Liver Cancer

Liver tumors may be noncancerous (benign) or cancerous (malignant).

Cancerous liver tumors are classified as primary (originating in the liver) or metastatic (spreading from elsewhere in the body). Most liver cancers are metastatic. Cancers often spread to the liver because when cancer cells break away from cancer elsewhere in the body, they often enter and travel through the bloodstream, and the liver filters most of the blood from the rest of the body.

Noncancerous liver tumors are relatively common and usually cause no symptoms. However, rarely, these tumors cause discomfort in the upper right part of the abdomen or cause the liver to enlarge or to bleed into the abdominal cavity. Noncancerous liver tumors include

• Hepatic cysts
• Hepatic granulomas
• Hemangiomas

Most noncancerous tumors are detected only when an imaging test—such as ultrasonography, computed tomography (CT), or magnetic resonance imaging (MRI)—is done for an unrelated reason. The liver usually functions normally even when a noncancerous tumor is present. Thus, results of blood tests to evaluate liver function are usually normal. Treatment may or may not be needed.

Cysts

Fluid-filled sacs (cysts) sometimes form in the liver. Most cause no symptoms or health problems. They are detected incidentally by imaging tests.

Rarely, people are born with many cysts in the liver (a disorder called polycystic liver disease). Usually, these people also have cysts in other organs, such as the kidneys (a disorder called polycystic kidney disease). The liver enlarges but usually continues to function well.

Primary liver cancers

Primary liver cancers are cancers that originate in the liver. The most common is hepatocellular carcinoma(hepatoma). At first, liver cancer usually causes only vague symptoms (such as weight loss, loss of appetite, and fatigue). As a result, the diagnosis is often made late, and the prognosis is usually poor.

Other primary liver cancers

Other primary liver cancers are uncommon or rare. For diagnosis, a biopsy is usually needed. Most people with these cancers have a poor prognosis. If the cancer has not spread, it can sometimes be removed. When it can be removed, people may live several years or longer.

Cholangiocarcinoma

This relatively slow-growing cancer originates in the lining of the bile ducts in or outside the liver. In China, infestation with liver flukes (a parasite) contributes to the development of this cancer. People with primary sclerosing cholangitis are at risk of developing cholangiocarcinoma.

Symptoms of the cancer are often vague but may include sudden deterioration of the person's general health, a mass in the upper right part of the abdomen, jaundice (a yellowish discoloration of the skin and the whites of the eyes), weight loss, and abdominal discomfort.

Fibrolamellar carcinoma

This type of hepatocellular carcinoma is rare. It usually affects relatively young adults. It is not caused by preexisting cirrhosis or hepatitis B or C and has no other known risk factors.

People with fibrolamellar carcinoma usually fare better than those with other types of hepatocellular carcinoma. Many live several years after this cancer is removed.

Hepatoblastoma

This cancer is rare but is one of the most common primary liver cancers in infants. Occasionally, it occurs in older children and may produce hormones (called gonadotropins) that result in early (precocious) puberty. No cause has been identified.

Health may generally deteriorate, and a mass may be felt in the upper right part of the abdomen.

Angiosarcoma

This rare cancer originates in the blood vessels of the liver. An angiosarcoma may be caused by exposure to vinyl chloride in the workplace, as occurs in the manufacture of polyvinyl chloride (PVC), or by exposure to arsenic. However, in most people, no cause is identified.

Diagnosis

• Physical examination
• Blood and imaging tests
• Sometimes liver biopsy

A hepatoblastoma is usually suspected when doctors feel a large mass in the upper right part of an infant's abdomen and the infant's health is deteriorating. Results of blood tests to measure levels of alpha-fetoprotein levels and imaging tests may help doctors make the diagnosis. Levels of alpha-fetoprotein—a protein normally produced by immature liver cells in fetuses—usually increase when liver cancer is present.

Cholangiocarcinoma in the liver, fibrolamellar carcinoma, hepatoblastoma, and angiosarcoma are diagnosed by liver biopsy (removal of a sample of liver tissue with a needle for examination under a microscope).

Cholangiocarcinoma of the bile ducts outside the liver is usually diagnosed using special x-ray techniques (such as endoscopic retrograde cholangiopancreatography [ERCP] or percutaneous transhepatic cholangiography—see Imaging Tests of the Liver and Gallbladder) or surgery. In two thirds of people with this type of cancer, the cancer has already spread to nearby lymph nodes by the time it is detected.

