Liver cancer may be primary (beginning in the liver) or secondary (arising from a cancer originating elsewhere in the body). Primary liver cancer is the type of liver cancer described in this section.
Liver (and biliary) cancers may cause abdominal pain, usually in the upper right side but may extend to the back and shoulder, itching, fluid in the abdomen (ascites) or legs (edema), weight loss, loss of appetite, feelings of fullness, nausea, vomiting, jaundice, and fever. Patients with risk factors should be screened even if symptoms are not present. Most cases of liver cancer can be detected by screening.
Hepatocellular carcinoma, or HCC, is the most common form of primary liver cancer, accounting for about 80-90% of new cases. The disease is more common in men than women for unknown reasons, and in the US accounts for about 21,400 new cases diagnosed each year. A typical patient is around age 65 and has had cirrhosis for a decade or more.
In developed nations, including the US, hepatitis C is largely responsible for cirrhosis and most cases of liver cancer. However, others causes such as heavy alcohol consumption and rising rates of metabolic syndrome – a cluster of disorders that include diabetes, hypertension and obesity – are making liver cancer a rapidly growing cause of cancer deaths in this US.
Worldwide, liver cancer is the fifth most common cancer worldwide, due to high rates of hepatitis B in Africa and Asia, which can lead to cirrhosis and liver cancer. Individuals in Asia and Africa usually contract hepatitis B at a younger age, and are diagnosed at a somewhat younger age.
Less common causes of HCC are certain genetic disorders such as hemochromatosis and alpha-1 antitrypsin deficiency. Autoimmune hepatitis and certain toxins such as aflatoxin (found on moldy grain and legumes), and chronic use of anabolic steroids or hormone replacement may also cause liver cancer. Individuals with a family history of liver cancer may also be at higher risk of HCC.
In addition to HCC, other types of primary liver cancer include cholangiocarcinomas and fibrolamellar hepatocellular cancer (FHC). Both are less common than HCC.
If liver cancer is suspected, physicians will perform a physical examination to check for lumps on the liver or hardening, and will take a medical history. To image the liver, a computed tomography (CT or CAT) scan and magnetic resonance imaging (MRI) will be performed.
In addition, blood tests are done to measure amounts of certain substances, called tumor markers, which are linked to liver cancer. The presence of one marker, alpha-fetoprotein (AFP) may indicate liver cancer, cirrhosis, or hepatitis if levels are elevated. Levels of red and white cells and platelets are also tested.
Physicians may also want to perform a liver biopsy to examine for cancer cells and damage from cirrhosis. During a liver biopsy, a physician removes a small amount of liver tissue using a thin needle inserted into the liver, which is guided by ultrasound or x-ray. Patients having a biopsy are given local anesthetic for the procedure and pain medication following it.
Surgery is often the preferred treatment for liver cancer. Advances in surgical tools and techniques, better imagining, and a better understanding of liver anatomy now make it possible for surgeons to remove up to 75% of a diseased liver while leaving the remaining liver to regenerate itself.
There are also other treatment options that may use in combination with surgery or on their own.
Radiofrequency ablation may be used for small tumors. With this technique, a special probe equipped with tiny electrodes that heat and kill cancer cells, is inserted through a tiny incision in the skin and guided to the tumor site by an ultrasound or CT scan.
For larger tumors, chemoembolization, may be used. With this technique, chemotherapy is injected into the hepatic artery via a catheter (narrow tube). The chemotherapy is combined with a substance that blocks off this artery (either permanently or temporarily), cutting off blood flow to the tumor and "starving" it.
Much of the chemotherapy is trapped near the tumor, which works directly on the cancer, while limiting the drug's contact with the rest of the body, therefore causing fewer side-effects than chemotherapies given systemically. The liver can continue getting blood from the other major hepatic blood supply, the portal vein, enabling it to function normally and continue to carry blood from the stomach and intestine.
IMRT and brachytherapy may also be used. In IMRT, precisely tumor-targeted radiation is given to treat the tumor, which spares healthy tissue. With brachytherapy, temporary or permanent radioactive seeds are placed near the tumor to deliver pinpointed radiation to the cancer.
Targeted therapies may be used as well to treat liver cancer. These drugs usually contain toxins that can systematically seek out, bind to, and destroy cancer cells, or cut off a tumor's blood supply, while generally leaving healthy cells alone. Although new, this type of drug offers promise because it can destroy cancer cells without the unwanted sided effects associated with radiation and chemotherapy.
NewYork-Presbyterian has an extremely active research program in liver cancer. Our medical center pioneered new biologic treatments for liver cancers, and we continue to conduct clinical trials with promising new drugs.
We participated in several clinical trials of the most promising drugs in HCC, called antiangiogenics. These drugs work by cutting off the blood supply to the tumor and thus, starving it. Two of the most promising new antiangiogenic drugs are bevacizumab (Avastin), a vascular endothelial growth factor (VEGF) inhibitor, and sorafenib (Nexavar), a multi-targeted kinase inhibitor, both of which have fewer side-effects than traditional chemotherapies. We participated in the pivotal international trial which showed a significant survival benefit for those taking sorafenib; that drug is now approved in the US for inoperable liver cancer. We also led a large clinical trial with bevacizumab for HCC.
We are also studying other molecularly targeted agents alone and in combinations which also show promise in treating this disease. In addition, we are using existing drugs in new ways. For example, we have initiated a new clinical trial with sorafenib to determine whether we can improve outcomes in patients with liver cancer who receive liver transplants but are at high-risk for recurrence.
Other research underway includes evaluating radiofrequency ablation to destroy tumor cells with intraoperative heated chemotherapy infused directly into the liver using an intra-arterial pump. The goal of this treatment is to eliminate any microscopic disease that remains following surgery.