Secondary liver cancer

Wednesday 1 June, 2016

Download PDF Order FREE booklet

On this page: Diagnosis | Staging | Prognosis | Treatment 


This section explains how secondary cancer in the liver is diagnosed and treated. For introductory information about secondary cancer in the liver, including its symptoms and causes, see key questions.

Diagnosis

Secondary cancer in the liver is diagnosed using several tests. These include blood tests and scans. A tissue examination (biopsy) is rarely done.

CT scan

A CT (computerised tomography) scan uses x-ray beams to take many pictures of the inside of the body, then compiles them into one detailed cross-sectional picture.

As part of the procedure, a dye (called the contrast) will be injected into one of your veins. The contrast travels through the bloodstream and shows up any abnormal areas. It may make you feel flushed and cause some discomfort in your abdomen. Symptoms should ease quickly, but tell the doctor if you feel unwell.

The dye used in a CT scan contains iodine. If you have had an allergic reaction to iodine or dyes during a previous scan, tell the medical team beforehand. You should also let them know if you’re diabetic, have kidney disease or are pregnant.

You will lie on an examination table and pass through the CT scanner, which is large and round like a doughnut. The whole procedure takes 15–20 minutes.

MRI scan

An MRI (magnetic resonance imaging) scan uses magnetic waves to create detailed cross-sectional pictures of organs in the body. These show the extent of the tumour and whether it is affecting the main blood vessels around the liver.

You may be injected with a dye (contrast) that highlights the organs in your body. You will then lie on an examination table that slides into a large metal tube that is open at both ends. The noisy, narrow machine makes some people feel anxious or uncomfortable (claustrophobic). If you think you may become distressed, mention it beforehand to your medical team. You may be given a mild sedative to help you relax or you might be able to bring someone into the room with you for support. You will usually be offered headphones or earplugs. The MRI scan may take between 30 and 90 minutes.

PET-CT scan

A positron emission tomography (PET) scan combined with a CT scan (see below) is a specialised imaging test available at some major metropolitan hospitals. It produces a three-dimensional colour image that may show where cancers are in the body.

A PET-CT scan is most commonly used for secondary cancer in the liver that has spread from the bowel or from a melanoma.

For the PET scan, you will be injected in the arm with a glucose solution containing a small amount of radioactive material. It takes 30–90 minutes for the solution to go through your body. During this time, you will be asked to sit quietly.

Your whole body will then be scanned for raised levels of radioactive glucose. Cancer cells show up brighter on the scan pictures because they are more active and take up more of the glucose solution than normal cells do.

During a PET scan, you will be exposed to radioactive material, but the dose is low and generally not harmful. The nuclear medicine staff who perform the scan will discuss this with you.

Ultrasound

This scan uses soundwaves to create a picture of the inside of your liver and its blood supply.

You will be asked to not eat or drink (fast) for about four hours before the ultrasound. During an ultrasound scan, you will lie on an examination table with your abdomen uncovered. A gel will be spread on your skin and a device called a transducer will be moved across your abdomen. The transducer creates soundwaves that echo when they meet something solid, such as an organ or tumour. A computer turns the soundwaves into a picture. An ultrasound is painless, and usually takes 15–20 minutes.

Biopsy

A biopsy is the removal of a tissue sample for examination under a microscope. This procedure is not commonly done for secondary cancer in the liver, but it may be done before surgery or other treatment if the diagnosis isn’t clear.

Before a biopsy, your blood may be tested to check it clots normally. This is because the liver contains many blood vessels, and there is a risk of bleeding. A sample of cells can be collected in three ways.

Fine needle aspiration (FNA)

A thin needle is passed through the skin of your abdomen into the tumour and a sample is removed so it can be examined under a microscope. Local anaesthetic is used to numb the area. An ultrasound helps to guide the needle to the right spot. Afterwards, you will stay in hospital for a few hours, or overnight if there is a high risk of bleeding.

Core biopsy

This procedure is similar to a fine needle aspiration, but the specimen and needle are larger and the results are more reliable. This procedure also means the liver can be checked for cirrhosis.

