Liver Cancer: Entire Lesson - Liver Cancer for Patients

Like all other body organs, your liver can get cancer. Liver cancer is a disease in which some of the cells in your liver begin to reproduce faster than they should. This can lead to liver masses called tumors. The medical term for the most common cancer that begins in the liver is hepatocellular carcinoma (pronounced "HEP-a-toe-SEL-yoo-ler KAR-sih-NOH-muh"), or HCC for short. Some people also call it "hepatoma." We will refer to HCC as "liver cancer" here.

People with cirrhosis are at increased risk of developing liver cancer. The cirrhosis may be due to hepatitis C virus, hepatitis B virus, alcohol, fatty liver, or other causes. People living with hepatitis B are also at risk of liver cancer even if they haven't developed cirrhosis, especially if they have a high hepatitis B viral load or are of Asian or African descent. Among patients living in the United States with both hepatitis C and cirrhosis, about 1-4% per year will develop liver cancer.

What is liver cancer screening?

Experts recommend that persons at risk of liver cancer be tested regularly, even if they have no symptoms. Testing for the presence of a disease before there are any symptoms is called screening. People at risk of liver cancer must be screened with an ultrasound of the abdomen, every 6 months, for life. A blood test for alpha-fetoprotein (AFP), which can be elevated in persons with liver cancer, can also be done every 6 months, in addition to the ultrasound.

What about hepatitis C patients who have been successfully treated?

A person who develops cirrhosis due to hepatitis C is still at risk of liver cancer, even if the hepatitis C is treated successfully and the virus can no longer be detected in the bloodstream (blood tests show a sustained virologic response, or SVR, has been achieved). Successful treatment of hepatitis C reduces the liver cancer risk by approximately 70%. However, the risk is not zero. Therefore, the person will still need liver cancer screening.

Who should be screened for liver cancer?

• anyone with cirrhosis, due to any underlying cause (hepatitis B, hepatitis C, alcohol, hemochromatosis, fatty liver, etc.)
• anyone infected with the hepatitis B virus who has a family history of liver cancer
• Asian men with hepatitis B, over age 40
• Asian women with hepatitis B, over age 50
• African and/or North American blacks with hepatitis B

A diagnosis of liver cancer can often be made with radiology tests alone, and without a biopsy. If a mass is seen in the liver with ultrasound, then usually either a computed tomography (CT) or magnetic resonance imaging (MRI) scan of the abdomen will be needed to look at the mass in more detail. If the mass is too small to make a diagnosis, then the health care provider will often recommend repeating the CT or MRI scan every few months to watch for any changes in the mass. Sometimes a blood test reveals high levels of a substance called alpha-fetoprotein, or AFP.

What are the symptoms of liver cancer?

Most people with liver cancer do not have any symptoms early on. Those who do have symptoms often have some pain in the right side of the abdomen, under the ribs, where the liver is located. Or they may have a build-up of fluid in their abdomen, called ascites.

• Liver cancer can cause death in a person with cirrhosis.
• Liver cancer is one of the most common cancers in the world, especially in Asia and Africa, and it is becoming increasingly common in the United States.
• If liver cancer is diagnosed in earlier stages, then there is a better chance of a good outcome.
• Patients with cirrhosis from any cause, including hepatitis C, hepatitis B, and alcohol use, have a greater risk of developing liver cancer.
• Preventing cirrhosis is the best way of preventing liver cancer.
• Screening for liver cancer is done with abdominal ultrasound every 6 months. A blood test called AFP can be added to the ultrasound, but it is not required.
• If something concerning such as a mass is seen on the ultrasound, usually a CT or MRI is performed to get more detailed views.
• A health care provider can usually determine whether liver cancer is present based on radiology tests, such as a CT or MRI of the abdomen. A biopsy of the liver, which refers to extracting a small sample of tissue with a hollow needle and testing it for liver cancer, is used less often. Biopsies can be difficult to perform and there are some risks involved.
• Liver cancer can be treated if it is detected early, but the treatment is very specialized. Patients should discuss the details thoroughly with their health care providers.
• One potential treatment for early-stage liver cancer is a liver transplant. This is a complicated form of treatment, because a patient first needs to be a good candidate for a liver transplant, then be evaluated at a liver transplant center and placed on a waiting list, and finally, be well enough to undergo a transplant when a donated liver becomes available.
• Patients with successfully treated hepatitis C who have cirrhosis still need ultrasounds every 6 months to screen for liver cancer. Cure of the hepatitis C virus with antiviral medications reduces the risk of liver cancer but does not make the risk zero.
• People with hepatitis B who are in a high-risk group for liver cancer
  should still be screened even if their hepatitis B is being treated. Antiviral treatment of HBV reduces the risk of liver cancer but does not reduce the risk to zero.

There are several types of treatment:

• Ablation
• Embolization or chemoembolization
• Y90 (or Transarterial radioembolization (TARE) or selective internal radiation therapy (SIRT))
• Surgical resection
• Systemic chemotherapy
• External Radiation therapy (SBRT)
• Liver transplant

Read more about each of these treatments on the following pages.

With this technique, surgeons or interventional radiologists place metal wires directly into a tumor and super-heat it, killing the cancer cells. This may be done through an operation in the abdomen where the liver can be examined directly, or it may be done through the skin.

