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Liver Cancer

Adult primary 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. The liver has many important functions, including:

  • Filtering harmful substances from the blood so they can be passed from the body in stools and urine.
  • Making bile to help digest fats from food.
  • Storing glycogen (sugar), which the body uses for energy.

Anatomy of the liver; drawing shows the right and left  front lobes of the liver, bile ducts, gallbladder, stomach, spleen, pancreas, colon, and small intestine. The two back lobes of the liver are not shown.

Anatomy of the liver. 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.

This summary refers to the treatment of primary liver cancer (cancer that begins in the liver). Treatment of metastatic liver cancer, which is cancer that begins in other parts of the body and spreads to the liver, is not discussed in this summary. Primary liver cancer can occur in both adults and children. Treatment for children, however, is different than treatment for adults.

Having hepatitis or cirrhosis can affect the risk of developing adult primary liver cancer.

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. People who think they may be at risk should discuss this with their doctor. The following are possible risk factors for adult primary liver cancer:

  • Having hepatitis B and/or hepatitis C.
  • Having a close relative with both hepatitis and liver cancer.
  • Having cirrhosis.
  • 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).

Possible signs of adult primary liver cancer include a lump or pain on the right side.

These symptoms may be caused by swelling of the liver. These and other symptoms may be caused by adult primary liver cancer or by other conditions. A doctor should be consulted if any of the following problems occur:

  • A hard lump on the right side just below the rib cage.
  • Discomfort in the upper abdomen on the right side.
  • Pain around the right shoulder blade.
  • Unexplained weight loss.
  • Jaundice (yellowing of the skin and whites of the eyes).
  • Unusual tiredness.
  • Nausea.
  • Loss of appetite.

Tests that examine the liver and the blood are used to detect (find) and diagnose adult primary liver cancer.

The following tests and procedures may be used:

  • 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.
  • Complete blood count (CBC): A procedure in which a sample of blood is drawn and checked for the following:
    • The number of red blood cells, white blood cells, and platelets.
    • The amount of hemoglobin (the protein that carries oxygen) in the red blood cells.
    • The portion of the blood sample made up of red blood cells.
  • 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. Other instruments may be inserted through the same or other incisions to perform procedures such as removing organs or taking tissue samples for biopsy.
  • Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. The sample may be taken using a thin needle inserted into the liver during an x-ray or ultrasound. This is called a fine-needle aspiration (FNA) biopsy. The biopsy may be done during a laparoscopy.
  • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, 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 body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
  • 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.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

  • 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 there is cirrhosis of the liver.

Prognosis is also affected by alpha-fetoprotein (AFP) levels.

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:

  • Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
  • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, 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 body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
  • Bone scan: A procedure to check if there are rapidly dividing cells, such as cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones and is detected by a scanner.
  • Doppler ultrasound: A type of ultrasound that uses differences in the ultrasound echoes to measure the speed and direction of blood flow.

There are three ways that cancer spreads in the body.

The three ways that cancer spreads in the body are:

  • Through tissue. Cancer invades the surrounding normal tissue.
  • Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
  • Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.

The following stages are used for adult primary liver cancer:

Stage I

In stage I, there is one tumor and it has not spread to nearby blood vessels.



Pea, peanut, walnut, and lime show tumor sizes.

Stage II

In stage II, one of the following is found:

  • one tumor that has spread to nearby blood vessels; or
  • more than one tumor, none of which is larger than 5 centimeters.

Stage III

Stage III is divided into Stage IIIA, IIIB, and IIIC.

  • In stage IIIA, one of the following is found:
    • more than one tumor larger than 5 centimeters; or
    • one tumor that has spread to a major branch of blood vessels near the liver.
  • In stage IIIB, there are one or more tumors of any size that have either:
    • spread to nearby organs other than the gallbladder; or
    • broken through the lining of the peritoneal cavity.
  • In stage IIIC, the cancer has spread to nearby lymph nodes.

Stage IV

In stage IV, cancer has spread beyond the liver to other places in the body, such as the bones or lungs. The tumors may be of any size and may also have spread to nearby blood vessels and/or lymph nodes.

For adult primary liver cancer, stages are also grouped according to how the cancer may be treated. There are 3 treatment groups:

Localized resectable

The cancer is found in the liver only, has not spread, and can be completely removed by surgery.

Localized and locally advanced unresectable

The cancer is found in the liver only and has not spread, but cannot be completely removed by surgery.

Advanced

Cancer has spread throughout the liver or has spread to other parts of the body, such as the lungs and bone.

Recurrent Adult Primary Liver Cancer

Recurrent adult primary liver cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the liver or in other parts of the body.

There are different types of treatment for patients with adult primary liver cancer.

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.

