Liver Cancer

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Learning about medical care for liver cancer can help you take an active part in making choices about your care. This tells about:

• Diagnosis and staging
  
  
• Treatment and supportive care
  
  
• Taking part in research studies

This has lists of questions that you may want to ask your doctor. Many people find it helpful to take a list of questions to a doctor visit. To help remember what your doctor says, you can take notes or ask whether you may use a tape recorder. You may also want to have a family member or friend go with you when you talk with the doctor--to take notes, ask questions, or just listen.

This is mainly about adult liver cancer. It does not deal with childhood liver cancer. .

Back to Top The Liver

The liver is the largest organ inside your abdomen. It's found behind your ribs on the right side of your body.

The liver does important work to keep you healthy:

• It removes harmful substances from the blood.
  
  
• It makes enzymes and bile that help digest food.
  
  
• It also converts food into substances needed for life and growth.

The liver gets its supply of blood from two vessels. Most of its blood comes from the hepatic portal vein. The rest comes from the hepatic artery.

   

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Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body.

Normal cells grow and divide to form new cells as the body needs them. When normal cells grow old or get damaged, they die, and new cells take their place.

Sometimes, this process goes wrong. New cells form when the body doesn't need them, and old or damaged cells don't die as they should. The buildup of extra cells often forms a mass of tissue called a growth, nodule, or tumor.

Growths in the liver can be benign (not cancer) or malignant (cancer). Benign tumors are not as harmful as malignant tumors:

• Benign tumors:
  • are rarely a threat to life
  • can be removed and usually don't grow back
  • don't invade the tissues around them
  • don't spread to other parts of the body
  
  
• Malignant growths:
  • may be a threat to life
  • sometimes can be removed but can grow back
  • can invade and damage nearby tissues and organs (such as the stomach or intestine)
  • can spread to other parts of the body

Most primary liver cancers begin in hepatocytes (liver cells). This type of cancer is called hepatocellular carcinoma or malignant hepatoma.

Liver cancer cells can spread by breaking away from the original tumor. They mainly spread by entering blood vessels, but liver cancer cells can also be found in lymph nodes. The cancer cells may attach to other tissues and grow to form new tumors that may damage those tissues. See the Staging section for information about liver cancer that has spread.

Back to Top

Risk Factors

When you get a diagnosis of cancer, it's natural to wonder what may have caused the disease. Doctors can't always explain why one person gets liver cancer and another doesn't. However, we do know that people with certain risk factors may be more likely than others to develop liver cancer. A risk factor is something that may increase the chance of getting a disease.

Studies have found the following risk factors for liver cancer:

• Infection with hepatitis B virus (HBV) or hepatitis C virus (HCV): Liver cancer can develop after many years of infection with either of these viruses. Around the world, infection with HBV or HCV is the main cause of liver cancer.
  
  HBV and HCV can be passed from person to person through blood (such as by sharing needles) or sexual contact. An infant may catch these viruses from an infected mother. Although HBV and HCV infections are contagious diseases, liver cancer is not. You can't catch liver cancer from another person.
  
  HBV and HCV infections may not cause symptoms, but blood tests can show whether either virus is present. If so, the doctor may suggest treatment. Also, the doctor may discuss ways to avoid infecting other people.
  
  In people who are not already infected with HBV, hepatitis B vaccine can prevent HBV infection. Researchers are working to develop a vaccine to prevent HCV infection.
  
  
• Heavy alcohol use: Having more than two drinks of alcohol each day for many years increases the risk of liver cancer and certain other cancers. The risk increases with the amount of alcohol that a person drinks.
  
  
• Aflatoxin: Liver cancer can be caused by aflatoxin, a harmful substance made by certain types of mold. Aflatoxin can form on peanuts, corn, and other nuts and grains. In parts of Asia and Africa, levels of aflatoxin are high. However, the United States has safety measures limiting aflatoxin in the food supply.
  
  
• Iron storage disease: Liver cancer may develop among people with a disease that causes the body to store too much iron in the liver and other organs.
  
