Liver cancer (primary)

The liver

The liver is the largest organ inside the body. It has many important jobs, including:

• storing sugars and fats, so they can be used for energy
• producing bile to help dissolve fat so it can be easily digested
• making proteins to help blood clot and to balance fluid in the body
• breaking down harmful substances, such as drugs and alcohol.

Unlike other internal organs a healthy liver may be able to repair itself if injured or if part of it is surgically removed during cancer treatment.

Liver cancer begins when cells inside the liver change and grow out of control. Liver cancer can be a primary cancer, meaning the cancer started in the liver, or a secondary cancer, meaning the cancer started in another part of the body and spread to the liver.

Secondary cancer in the liver is much more common than primary liver cancer in Australia. Each year in Australia, more than 3000 people are diagnosed with primary liver cancer. Almost three times more men are affected than women.

Symptoms of liver cancer

Liver cancer often doesn’t cause any symptoms in the early stages, but they may appear as the cancer grows or spreads. There are several possible symptoms:

• weakness and tiredness (fatigue)
• pain in the abdomen (belly), or in the right shoulder blade
• hard lump on the right side of the abdomen
• appetite loss and feeling sick (nausea)
• unexplained weight loss
• yellowing of the skin and eyes (jaundice)
• dark urine (wee) and pale faeces (poo)
• itchy skin
• a swollen abdomen caused by fluid build-up (ascites).

Not everyone with these symptoms has liver cancer. If you have any of these symptoms or are worried, always see your doctor.

Risk factors for liver cancer

Primary liver cancer most often develops in people with underlying liver disease, usually cirrhosis.

In cirrhosis, healthy liver cells are replaced by scar tissue, and benign nodules (non-cancerous lumps) form throughout the liver. As this gets worse (advanced cirrhosis), the liver stops working properly. Cirrhosis may be caused by:

• long-term (chronic) infection with hepatitis B or hepatitis C virus
• drinking too much alcohol
• metabolic-associated fatty liver disease (MAFLD) as a result of obesity and/or type two diabetes
• having too much iron in the bloodstream (haemochromatosis)
• certain autoimmune conditions (e.g. primary biliary cholangitis).

Other risk factors for liver cancer are smoking tobacco or having a family history of hepatocellular carcinoma (HCC). Aboriginal and Torres Strait Islander peoples and migrants from countries with higher rates of hepatitis B infection (e.g. countries in the Asia-Pacific region and Sub-Saharan Africa) are also at greater risk of developing primary liver cancer.

Having these risk factors doesn’t mean you will develop primary liver cancer. If you are worried about your risk factors, ask your doctor for advice.

Tests for liver cancer

Liver cancer may be diagnosed using several tests. These include:

• blood tests – to help doctors work out what type of liver cancer may be present and how well the liver is working
• imaging scans – an ultrasound scan is usually the imaging scan first used to look for liver cancer and to monitor people with cirrhosis. An ultrasound alone cannot confirm a diagnosis of liver cancer, so you will also have one or more other scans.
• biopsy – a small sample of liver tissue is removed and checked for cancer cells. The sample of cells is usually collected with a core biopsy. The doctor will give you a local anaesthetic to numb the area, and then pass a needle through the skin of the abdomen to remove a sample of tissue from the tumour.

If the tests show that you have secondary cancer in the liver, you may need further tests to find out where the cancer started.

Types of liver cancer

The most common type of primary liver cancer that can affect adults is hepatocellular carcinoma (HCC). HCC starts in the hepatocytes, the main type of cell in the liver.

Less common types of primary liver cancer include:

• cholangiocarcinoma, also known as bile duct cancer, can start in the bile ducts that connect the liver to the bowel and gall bladder
• angiosarcoma and hemangiosarcoma are a very rare type of liver cancer that start in the blood vessels
• hepatoblastoma is a rare form of liver cancer that affects only young children.

Stages of liver cancer

The stage of a cancer describes how large it is, where it is and whether it has spread in the body.

Knowing the stage of a liver cancer helps doctors plan the best treatment for you.

Primary liver cancer is staged using the Barcelona Clinic Liver Cancer (BCLC) staging system. The system has five stages:

• Category 0 describes very early liver cancer.
• Category A describes early liver cancer.
• Category B describes intermediate liver cancer.
• Category C describes advanced liver cancer.
• Category D describes end-stage liver cancer.

To work out a cancer’s stage, your doctor will consider:

• the size of the tumour
• the number of tumours
• whether the cancer has spread to blood vessels, lymph nodes or other organs
• how well you are functioning in daily life and how active you are
• how well the liver is working (using a Child-Pugh score).

The Child-Pugh score records how well the liver is working. In this system, liver function is ranked as:

• A (some damage but is working normally);
• B (moderate damage, affecting how well the liver is working); or
• C (very damaged and not working well).

A severely damaged liver may not be able to cope with some types of cancer treatment. Ask your doctor or nurse for more information about the stage of your cancer. You can also read more from Cancer Council about liver cancer staging.

Prognosis and survival rates for liver cancer

Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis with your doctor, but it is not possible for anyone to predict the exact course of a disease. To work out your prognosis, your doctor will consider:

• test results
• the type of liver cancer, its stage and how fast it is growing
• whether you have cirrhosis and how well the liver is working
• how well you respond to treatment
• other factors such as your age, fitness and overall health.

The prognosis for liver cancer tends to be better when the cancer is still in the early stages, but liver cancer is often found later.

It is important to know that although the statistics for primary liver cancer can be frightening, they are based on an average of many cases and may not apply to your situation.

Talk to your doctor about how to interpret any statistics that you come across.