Laparoscopy

Small cuts are made in the abdomen, and a thin tube containing a light and a camera (a laparoscope) is inserted to look at the liver. Carbon dioxide or air gas is used to increase the size of your abdomen to make it easier for the surgeon to see. Samples are taken and the cut is closed with stitches. This procedure is done if your doctor thinks the cancer may be in other areas of the body. Laparoscopy is sometimes called keyhole surgery.

Further tests

If the tests outlined above show you have secondary cancer in the liver, you may need further tests to work out where the primary cancer started.

Some people have:

  • an examination of the bowel (colonoscopy), the stomach (endoscopy) and, for women, the breasts (mammogram)
  • blood tests to measure the level of tumour markers such as carcinoembryonic antigen (CEA)
  • a urine test to check the kidneys or bladder.

In other cases, it will be clear where the primary cancer began, as you may have been treated for cancer in the past. This is common for people who have previously been diagnosed with bowel cancer. Sometimes, even after several tests, the primary cancer can’t be found. This is called cancer of unknown primary (CUP).

Staging

Working out whether the cancer has spread from the primary cancer site – and if so, how far – is called staging. Knowing the stage helps your health care team recommend the best treatment for you.

Staging is based on how far from the original tumour site the cancer has travelled. Because secondary cancer in the liver is cancer that has spread from a primary location (for example, the bowel) to a distant organ (the liver), it is considered to be the most advanced cancer.

Prognosis

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

  • test results
  • the type of cancer, where it is in the body, and the rate of growth
  • how well you respond to treatment
  • other factors such as your age, fitness and overall health.

Although most cases of secondary cancer in the liver can’t be cured, treatment can keep some cancers under control for months or years. For more information see Living with Advanced Cancer or call Cancer Council 13 11 20. Whatever the prognosis, palliative treatment can relieve symptoms, such as pain, to improve quality of life. It can be used at any stage of advanced cancer.

Treatment

The aim of treatment for secondary cancer in the liver is to control or shrink the cancer and improve your quality of life. The types of treatment suitable for you will depend on the location of the primary cancer, the size and number of tumours, and your age and general health.

The main treatments for secondary cancer in the liver are chemotherapy or a combination of surgery and chemotherapy. You may also be given palliative treatment.

Chemotherapy

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

The type of drugs used will depend on where in the body the primary cancer started. For example, if you have cancer of the breast that has spread to the liver, you’ll have chemotherapy designed to treat breast cancer.

You will probably have a combination of two or three chemotherapy drugs.

Chemotherapy may be used at different times:

  • before surgery, to shrink the secondary cancer and make it easier to remove (neoadjuvant chemotherapy)
  • after surgery, to get rid of any remaining cancer cells (adjuvant chemotherapy)
  • to slow down cancer growth and reduce symptoms such as pain (palliative treatment).

Chemotherapy is usually given as a course of drugs over weeks or months. The drugs may be injected into a vein (given intravenously) or taken by mouth as tablets.

During chemotherapy, you will have a higher risk of bleeding or getting an infection. If you develop a temperature over 38°C, contact your doctor or go to the emergency department.

Side effects of chemotherapy

Chemotherapy drugs circulate in the whole body and can affect normal, healthy cells as well as cancer cells. Common side effects include nausea; loss of appetite; tiredness; hair loss; skin changes; tingling or numbness in fingers and toes; and mouth sores.

People react to chemotherapy differently – some people have few side effects, while others have many. Most side effects are temporary, and there are ways to prevent or manage them.

To find out more see Understanding Chemotherapy.

Surgery

The aim of surgery (resection) is to remove the part of the liver that contains cancer. This is the most effective treatment, but it is not always possible. Surgery may be possible if there is enough healthy liver and the cancer hasn’t spread to other parts of the body where it can’t be removed (such as the bones).

Some people need surgery for both the secondary cancer in the liver and the primary cancer. These operations may be done separately or at the same time. The amount of liver removed depends on the size and position of the tumour(s). You may have one of the following surgeries:

  • partial hepatectomy – removes part of the liver
  • hemihepatectomy – removes a whole lobe of the liver
  • segmentectomy – removes a small section of the liver.

The gall bladder may also be taken out, as it is attached to the liver between the right and left lobes. Occasionally, part of the diaphragm muscle may also be removed.