  
• Cirrhosis: Cirrhosis is a serious disease that develops when liver cells are damaged and replaced with scar tissue. Many exposures cause cirrhosis, including HBV or HCV infection, heavy alcohol use, too much iron stored in the liver, certain drugs, and certain parasites. Almost all cases of liver cancer in the United States occur in people who first had cirrhosis, usually resulting from hepatitis B or C infection, or from heavy alcohol use.
  
  
• Obesity and diabetes: Studies have shown that obesity and diabetes may be important risk factors for liver cancer.

The more risk factors a person has, the greater the chance that liver cancer will develop. However, many people with known risk factors for liver cancer don't develop the disease.

Back to Top Symptoms

Early liver cancer often doesn't cause symptoms. When the cancer grows larger, people may notice one or more of these common symptoms:

• Pain in the upper abdomen on the right side
  
  
• A lump or a feeling of heaviness in the upper abdomen
  
  
• Swollen abdomen (bloating)
  
  
• Loss of appetite and feelings of fullness
  
  
• Weight loss
  
  
• Weakness or feeling very tired
  
  
• Nausea and vomiting
  
  
• Yellow skin and eyes, pale stools, and dark urine from jaundice
  
  
• Fever

These symptoms may be caused by liver cancer or other health problems. If you have any of these symptoms, you should tell your doctor so that problems can be diagnosed and treated as early as possible.

Back to Top Diagnosis

If you have symptoms that suggest liver cancer, your doctor will try to find out what's causing the problems.

You may have one or more of the following tests:

• Physical exam: Your doctor feels your abdomen to check the liver, spleen, and other nearby organs for any lumps or changes in their shape or size. Your doctor also checks for ascites, an abnormal buildup of fluid in the abdomen. Also, your skin and eyes may be checked for signs of jaundice.
  
  
• Blood tests: Many blood tests may be used to check for liver problems. One blood test detects alpha-fetoprotein (AFP). High AFP levels could be a sign of liver cancer. Other blood tests can show how well the liver is working.
  
  
• CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your liver and other organs and blood vessels in your abdomen. You may receive an injection of contrast material so that your liver shows up clearly in the pictures. On the CT scan, your doctor may see tumors in the liver or elsewhere in the abdomen.
  
  
• MRI: A large machine with a strong magnet linked to a computer is used to make detailed pictures of areas inside your body. Sometimes contrast material makes abnormal areas show up more clearly on the picture.
  
  
• Ultrasound test: The ultrasound device uses sound waves that can't be heard by humans. The sound waves produce a pattern of echoes as they bounce off internal organs. The echoes create a picture (sonogram) of your liver and other organs in the abdomen. Tumors may produce echoes that are different from the echoes made by healthy tissues.

Biopsy

A biopsy usually is not needed to diagnose liver cancer, but in some cases, the doctor may remove a sample of tissue. A pathologist uses a microscope to look for cancer cells in the tissue.

The doctor may obtain tissue in one of several ways:

• A needle through the skin: The doctor inserts a thin needle into the liver to remove a small amount of tissue. CT or ultrasound may be used to guide the needle.
  
  
• Laparoscopic surgery: The surgeon makes a few small incisions in your abdomen. A thin, lighted tube (laparoscope) is inserted through the incision. The laparoscope has a tool to remove tissue from the liver.
  
  
• Open surgery: The surgeon can remove tissue from the liver through a large incision.

Back to Top Staging

If liver cancer is diagnosed, your doctor needs to learn the extent (stage) of the disease to help you choose the best treatment. Staging is an attempt to find out whether the cancer has spread, and if so, to what parts of the body.

When liver cancer spreads, the cancer cells may be found in the lungs. Cancer cells also may be found in the bones and in lymph nodes near the liver.

When cancer spreads from its original place to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary tumor. For example, if liver cancer spreads to the bones, the cancer cells in the bones are actually liver cancer cells. The disease is metastatic liver cancer, not bone cancer. It's treated as liver cancer, not bone cancer. Doctors sometimes call the new tumor "distant" or metastatic disease.

To learn whether the liver cancer has spread, your doctor may order one or more of the following tests:

• CT scan of the chest: A CT scan often can show whether liver cancer has spread to the lungs.
  
  
• Bone scan: The doctor injects a small amount of a radioactive substance into your blood vessel. It travels through the bloodstream and collects in the bones. A machine called a scanner detects and measures the radiation. The scanner makes pictures of the bones. The pictures may show cancer that has spread to the bones.
  