Four types of standard treatment are used:

Surgery

The following types of surgery may be used to treat liver cancer:

  • Cryosurgery: A treatment that uses an instrument to freeze and destroy abnormal tissue, such as carcinoma in situ. This type of treatment is also called cryotherapy. The doctor may use ultrasound to guide the instrument.
  • Partial hepatectomy: Removal of the part of the liver where cancer is found. The part removed may be a wedge of tissue, an entire lobe, or a larger portion of the liver, along with some of the healthy tissue around it. The remaining liver tissue takes over the functions of the liver.
  • Total hepatectomy and liver transplant: Removal of the entire liver and replacement 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.
  • Radiofrequency ablation: The use of a special probe with tiny electrodes that kill cancer cells. Sometimes the probe is inserted directly through the skin and only local anesthesia is needed. In other cases, the probe is inserted through an incision in the abdomen. This is done in the hospital with general anesthesia.

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. Radiation therapy is given in different ways:

  • External radiation therapy uses a machine outside the body to send radiation toward the cancer.
  • Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.
  • Drugs called radiosensitizers may be given with the radiation therapy to make the cancer cells more sensitive to radiation therapy.
  • Radiation may be delivered to the tumor using radiolabeled antibodies. Radioactive substances are attached to antibodies made in the laboratory. These antibodies, which target tumor cells, are injected into the body and the tumor cells are killed by the radioactive substance.

The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy).

Regional chemotherapy is usually used to treat liver cancer. A small pump containing anticancer drugs may be placed in the body. The pump puts the drugs directly into the blood vessels that go to the tumor.

Another type of regional chemotherapy is chemoembolization of the hepatic artery. The anticancer drug is injected into the hepatic artery through a catheter (thin tube). The drug is mixed with a substance that blocks the artery, cutting off blood flow to the tumor. Most of the anticancer drug is trapped near the tumor and only a small amount of the drug reaches other parts of the body. The blockage may be temporary or permanent, depending on the substance used to block the artery. The tumor is prevented from getting the oxygen and nutrients it needs to grow. The liver continues to receive blood from the hepatic portal vein, which carries blood from the stomach and intestine.

The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Percutaneous ethanol injection

Percutaneous ethanol injection is a cancer treatment in which a small needle is used to inject ethanol (alcohol) directly into a tumor to kill cancer cells. The procedure may be done once or twice a week. Usually local anesthesia is used, but if the patient has many tumors in the liver, general anesthesia may be needed.

New types of treatment are being tested in clinical trials.

This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied.

Hyperthermia therapy

Hyperthermia therapy is a type of treatment in which body tissue is exposed to high temperatures to damage and kill cancer cells or to make cancer cells more sensitive to the effects of radiation and certain anticancer drugs. Because some cancer cells are more sensitive to heat than normal cells are, the cancer cells die and the tumor shrinks.

Biologic therapy

Biologic therapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country.

Follow-up tests may be needed.

Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.

Treatment Options for Adult Primary Liver Cancer

  • Localized Resectable Adult Primary Liver Cancer
  • Localized and Locally Advanced Unresectable Adult Primary Liver Cancer
  • Advanced Adult Primary Liver Cancer
  • Recurrent Adult Primary Liver Cancer

Localized Resectable Adult Primary Liver Cancer

Treatment of localized resectable adult primary liver cancer may include the following:

  • Surgery (partial hepatectomy).
  • Surgery (total hepatectomy) and liver transplant.
  • A clinical trial of regional or systemic chemotherapy or biologic therapy following surgery.

Localized and Locally Advanced Unresectable Adult Primary Liver Cancer

Treatment of localized and locally advanced unresectable adult primary liver cancer may include the following:

  • Surgery (cryosurgery or radiofrequency ablation).
  • Chemotherapy (chemoembolization, regional chemotherapy, or systemic chemotherapy).
  • Percutaneous ethanol injection.
  • Surgery (total hepatectomy) and liver transplant.
  • Radiation therapy with radiosensitizers.
  • A clinical trial of a combination of surgery, chemotherapy, and radiation therapy. Hyperthermia therapy may also be used. Chemotherapy and radiation therapy may be used to shrink the tumor before surgery.

Advanced Adult Primary Liver Cancer

There is no standard treatment for advanced adult primary liver cancer. Patients may consider taking part in a clinical trial. Treatment may be a clinical trial of biologic therapy, chemotherapy, and/or radiation therapy with or without radiosensitizers. These treatments may be given as palliative therapy to help relieve symptoms and improve the quality of life.

Recurrent Adult Primary Liver Cancer

Treatment of recurrent adult primary liver cancer may include the following:

  • Surgery (partial hepatectomy).
  • Surgery (total hepatectomy) and liver transplant.
  • Chemotherapy (chemoembolization or systemic chemotherapy).
  • Percutaneous ethanol injection.
  • A clinical trial of a new therapy.


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