Hepatic Cancer

Hepatic cancer, also known as liver cancer, is a serious disease where cancer cells grow in the liver—one of the body’s largest and most vital organs. Most cases occur in people who already have long-term liver damage or disease.

Table of contents

• What is hepatic cancer?
• Types of hepatic cancer
• The liver and its functions
• Signs and symptoms
• Causes and risk factors
• How doctors diagnose hepatic cancer
• Treatment options

What is hepatic cancer?

Hepatic cancer is a disease in which cancer cells form in the tissues of the liver. When healthcare professionals talk about liver cancer, they usually mean primary liver cancer—cancer that starts in the liver itself. This is different from cancer that begins somewhere else in the body and then spreads to the liver, which is called secondary or metastatic liver cancer^[1][2].

The liver is one of the largest organs in the body and performs many critical jobs. No one can live without a functioning liver^[3]. Hepatic cancer is relatively uncommon in the United States, though its occurrence is rising, mainly because of the spread of hepatitis C virus infection^[4]. Worldwide, liver cancer is the sixth most common cancer and the third leading cause of cancer deaths^[4].

In the United States, about 24,500 men and 10,000 women are diagnosed with liver cancer each year^[1]. Men are more than twice as likely as women to receive this diagnosis^[5][7]. Most people diagnosed are age 60 or older^[13].

Types of hepatic cancer

There are several types of primary liver cancer. Because the liver is made up of different kinds of cells, different types of cancer can form within it^[10].

Hepatocellular carcinoma (HCC) is the most common form of liver cancer. It accounts for more than 90% of primary liver cancers and starts in the liver cells called hepatocytes, which make up the main functional part of the liver^[2][3][4]. About three out of four primary liver cancers are hepatocellular carcinomas^[10]. Some hepatocellular carcinomas begin as a single tumor that grows larger, while others start as many small tumors scattered throughout the liver^[10].

Cholangiocarcinoma, also called bile duct cancer, starts in the tubes (bile ducts) that connect the liver to other organs of the digestive system. About 10 to 20 percent of primary liver cancers are cholangiocarcinomas^[3][10]. These tumors can arise inside the liver (intrahepatic) or outside it (extrahepatic)^[10]. This is a rare cancer with a five-year survival rate of about 2 percent^[7].

Hepatoblastoma most commonly occurs in children younger than four years old. It is very rare and usually does not spread outside the liver^[7].

Hepatic angiosarcoma is a very rare type that represents about 1% of all primary liver cancers. This cancer begins in the lining of blood vessels in the liver and may also affect other organs^[3].

The liver and its functions

• Liver
• Bile ducts
• Gallbladder
• Stomach
• Intestines
• Pancreas

The liver is a football-sized organ located in the upper right part of your abdomen, beneath the diaphragm and beside your stomach^[1][2]. It has two lobes and fills the upper right side of the abdomen inside the rib cage^[2]. The liver has more than 500 known functions^[1].

The main jobs of the liver include producing bile to help digest fats from food, storing sugar (glycogen) that the body uses for energy, and filtering harmful substances from the blood so they can be removed from the body in stools and urine^[2]. The liver also processes and stores nutrients absorbed from the intestines, produces proteins that help blood clot and stop bleeding, and balances chemicals in the blood^[1][2].

Signs and symptoms

In its early stages, liver cancer may not cause symptoms that can be seen or felt^[5]. Unfortunately, you can have very early liver cancer without any symptoms at all^[3]. As the cancer grows larger, people may notice one or more common symptoms. It is important to remember that these symptoms could also be caused by other health conditions^[5].

Symptoms of hepatic cancer may include^[2][3][5]:

• A hard lump on the right side just below the rib cage
• Discomfort or pain in the upper abdomen on the right side
• A swollen abdomen
• Pain near the right shoulder blade or in the back
• Jaundice—yellowing of the skin and whites of the eyes caused by high levels of a substance called bilirubin in the blood
• Easy bruising or bleeding
• Unusual tiredness or weakness
• Nausea and vomiting
• Loss of appetite or feeling full after eating a small meal
• Weight loss for no known reason
• Pale, chalky bowel movements and dark urine
• Fever
• Itching

If you have any of these symptoms, talk to your doctor. If symptoms last longer than two weeks, it is best to see a healthcare provider^[13].

Causes and risk factors

Hepatic cancer happens when something affects the healthy liver cells’ DNA, which carries the genes that tell our cells how to function. When DNA changes or mutates, cells get new instructions. Certain medical conditions and other factors can affect your liver’s DNA and increase your risk of developing liver cancer^[3].

The most common risk factor for liver cancer is long-term infection with hepatitis B (HBV) or hepatitis C (HCV). These infections can cause cirrhosis, which is severe scarring of the liver. Cirrhosis can lead to liver cancer^[3][5]. Hepatitis B and C account for more than 70% of cases of hepatocellular carcinoma^[4]. About 80% of liver cancer patients have a history of hepatitis infection^[7][23].

Hepatitis is responsible for the vast majority of liver cancer cases. There is a preventive vaccine for hepatitis B, but not for hepatitis C. These viruses can cause scarring of the liver, and as the liver tries to repair and replace damaged tissue, faulty DNA copying and cell division can lead to cancer^[7]. The hepatitis B vaccine was the first preventive cancer vaccine developed, in 1982^[19].