  
• PET scan: You receive an injection of a small amount of radioactive sugar. The radioactive sugar gives off signals that the PET scanner picks up. The PET scanner makes a picture of the places in your body where the sugar is being taken up. Cancer cells show up brighter in the picture because they take up sugar faster than normal cells do. A PET scan shows whether liver cancer may have spread.

Back to Top Treatment

Treatment options for people with liver cancer are surgery (including a liver transplant), ablation, embolization, targeted therapy, radiation therapy, and chemotherapy. You may have a combination of treatments.

The treatment that's right for you depends mainly on the following:

• the number, size, and location of tumors in your liver
  
  
• how well your liver is working and whether you have cirrhosis
  
  
• whether the cancer has spread outside your liver

Other factors to consider include your age, general health, and concerns about the treatments and their possible side effects.

At this time, liver cancer can be cured only when it's found at an early stage (before it has spread) and only if people are healthy enough to have surgery. For people who can't have surgery, other treatments may be able to help them live longer and feel better. Many doctors encourage people with liver cancer to consider taking part in a clinical trial. Clinical trials are research studies testing new treatments. They are an important option for people with all stages of liver cancer. See the Taking Part in Cancer Research section.

Your doctor may refer you to a specialist, or you may ask for a referral. Specialists who treat liver cancer include surgeons (especially hepatobiliary surgeons, surgical oncologists, and transplant surgeons), gastroenterologists, medical oncologists, and radiation oncologists. Your health care team may also include an oncology nurse and a registered dietitian.

Your health care team can describe your treatment choices, the expected results of each, and the possible side effects. Because cancer therapy often damages healthy cells and tissues, side effects are common. Before treatment starts, ask your health care team about possible side effects and how treatment may change your normal activities. You and your health care team can work together to develop a treatment plan that meets your needs.

Surgery

Surgery is an option for people with an early stage of liver cancer. The surgeon may remove the whole liver or only the part that has cancer. If the whole liver is removed, it's replaced with healthy liver tissue from a donor.

You and your surgeon can talk about the types of surgery and which may be right for you.

Removal of part of the liver

Surgery to remove part of the liver is called partial hepatectomy. A person with liver cancer may have part of the liver removed if lab tests show that the liver is working well and if there is no evidence that the cancer has spread to nearby lymph nodes or to other parts of the body.

The surgeon removes the tumor along with a margin of normal liver tissue around the tumor. The extent of the surgery depends on the size, number, and location of the tumors. It also depends on how well the liver is working.

As much as 80 percent of the liver may be removed. The surgeon leaves behind normal liver tissue. The remaining healthy tissue takes over the work of the liver. Also, the liver can regrow the missing part. The new cells grow over several weeks.

It takes time to heal after surgery, and the time needed to recover is different for each person. You may have pain or discomfort for the first few days. Medicine can help control your pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more pain control.

It's common to feel tired or weak for a while. Also, you may have diarrhea and a feeling of fullness in the abdomen.

The health care team will watch you for signs of bleeding, infection, liver failure, or other problems.

Liver transplant

A liver transplant is an option if the tumors are small, the disease has not spread outside the liver, and suitable donated liver tissue can be found.

Donated liver tissue comes from a deceased person or a live donor. If the donor is living, the tissue is part of a liver, rather than a whole liver.

While you wait for donated liver tissue to become available, the health care team monitors your health and provides other treatments.

When healthy liver tissue from a donor is available, the transplant surgeon removes your entire liver (total hepatectomy) and replaces it with the donated tissue. After surgery, your health care team will give you medicine to help control your pain. You may need to stay in the hospital for several weeks. During that time, your health care team monitors how well your body is accepting the new liver tissue. You'll take medicine to prevent your body's immune system from rejecting the new liver. These drugs may cause puffiness in your face, high blood pressure, or an increase in body hair.

Ablation

Methods of ablation destroy the cancer in the liver. They are treatments to control liver cancer and extend life. They may be used for people waiting for a liver transplant. Or they may be used for people who can't have surgery or a liver transplant. Surgery to remove the tumor may not be possible because of cirrhosis or other conditions that cause poor liver function, the location of the tumor within the liver, or other health problems.