Treatment

• Surgical removal of cancer

Usually, treatment of these cancers has little effect, and most people die within a few months of when the cancer was detected. However, if the cancer is detected relatively early, it may be surgically removed, offering the hope of long-term survival.

Metastatic liver cancer

Metastatic liver cancer is a cancer that has spread to the liver from elsewhere in the body.

• Weight loss and a poor appetite may be the first symptoms.
• Doctors base the diagnosis on results of blood tests and usually biopsy.
• Chemotherapy drugs and radiation therapy may help relieve symptoms but do not cure the cancer.

Metastatic liver cancer most commonly originates in the lungs, breasts, large intestine, pancreas, or stomach. Leukemia (a cancer of white blood cells) and lymphoma (a cancer of the lymph system), especially Hodgkin lymphoma, may involve the liver.

Cancers spread to the liver because the liver filters most of the blood from the rest of the body, and when cancer cells break away from a primary cancer, they often enter and travel through the bloodstream. Sometimes the discovery of metastatic liver cancer is the first indication that a person has cancer.

Symptoms

Often, the first symptoms are vague. They include weight loss, poor appetite, and sometimes fever. Typically, the liver is enlarged and hard. It may feel tender and often lumpy. Occasionally, the spleen is enlarged, especially if the cancer originated in the pancreas. At first, unless the cancer is blocking the bile ducts, the person has mild or no jaundice (a yellowish discoloration of the skin and the whites of the eyes). Later, the abdomen may become swollen (distended) with fluid (a condition called ascites).

In the weeks before death, jaundice progressively worsens. People may become confused and drowsy as toxins accumulate in the brain because the liver is too damaged to remove them from the blood. This condition is called hepatic encephalopathy.

Diagnosis

• Liver imaging tests

Doctors may suspect metastatic liver cancer in people who lose weight and have an enlarged liver or who have a cancer that tends to spread to the liver. However, doctors often have difficulty diagnosing the cancer until it is advanced.

If doctors suspect liver cancer, liver function tests, which are simple blood tests, are done to evaluate how well the liver is functioning. Results may be abnormal, as they are in many disorders. Thus, this finding cannot confirm the diagnosis. Ultrasonography is usually helpful, but computed tomography (CT) and magnetic resonance imaging (MRI) of the liver are usually more accurate in detecting the cancer. Before CT or MRI is done, a contrast agent is injected into a vein. The contrast agent helps make abnormalities, if present, easier to check for Imaging Tests of the Liver and Gallbladder). However, imaging tests cannot always detect small tumors or distinguish cancer from cirrhosis or other abnormalities.

            Metastatic Liver Cancer

A liver biopsy (removal of a sample of liver tissue with a needle for examination under a microscope) is done if the diagnosis is unclear after imaging tests or if more information is needed to help with treatment decisions. To improve the chances of obtaining cancerous tissue, doctors use ultrasonography or CT to guide the placement of the biopsy needle. Alternatively, doctors may insert a flexible viewing tube (laparoscope) through a tiny incision in the abdomen to better identify and obtain cancerous tissue.

Treatment

• Chemotherapy
• Radiation
• Surgery

Treatment depends on how far the cancer has spread and what the primary cancer is. Options include the following:

• Chemotherapy drugs: These drugs may be used to temporarily shrink the tumor and prolong life, but they do not cure the cancer. Chemotherapy drugs may be injected into the liver's main artery (the hepatic artery), delivering a large amount of the drugs directly to the cancer cells in the liver. With this method, the rest of the body is less exposed to the drugs, and thus side effects are fewer and milder.
• Radiation therapy to the liver: Sometimes this treatment reduces severe pain caused by advanced cancer, but it has little other benefit.
• Surgery: If only a single tumor or a few tumors are found in the liver, they may be surgically removed, especially if they originated in the intestines. However, not all experts consider this surgery worthwhile.

If the primary cancer is leukemia or lymphoma, doctors focus on treating that cancer.

If cancer has spread extensively, usually all a doctor can do is relieve the symptoms . People may prepare an advance directive to specify the type of care they desire if they become unable to make decisions about care.