Hepatocellular carcinoma occurs in about 85% of patients diagnosed with cirrhosis. Most people who have cancer in the liver have cirrhosis^[4]. More than 80% of HBV-related liver cancer cases have underlying cirrhosis^[4]. However, liver cancer can occur even without cirrhosis in patients infected with hepatitis B^[4].

Other conditions and behaviors that increase your risk of getting liver cancer include^[3][5][4]:

• Being overweight or having obesity
• Heavy drinking of beverages containing alcohol
• Metabolic dysfunction-associated steatotic liver disease (MASLD), a condition where extra fat builds up in the liver that is not caused by alcohol
• Non-alcoholic steatohepatitis (NASH), inflammation of the liver related to fat buildup
• Type 2 diabetes
• Smoking cigarettes
• Eating foods contaminated with aflatoxin, a fungus that can grow on foods like grains and nuts that have not been stored properly
• Hemochromatosis, a condition in which the body takes up and stores more iron than it needs

Increasing age is the most important risk factor for most cancers^[17].

How doctors diagnose hepatic cancer

Your healthcare provider will do a physical examination and ask about your symptoms. They may perform several tests to diagnose liver cancer^[3].

Liver lesions smaller than 1 centimeter found during screening in patients at high risk do not require further diagnostic evaluation. Close follow-up every 3 months is common^[17].

For liver lesions larger than 1 centimeter in people at risk of hepatic cancer, a diagnosis can be made using imaging tests, biopsy, or both^[17]. Sometimes, liver cancer can be reliably diagnosed on imaging studies such as CT scans or MRIs, and a biopsy may not be needed^[11][24].

Diagnostic tests may include^[3]:

• Blood tests—Healthcare providers may do blood tests for cancer and liver function tests
• Angiogram—This test helps healthcare providers examine your liver’s blood vessels
• CT scan (computed tomography scan)—This test takes detailed images of your liver and gives providers information about tumor size and location
• MRI (magnetic resonance imaging)—This test uses a large magnet, radio waves, and a computer to produce very clear images of your liver’s insides
• Liver ultrasound—This test uses sound waves to take pictures of the inside of your liver
• ERCP test—Your provider may do this test to diagnose bile cancer in your liver
• Liver biopsy—Your provider may take a small sample of liver tissue to examine under a microscope

Treatment options

Your healthcare team will create a treatment plan just for you based on your health and specific information about the cancer. Treatment depends on the stage of cancer, how well your liver is working, the amount of scarring in the liver, whether the cancer can be completely removed by surgery, and your overall health^[16].

Liver cancer is often at an advanced stage when it is diagnosed, so treatment options may be limited^[16]. The specialist care team looking after you will explain the treatments, benefits and side effects, work with you to create the best treatment plan, and help you manage any side effects^[18].

Surgery may be an option if liver cancer is found early, is small, and has not spread. Surgery can remove part or all of your liver. If all of it is removed, you will need a liver transplant to replace your liver with a donated one^[18]. A partial hepatectomy removes the part of the liver where cancer is found, along with some healthy tissue around it. The remaining liver tissue takes over the functions of the liver and may regrow^[14].

Liver transplant involves removing the entire liver and replacing it with a healthy donated liver. This may be done when the disease is in the liver only and a donated liver can be found^[14].

Ablation therapy uses different methods to remove or destroy tissue. Types include^[14]:

• Radiofrequency ablation—Special needles inserted into the tumor use high-energy radio waves to heat and kill cancer cells
• Microwave therapy—The tumor is exposed to high temperatures created by microwaves
• Percutaneous ethanol injection—A small needle injects pure alcohol directly into a tumor to kill cancer cells
• Cryoablation—An instrument freezes and destroys cancer cells

Embolization therapy uses substances to block or decrease blood flow through the liver artery to the tumor. When the tumor does not get the oxygen and nutrients it needs, it will not continue to grow^[14]. Types include transarterial embolization (TAE) and transarterial chemoembolization (TACE), which also delivers chemotherapy medicine^[14][16].

Chemotherapy uses medicines to kill cancer cells. For liver cancer, the chemotherapy medicine is usually given into the blood vessels of the cancer to stop the cancer from growing^[18].

Targeted therapy uses drugs that target specific proteins on cancer cells. It is used for advanced liver cancer^[16]. Several targeted medicines are approved for liver cancer, including bevacizumab, which targets blood vessel growth^[19].

Immunotherapy is a class of treatments that helps strengthen or restore the immune system’s ability to fight cancer. For advanced hepatocellular carcinoma, the standard of care is the immunotherapy combination of atezolizumab (a checkpoint inhibitor) and bevacizumab^[19]. Other approved immunotherapies include nivolumab, pembrolizumab, ipilimumab, durvalumab, and dostarlimab^[19].

Radiation therapy uses radiation to kill cancer cells. Types include external radiation therapy and internal radiation therapy^[16]. Selective internal radiation therapy (SIRT) involves injecting radioactive beads into the liver’s blood supply to stop the cancer growing^[18].

If you have advanced liver cancer that cannot be cured, the aim of treatment will be to limit the cancer and its symptoms and help you live longer. You will be referred to a special team called the palliative care team or symptom control team who will work with you to help manage your symptoms and make you feel more comfortable^[18].