Methods of ablation include the following:

• Radiofrequency ablation: The doctor uses a special probe that contains tiny electrodes to kill the cancer cells with heat. Ultrasound, CT, or MRI may be used to guide the probe to the tumor. Usually, the doctor can insert the probe directly through your skin, and only local anesthesia is needed.
  
  Sometimes, surgery under general anesthesia is needed. The doctor inserts the probe through a small incision in your abdomen (using a laparoscope) or through a wider incision that opens your abdomen.
  
  Some people have pain or a slight fever after this procedure. Staying overnight in the hospital is not usually needed.
  
  Radiofrequency ablation is a type of hyperthermia therapy. Other therapies that use heat to destroy liver tumors include laser or microwave therapy. They are used less often than radiofrequency ablation.
  
  
• Percutaneous ethanol injection: The doctor uses ultrasound to guide a thin needle into the liver tumor. Alcohol (ethanol) is injected directly into the tumor and kills cancer cells. The procedure may be performed once or twice a week. Usually local anesthesia is used, but if you have many tumors in the liver, general anesthesia may be needed.
  
  You may have fever and pain after the injection. Your doctor can suggest medicines to relieve these problems.

Embolization

For those who can't have surgery or a liver transplant, embolization or chemoembolization may be an option. The doctor inserts a tiny catheter into an artery in your leg and moves the catheter into the hepatic artery. For embolization, the doctor injects tiny sponges or other particles into the catheter. The particles block the flow of blood through the artery. Depending on the type of particles used, the blockage may be temporary or permanent.

Without blood flow from the hepatic artery, the tumor dies. Although the hepatic artery is blocked, healthy liver tissue continues to receive blood from the hepatic portal vein.

For chemoembolization, the doctor injects an anticancer drug (chemotherapy) into the artery before injecting the tiny particles that block blood flow. Without blood flow, the drug stays in the liver longer.

You'll need to be sedated for this procedure, but general anesthesia is not usually needed. You'll probably stay in the hospital for 2 to 3 days after the treatment.

Embolization often causes abdominal pain, nausea, vomiting, and fever. Your doctor can give you medicine to help lessen these problems. Some people may feel very tired for several weeks after the treatment.

Targeted Therapy

People with liver cancer who can't have surgery or a liver transplant may receive a drug called targeted therapy. Sorafenib (Nexavar) tablets were the first targeted therapy approved for liver cancer.

Targeted therapy slows the growth of liver tumors. It also reduces their blood supply. The drug is taken by mouth.

Side effects include nausea, vomiting, mouth sores, and loss of appetite. Sometimes, a person may have chest pain, bleeding problems, or blisters on the hands or feet. The drug can also cause high blood pressure. The health care team will check your blood pressure often during the first 6 weeks of treatment.

You may want to read the NCI fact sheet Targeted Cancer Therapies.

Radiation Therapy

Radiation therapy uses high-energy rays to kill cancer cells. It may be an option for a few people who can't have surgery. Sometimes it's used with other approaches. Radiation therapy also may be used to help relieve pain from liver cancer that has spread to the bones.

Doctors use two types of radiation therapy to treat liver cancer:

• External radiation therapy: The radiation comes from a large machine. The machine aims beams of radiation at the chest and abdomen.
  
  
• Internal radiation therapy: The radiation comes from tiny radioactive spheres. A doctor uses a catheter to inject the tiny spheres into your hepatic artery. The spheres destroy the blood supply to the liver tumor.

The side effects from radiation therapy include nausea, vomiting, or diarrhea. Your health care team can suggest ways to treat or control the side effects.

You may find it helpful to read the NCI booklet Radiation Therapy and You.

Chemotherapy

Chemotherapy, the use of drugs to kill cancer cells, is sometimes used to treat liver cancer. Drugs are usually given by vein (intravenous). The drugs enter the bloodstream and travel throughout your body.

Chemotherapy may be given in an outpatient part of the hospital, at the doctor's office, or at home. Rarely, you may need to stay in the hospital.