Treatment for liver cancer

Treatment for liver cancer will depend on whether it is a primary or secondary cancer. Treatment also depends on the size of the cancer, whether it is contained in one part of the liver, whether major blood vessels are involved and whether you have cirrhosis. Your doctor will also consider your age and your general health.

You might feel confused or unsure about your treatment options and decisions. It’s okay to ask your treatment team to explain the information to you more than once. It’s often okay to take some time to think about your decisions.

Surgery

The aim of surgery is to remove all the cancer from the liver, as well as a margin of healthy tissue. This is known as a liver resection or partial hepatectomy.

A liver resection is usually performed in a specialist treatment centre, and is suitable for only a small number of people with liver cancer. The liver needs to repair itself after the surgery, so a resection is only an option when the liver is working well.

After the surgery, the portion of the liver that remains will start to grow, even if up to three-quarters of it has been removed. The liver will usually regrow to its normal size within a few months, although its shape may be slightly changed.

Sometimes the surgeon needs to remove so much of the liver that the remaining portion may not be large enough to recover. In this case, you may have a portal vein embolisation (PVE) about 4 to 8 weeks before the liver resection.

Liver transplant

A transplant involves removing the whole liver and replacing it with a healthy liver from another person (a donor). This treatment is effective for liver cancer, but it is generally used only in people with a single tumour or several small tumours.

To be considered for a liver transplant you need to be reasonably fit, not smoke or take illegal drugs, and have stopped drinking alcohol for at least six months.

Donor livers are rare and waiting for a suitable liver may take many months or even several years. During this time, the cancer may continue to grow. As a result, most people will have other treatment during this time to control the cancer while they wait for a donor.

Tumour ablation

For tumours smaller than 3 cm, you may be offered tumour ablation. This destroys the tumour without removing it and may be the best option if you cannot have surgery or are waiting for a transplant. Ablation can be done in different ways, depending on the size, location and shape of the tumour.

There are several types of tumour ablation:

• Thermal ablation – this uses heat to destroy a tumour. The heat may come from radio waves (radiofrequency ablation) or microwaves (microwave ablation).
• Alcohol injection – this involves injecting pure alcohol (ethanol) into the tumour. It isn’t available at all hospitals but is used occasionally if other forms of ablation aren’t possible.
• Cryotherapy – also known as cryosurgery, cryotherapy kills cancer cells by freezing them. This treatment is not widely available but is offered occasionally.

Radiation therapy

Liver cancer is sensitive to radiation but so are healthy liver cells. Selective internal radiation therapy (SIRT) and stereotactic body radiation therapy (SBRT) can deliver radiation directly to the tumour while limiting the damage to the healthy part of the liver.

Chemotherapy and transarterial chemoembolisation (TACE)

Chemotherapy is the use of drugs to kill, shrink or slow the growth of cancer cells.

Traditional chemotherapy may be used to treat secondary cancer in the liver, but is rarely used for primary liver cancer. Instead, transarterial chemoembolisation, or TACE, delivers high doses of chemotherapy directly to the tumour. It is usually used for people who can’t have surgery or are waiting for a liver transplant.

Drug therapies

Two types of drug therapies are available to treat primary liver cancer – immunotherapy and targeted therapy. Drug therapies can spread throughout the whole body to treat cancer cells wherever they may have spread.

Drug treatment for advanced liver cancer is changing quickly and new treatments may become available in the near future. You may also be able to get new drugs through clinical trials.

Talk to your doctor about the latest developments and whether there are any suitable clinical trials for you.

All cancer treatments can have side effects. Your treatment team will discuss these with you before you start treatment. Talk to your doctor or nurse about any side effects you are experiencing.

Managing symptoms of liver cancer

Liver cancer can cause various symptoms, but there are ways to manage them. Symptoms can include:

• jaundice
• pain
• poor appetite and weight loss
• fluid build-up
• fatigue
• confusion

Read more from Cancer Council about managing cancer symptoms, or call Cancer Council on 13 11 20 to speak with a caring cancer nurse for support. You can also call 13 14 50 to speak to an interpreter.

With advanced cancer, the palliative care team may be involved in symptom management.

Living with advanced cancer

Advanced cancer usually means cancer that is unlikely to be cured. Some people can live for many months or years with advanced cancer. During this time palliative care services can help.

Most people continue to have treatment for advanced cancer as part of palliative care, as it helps manage the cancer and improve their day-to-day lives. Many people think that palliative care is for people who are dying, but palliative care is for any stage of advanced cancer. There are doctors, nurses and others who specialise in palliative care.

Treatment may include chemotherapy, radiation therapy, or another type of treatment. It can help in these ways:

• slow the growth of the cancer
• shrink the cancer
• help you to live more comfortably by managing symptoms, like pain.

Treatment depends on:

• where the cancer started
• how far it has spread
• your general health
• your preferences and what you want to do.

Ask your doctor about treatment and palliative care services that may help you.

Support for carers, family and friends

Caring for someone with cancer can be difficult sometimes. If you are caring for someone with liver cancer, these organisations can help:

• Cancer Council Victoria Tel. 13 11 20
• Carer Gateway Tel. 1800 422 737
• Carers Australia Tel. 1800 514 845

Where to get help

• Your GP (doctor)
• Palliative care team
• Cancer Council Victoria
  • Information and support line Tel. 13 11 20 (or 13 14 50 for an interpreter)
  • Liver cancer
  • Cancer Council Victoria, My Cancer Guide - Find support services that are right for you.
• WeCan website helps people affected by cancer find the information, resources and support services they may need following a diagnosis of cancer
• LiverWELL champions the interests of people affected by or at risk of viral hepatitis and liver disease.