.
  

What is staging?

Staging describes the extent of the cancer.  It determines if the cancer has spread and if so, what parts of the body are affected.  Staging a cancer is important to assist the doctor to determine the appropriate course of treatment and assess an accurate prognosis. 

The most common staging system is the TNM.

• T – size of the tumor
• N – degree to which regional lymph nodes are involved
• M – the absence or presence of distant metastases

Once the TNM has been determined, then a stage of I, II, III or IV is assigned.

• Stage I – cancers are small and local and usually curable
• Stage II & III – typically these are locally advanced and could involve the lymph nodes
• Stage IV – cancer has metastasized and can be inoperable
  

What are treatment options?

There are four standard treatments used.  Treatment depends on the stage of the cancer and the health of the patient. 

Surgery

• Cryosurgery – A treatment used to freeze abnormal tissue.
• Partial hepatectomy – This removes the part of the liver where cancer is found.
• Total hepatectomy – This removes the entire live and a liver transplant is required.  A person cannot live without their liver.
• Radiofrequency ablation – This involves a special probe that uses electrodes to kill cancer cells.

Radiation Therapy

• External radiation – This uses high energy radiation to kill cancer cells.
• Internal radiation – Radioactive substances is put into sealed materials such as needles, seeds and put near or into the cancer.
• Radiosensitizers – These drugs make the cancer cells more sensitive to radiation.
• Radiolabeled antibodies – Antibodies containing radioactive substances are injected into the body to kill the cancer cells.

Chemotherapy

• Systemic chemotherapy – Anti-cancer drugs are administered through the veins or orally to kill cancer cells.
• Regional chemotherapy - A pump containing anti-cancer drugs are placed in the body to directly supply the blood vessels that go to the tumor.

Percutaneous ethanol injection

• This treatment involves injecting ethanol,  an alcohol, directly into the tumor to kill the cancer cells.
  

What clinical trials are available?

Clinical trials are studies that seek to find better ways to prevent, screen, diagnose and treat a disease such as cancer.  Clinical trials test new approaches to treatment, such as new drugs, new approaches to surgery or radiation therapy, or a combination of treatments.

Learn more about clinical trials.

What questions should I ask my doctor?

It is often helpful to make a list of questions before an appointment.  This will help you to remember what the doctor says.  Patients and care givers can write notes or ask if they may use a tape recorder.  Sometimes it is helpful to have a family member or friend at the appointment to take notes, ask questions or just listen.  Below are a few suggested questions a patient may ask their doctor.

Will you please write down the type of cancer that I have?

What stage is my cancer and what does that mean?

What are my treatment options?

What treatment do you recommend and why?

What are the risks and benefits of each treatment?

What are possible side effects of treatment?

How will you help manage my side effects?

How will treatment affect my normal activities?

Are there specific things I must do to get ready for treatment?

Are there other things I can be doing to help with my treatment, such as diet and exercise?

What resources can I use to learn more about my cancer and help me deal with it?

Make an appointment

Resources

American Cancer Society – www.cancer.org, 1-800-ACS-2345

National Cancer Institute – www.cancer.gov, 1-800-4CANCER