The side effects of chemotherapy depend mainly on which drugs are given and how much. Common side effects include nausea and vomiting, loss of appetite, headache, fever and chills, and weakness.

Some drugs lower the levels of healthy blood cells, and you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells. Some side effects may be relieved with medicine.

You may wish to read the NCI booklet Chemotherapy and You.

Back to Top Second Opinion

Before starting treatment, you may want a second opinion about your diagnosis, the stage of cancer, and the treatment plan. You may also want to find a medical center that has a lot of experience with treating people with liver cancer. You may even want to talk to several different doctors about all of the treatment options, their side effects, and the expected results. For example, you could discuss your treatment plan with a hepatobiliary surgeon, radiation oncologist, and medical oncologist.

Some people worry that the doctor will be offended if they ask for a second opinion. Usually the opposite is true. Most doctors welcome a second opinion. And many health insurance companies will pay for a second opinion if you or your doctor requests it. Some companies require a second opinion.

If you get a second opinion, the second doctor may agree with your first doctor's diagnosis and treatment plan. Or the second doctor may suggest another approach. Either way, you have more information and perhaps a greater sense of control. You can feel more confident about the decisions you make, knowing that you've looked at your options.

It may take some time and effort to gather your medical records and see another doctor. In most cases, it's not a problem to take several weeks to get a second opinion. The delay in starting treatment usually will not make treatment less effective. To make sure, you should discuss this delay with your doctor.

There are many ways to find a doctor for a second opinion. You can ask your doctor, a local or state medical society, a nearby hospital, or a medical school for names of specialists.

Also, you can request a consultation with specialists at the National Institutes of Health Clinical Center in Bethesda, Maryland. Specialists in the NCI Surgery Branch provide consultations and surgical care for people with liver cancer. The telephone number is 301-496-4164. The Web site is located at http://ccr.cancer.gov/labs/lab.asp?labid=93.

The NCI Cancer Information Service at 1-800-4-CANCER (1-800-422-6237) can tell you about nearby treatment centers. Other sources can be found in the NCI fact sheet How To Find a Doctor or Treatment Facility If You Have Cancer.

Back to Top Supportive Care

Liver cancer and its treatment can lead to other health problems. You can have supportive care before, during, and after cancer treatment.

Supportive care is treatment to control pain and other symptoms, to relieve the side effects of therapy, and to help you cope with the feelings that a diagnosis of cancer can bring. You may receive supportive care to prevent or control these problems and to improve your comfort and quality of life during treatment.

You can get information about supportive care at http://www.cancer.gov/cancerinfo/coping on the NCI Web site and from the NCI Cancer Information Service at 1-800-4-CANCER (1-800-422-6237) or LiveHelp (http://www.cancer.gov/help).

Pain Control

Liver cancer and its treatment may lead to pain. Your doctor or a specialist in pain control can suggest several ways to relieve or reduce pain:

• Pain medicine: Medicines often can relieve pain. (These medicines may make people drowsy and constipated, but resting and taking laxatives can help.)
  
  
• Radiation therapy: Radiation therapy can help relieve pain by shrinking the cancer.
  
  
• Nerve block: The doctor may inject alcohol into the area around certain nerves in the abdomen to block the pain.

The health care team may suggest other ways to relieve or reduce pain. For example, massage, acupuncture, or acupressure may be used along with other approaches. Also, you may learn to relieve pain through relaxation techniques such as listening to slow music or breathing slowly and comfortably.

More information about pain control can be found in the NCI booklet Pain Control.

Sadness and Other Feelings

It's normal to feel sad, anxious, or confused after a diagnosis of a serious illness. Some people find it helpful to talk about their feelings. See the Sources of Support section.

Back to Top Nutrition

It's important to meet your nutrition needs before, during, and after cancer treatment. You need the right amount of calories, protein, vitamins, and minerals. Getting the right nutrition can help you feel better and have more energy.

However, you may be uncomfortable or tired, and you may not feel like eating. You also may have side effects of treatment such as poor appetite, nausea, vomiting, or diarrhea. Your doctor, a registered dietitian, or another health care provider can advise you about ways to have a healthy diet.

Careful planning and checkups are important. Liver cancer and its treatment may make it hard for you to digest food and maintain your weight. Your doctor will check you for weight loss, weakness, and lack of energy.

