Cancer involving the liver

There are two types of liver cancer, primary and secondary. Primary begins in the liver whereas secondary is caused by the spread of cancer from elsewhere in the body. Each year over 90,000 people in the Uk have liver cancer.

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The liver can be involved by cancer in two main ways. Primary liver cancer begins in the liver and is relatively rare. Secondary liver cancer starts elsewhere in the body and spreads to the liver usually via the bloodstream. Metastatic liver disease is another term for this type of secondary liver cancer.

The liver is a large internal organ in the body with an abundant blood supply. Secondary liver cancer is therefore very common in many types of malignancy. It is 30 times more frequent that the rarer primary liver cancer.

Primary liver cancer

Primary liver cancer can arise from the liver cells themselves. This is called hepatocellular cancer (HCC or hepatoma). Some liver cancers arise from the cells lining the ducts taking bile to the intestine. These are called cholangiocarcinomas and are essentially biliary tract tumours and will not be further discussed here.

Hepatocellular cancer (HCC)

Symptoms of hepatocellular cancer are pain or discomfort in the right upper quadrant over the liver, weight loss, abdominal distension or ascites. Most HCC occurs in patients who already have chronic liver disease or cirrhosis. The cirrhosis or advanced fibrosis of the liver may be due to excess alcohol, chronic viral hepatitis B or hepatitis C, autoimmune liver disease, non-alcoholic fatty liver disease or excess iron deposits in the liver due to a genetic defect (called haemochromatosis).

In the developed world, the incidence of HCC associated with non-alcoholic fatty liver disease caused by diabetes and obesity is increasing. In the less developed world, chronic viral hepatitis B acquired at birth is the more common cause for cirrhosis with the late complication of hepatocellular carcinoma.

Patients who are not known to have liver disease can develop symptoms of HCC when they first come to medical attention. Patients with cirrhosis are put under regular surveillance with tests for HCC performed every 6 months due to the increased risk of the disease. Thus, primary liver cancer patients may be identified before symptoms develop.

How is primary liver cancer diagnosed?

Alphafetoprotein is the most useful blood test in diagnosing HCC although this test cannot be used alone to make a diagnosis of HCC as it is often normal in patients with the disease. Liver ultrasound may show a focal abnormal area in the liver and is useful for surveillance in patients with cirrhosis. Confirmation with CT and MRI scanning is usually performed. Biopsies of HCC are not usually undertaken due to the risk of bleeding or spreading the cancer.

How is primary liver cancer treated?

There are a number of different treatments for hepatocellular carcinoma. As this is a relatively rare disease it is usually managed by the multidisciplinary teams at specialist centres to optimise the treatment for each individual. Surgical options include resection of the part of the liver affected by cancer. The tumour however must be small and ideally single. The remaining liver must be sufficiently healthy to cope after surgery. Another surgical alternative is whole liver transplant. This has the advantage of also treating the underlying liver cirrhosis. For surgical treatment to be considered, tumours must ideally be single and less than 5 cm. Multiple tumours should be < 3 cm. The cancer must not have spread outside the liver.

Liver transplantation is clearly limited by the availability of donated livers. Currently demand for transplantation far organ availability.

Other treatments for primary liver cancer

Other treatments for HCC can be given if surgery is not possible. Additional treatments to try and reduce the cancer size include the use of chemotherapy. Anti-cancer chemotherapy drugs can be given as tablets or given intravenously into the bloodstream to treat HCC. A more modern technique is called transarterial chemoembolization (TACE). Here chemotherapy is given directly into the cancer containing area of the liver. In addition, tiny beads of gel are injected to block the blood supply to the tumour. This increases the effectiveness of the chemotherapy. Other local treatments include:

Radiofrequency ablation (RFA)

 This treatment uses targeted radio waves to heat up the cancer and destroy it.

Alcohol injection

 Concentrated alcohol kills cancer cells. HCC tumours can be identified on scanning and directly injected with alcohol via a needle to destroy the malignant cells.

Radio embolisation

 After blocking the blood supply to the tumour, radiation instead of drugs can be used to kill the cancer cells.

Biologic treatment

Drugs that block the internal cell process are currently used to treat Hepatocellular Carcinoma. Sorafenib is promising in reducing cancer growth in this tumour.

Primary Liver Cancer is rare and treatment options are many and complex. Treatment is therefore best provided by considering each individual case in multidisciplinary teams in specialist liver centres.

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Secondary liver cancer

Cancer treatment is usually most effective if the cancer is small and localised to its primary site of origin. Cancers that have spread away from the original site are called metastatic. One of the most common sites for metastatic disease is the liver. The original site may be in the lung, breast, colon and pancreas or literally anywhere in the body. Secondary metastatic liver cancer may not be apparent when the cancer first appears and is treated but reveals itself much later, even after treatment for the origin tumour.

Symptoms of secondary liver cancer

Discomfort in the right upper part of the abdomen, tiredness, weight loss, and jaundice or yellowing of the skin.

How is secondary liver cancer diagnosed?

It is routine to look for evidence of secondary cancer spread when cancer is first diagnosed anywhere in the body. This process is known as "staging". Staging is crucial in deciding the best type or combination of cancer treatments to recommend. Imaging scans used solely or in combination to diagnose secondary liver cancer include abdominal ultrasound, CT scan, MRI scan and PET scan. To confirm the diagnosis a liver biopsy may be needed. This involves obtaining a representative piece of tissue from the liver with a needle. A biopsy is especially used if the site of the original cancer is not identified as sometimes can occur.

How is secondary liver cancer treated?

The treatment of secondary metastatic liver cancer is predominantly by anti-cancer drugs (i.e. chemotherapy). The exact regime will depend on the site of the primary or original tumour. Often more than one type of drug combination will be used as first, second or even third line chemotherapy treatment. This is a complex area and chemotherapy drugs have significant side-effects. Treatment recommendations are usually left to specialist oncologists. Occasionally, surgery can be appropriate for secondary liver cancer. Resection or removal of secondaries can be used if there is one or only a few secondary tumours localised to one area of the liver.

Colorectal cancer liver secondaries can be treated in this way in particular. Unfortunately, in the majority of cases, surgery is ineffective as there are tiny secondaries throughout the liver that are unseen on scans which grow after the initial surgery. Radiotherapy and other techniques can be used if the secondaries were particularly painful but this is usually palliative rather than curative. As cancer treatment progresses, cancer specialists will usually arrange regular CT scans to identify any liver secondaries forming or to assess whether treatment has been successful in making them smaller. Treatment options will strongly depend upon the results of such monitoring.

Last updated

Consultant Gastroenterologis at The Shrewsbury and Telford Hospital NHS Trust and Specialises in Gastrointestinal and Liver services
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