This form of treatment can kill either small or medium-size liver tumors (often, up to 5 centimeters in size). This treatment can cause stress to the liver, and sometimes patients are kept in the hospital for a day or longer for observation. This procedure is done under sedation.

With this technique, interventional radiologists pass special plastic tubes (called catheters) into the arteries of the liver, directly cutting off the blood supply to liver tumors. The catheters are usually passed up to the liver through one of the main arteries in the groin or wrist. This technique is excellent for killing several small tumors in the same area or tumors that cannot be treated effectively by any other method. One advantage of this technique is that liver tumors get almost all their blood supply from arteries, but healthy areas of the liver get most of their blood from veins.

This treatment can involve simply cutting off blood from arteries (embolization) or putting chemotherapy medications directly into the arteries going to the tumors (chemoembolization). The technique is sometimes used immediately before a liver transplant, in an attempt to kill all the tumor cells so that they do not move into the new liver. This procedure is done under sedation.

With this technique, interventional radiologists pass special plastic tubes (called catheters) into the arteries of the liver, directly seeding particles delivering radiation into tumor. The catheters are usually passed up to the liver through one of the main arteries in the groin or wrist. This technique is excellent for killing several small tumors in the same area or tumors that cannot be treated effectively by any other method. One advantage of this technique is that liver tumors get almost all their blood supply from arteries, but healthy areas of the liver get most of their blood from veins.

The technique is sometimes used immediately before a liver transplant, in an attempt to kill all the tumor cells so that they do not move into the new liver. This procedure is done under sedation.

Surgical resection involves surgeons cutting out the tumors from the liver directly. The procedure is performed with the patient unconscious in an operating room. This is a very effective treatment for liver cancer, but the surgery can be performed only if the patient's liver is functioning well enough to allow a portion of it to be removed. Surgical resection can be quite stressful to the liver because it is cut directly. Patients often remain in the hospital for monitoring for several days after receiving this treatment.

Chemotherapy is treatment in which medications that are toxic to tumors are given to patients by intravenous infusion or in pill form. There are multiple medications and some combination of medications that have become available for patients with liver cancer over the past few years.

External beams are used to target liver cancer for treatment. We call this SBRT which is short for giving external radiation to treat liver cancer. This option can shrink the tumor and slow its growth. For the most part, treatment is given by radiation oncologist usually for 5 sessions every other day.

However, before starting this treatment, they need to inject tiny markers into liver near cancer to make sure they are targeting the correct area of the liver. This is usually done under sedation. This needs to be confirmed by another cat scan to make sure markers are placed correctly. All of these steps need to happen prior to your treatment. They also need to create a mold that would help you remain still during the procedure. You would need to stay still in the mold for the duration of treatment which is usually 45-60 min.

Liver transplant is an effective treatment for liver cancer if the tumors are very small and are in a few areas of the liver. Once cancer has spread to blood vessels within the liver or has moved outside the liver, it is too late to control the cancer with a transplant. The advantage of performing a transplant when liver cancer is still in the early stage is that more tumors can form in the liver over time and replacing the entire liver with a transplanted one lower the risk of that happening.

Transplantation is the most complex form of treatment for liver cancer. The section on Liver Transplant provides more details about the process of being referred to a transplant center and possibly being placed on a transplant waiting list. Patients with liver cancer who are good candidates for a transplant and who want to pursue this option are often given priority for receiving a donated liver in the current U.S. national system after waiting 6 months to ensure local treatment has been effective

For patients with hepatitis C, if the treatments against the virus are successful in clearing the virus, the treatment can also actually reduce the risk of developing liver cancer. If the virus is cleared, that will reduce the chance of developing cirrhosis. For patients who already have cirrhosis, the treatment can sometimes reduce the risk that liver cancer will develop.

For patients who have cirrhosis resulting from hepatitis C or alcohol use, the risk of further damage to the liver can be reduced by avoiding alcohol.

Patients with advanced cirrhosis can be evaluated for a liver transplant before liver cancer develops.

Patients with hepatitis B and a high hepatitis B viral load can be treated with medications for hepatitis B. Reducing the hepatitis B viral load will reduce the chance of developing liver cancer.

Liver cancer is becoming more common as a late complication of chronic hepatitis C infection among patients who have developed cirrhosis. Patients who are concerned about their risk of cancer should discuss with their medical care providers how they can protect themselves from it. Tests that take images of the liver (e.g., ultrasound, CT, MRI scans), together with measurements of AFP levels in the blood, can detect liver cancer early much of the time.

Once liver cancer is diagnosed, a patient should discuss the options for treatment with health care professionals who have experience managing this type of cancer. This often involves liver specialists, surgeons, interventional radiologists, cancer specialists (called oncologists), and other professionals. Within the VA health care system, this may involve care at larger facilities where more management options are available.

Treatment of liver cancer can involve a lot of discussions and information. Sometimes a number of treatments are required over time to control the cancer. The most important thing for patients with cancer to do is continue discussing plans for treatment with their health care providers, so that they have the widest range of options available and can decide with their providers which options are best for them

• Liver Cancer Patient Guide
  VA National Viral Hepatitis Program
• American Liver Foundation
  Nonprofit organization promoting liver disease prevention and liver wellness
• American Cancer Society
  An overview of liver cancer, including risk factors, symptoms, how it is found, and how it is treated.
• National Cancer Institute
  Information on liver cancer causes, prevention, screening, treatment, statistics, and research, as well as coping with the many issues and concerns of living with cancer.