You may want to read the NCI booklet Eating Hints. It contains many useful ideas and recipes.

Back to Top Follow-up Care

You'll need regular checkups (such as every 3 months) after treatment for liver cancer. Checkups help ensure that any changes in your health are noted and treated if needed. If you have any health problems between checkups, you should contact your doctor.

Sometimes liver cancer comes back after treatment. Your doctor will check for return of cancer. Checkups may include a physical exam, blood tests, ultrasound, CT scans, or other tests.

For people who have had a liver transplant, the doctor will test how well the new liver is working. The doctor also will watch you closely to make sure the new liver isn't being rejected. People who have had a liver transplant may want to discuss with the doctor the type and schedule of follow-up tests that will be needed.

The NCI has publications to help answer questions about follow-up care and other concerns. You may find it helpful to read the NCI booklet Facing Forward: Life After Cancer Treatment. You may also want to read the NCI fact sheet Follow-up Care After Cancer Treatment.

Back to Top Sources of Support

Learning that you have liver cancer can change your life and the lives of those close to you. These changes can be hard to handle. It's normal for you, your family, and your friends to need help coping with the feelings that a diagnosis of cancer can bring.

Concerns about treatments and managing side effects, hospital stays, and medical bills are common. You may also worry about caring for your family, keeping your job, or continuing daily activities. Here's where you can go for support:

• Doctors, nurses, and other members of your health care team can answer questions about treatment, working, or other activities.
  
  
• Social workers, counselors, or members of the clergy can be helpful if you want to talk about your feelings or concerns. Often, social workers can suggest resources for financial aid, transportation, home care, or emotional support.
  
  
• Support groups also can help. In these groups, patients or their family members meet with other patients or their families to share what they have learned about coping with the disease and the effects of treatment. Groups may offer support in person, over the telephone, or on the Internet. You may want to talk with a member of your health care team about finding a support group.
  
  
• Information specialists at 1-800-4-CANCER (1-800-422-6237) and at LiveHelp (http://www.cancer.gov/help) can help you locate programs, services, and publications. They can send you a list of organizations that offer services to people with cancer.

For tips on coping, you may want to read the NCI booklet Taking Time: Support for People With Cancer.

Back to Top Taking Part in Cancer Research

Cancer research has led to real progress in liver cancer detection and treatment. Because of research, people with liver cancer can look forward to a better quality of life. Continuing research offers hope that, in the future, even more people with this disease will be treated successfully.

Doctors all over the world are conducting many types of clinical trials (research studies in which people volunteer to take part). Clinical trials are designed to find out whether new approaches are safe and effective.

Doctors are studying many types of treatment and their combinations:

• Liver transplant: The National Institute of Diabetes and Digestive and Kidney Diseases, an agency of the National Institutes of Health, is sponsoring the Adult to Adult Living Donor Liver Transplantation Cohort Study. This trial will study whether it's better to transplant a whole liver from a deceased donor or a part of a liver from a living donor.
  
  
• Radiofrequency ablation and chemotherapy: Doctors are studying the combination of radiofrequency ablation with an anticancer drug.
  
  
• Targeted therapy: Doctors are studying new targeted therapies with people who have liver cancer.

Even if the people in a trial do not benefit directly, they may still make an important contribution by helping doctors learn more about liver cancer and how to control it. Although clinical trials may pose some risks, doctors do all they can to protect their patients.

If you're interested in being part of a clinical trial, talk with your doctor. You may want to read the NCI booklet Taking Part in Cancer Treatment Research Studies. It describes how treatment studies are carried out and explains their possible benefits and risks.

The NCI Web site includes a section on clinical trials at http://www.cancer.gov/clinicaltrials. It has general information about clinical trials as well as detailed information about specific ongoing studies of liver cancer. The NCI Cancer Information Service at 1-800-4-CANCER (1-800-422-6237) and at LiveHelp at http://www.cancer.gov/help can answer questions and provide information about clinical trials.

Back to Top National Cancer Institute Services

You may want more information for yourself, your family, and your doctor. The NCI offers comprehensive research-based information for patients and their families, health professionals, cancer researchers, advocates, and the public.