The liver can repair itself easily if it is not damaged already. The portion of the liver that remains after resection will start to grow, even if up to three-quarters of it is removed. The liver will usually regrow to normal size within a few months, although its shape may be slightly changed.

After surgery, your medical team will monitor you for signs of bleeding and infection. Some people experience jaundice (yellowing of the skin and whites of the eyes). This is usually temporary and improves as the liver grows back. See more information on recovering from surgery.

Two-stage surgery

People with tumours in both lobes of the liver sometimes need surgery that is carried out in two stages.

First stage – The tumours are removed from one lobe of the liver (partial hepatectomy). Sometimes this operation is combined with tumour ablation or removal of the primary tumour.

Second stage – You will need to wait two months to allow your body to recover and the liver to regrow. Before you have the second operation, the size of your liver will be checked. If enough of the liver has regrown, the tumours in the second lobe will be removed with another partial hepatectomy.

How the surgery is done

Most operations for secondary cancer in the liver are done with a large cut in the upper abdomen. This is known as open surgery.

However, it is becoming more common for liver tumours to be removed with several smaller cuts (keyhole or laparoscopic surgery). The surgeon will insert a tiny camera (laparoscope) into one of the cuts.

People who have laparoscopic surgery usually have a shorter hospital stay, less pain and a faster recovery time. However, laparoscopic surgery is not available in all hospitals. Talk to your surgeon about the most suitable option for you.

Targeted therapies

New drugs known as targeted therapies attack specific particles (molecules) in cancer cells to stop their growth or reduce the size of the tumour.

Targeted therapies are sometimes used to treat secondaries from bowel or breast cancer. If you were first treated for bowel cancer, you might have bevacizumab (Avastin®) or cetuximab. If you were first treated for breast cancer, you may be given the drug trastuzumab (Herceptin®). Targeted therapies may be used after or together with other treatments for secondary cancer in the liver.

Side effects of targeted therapies vary depending on the drugs used. The most common side effects include high blood pressure and diarrhoea. Talk to your doctor about managing side effects.

Radioembolisation (selective internal radiation therapy or SIRT)

Radioembolisation (also known as selective internal radiation therapy or SIRT) is a combination of internal radiotherapy and a procedure called embolisation. It involves placing high doses of radiotherapy in the form of radioactive beads directly into the liver. It is performed by an interventional radiologist.

SIRT is used for bowel cancer and other cancers that have spread to the liver when the tumours can’t be removed with surgery. It’s often used if there are many small tumours throughout the liver.

Before treatment (work-up day)

You will have a number of tests, including an angiogram and a simulation of the treatment. An angiogram shows up the blood vessels in the liver and helps to map where the radioactive beads need to go.

This test takes about 45 minutes and you will be observed for 3–4 hours afterwards. You may also have CT and lung scans, which take about an hour. If the results of these tests are good, you will have treatment about 1–2 weeks later.

During treatment (delivery day)

You will have another angiogram. A cut will be made in the groin area and a catheter will be passed through to the hepatic artery. The tiny radioactive beads, which are known as SIR-Spheres®, are then inserted directly into the artery supplying the liver tumour. These beads can deliver a high dose of radiation directly while causing little damage to normal liver tissue.

The procedure takes about an hour and you will be monitored closely for 3–4 hours before being taken to a general ward, where you will recover overnight.

Side effects of SIRT

These can include flu-like symptoms, nausea, pain and fever. Side effects can be treated with medication, and you usually can go home within 24 hours.

Palliative treatment

Palliative treatment helps to improve people’s quality of life by reducing symptoms of cancer without trying to cure the disease. It is particularly important for people with secondary cancer. However, it is not just for end-of-life care and it can be used at different stages of cancer.

As well as slowing the spread of cancer, palliative treatment can relieve pain and help manage other symptoms. The treatment may include radiotherapy, chemotherapy, targeted therapies or other types of medication.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aim to meet your physical, emotional, practical and spiritual needs. The team also provides support to families and carers.

For more information see Understanding Palliative Care and Living with Advanced Cancer.

Managing symptoms

There are ways to relieve symptoms such as pain, swelling and jaundice. The palliative care team may also be involved in managing your symptoms.

Ascites

This is when fluid builds up in your abdomen. It causes swelling and pressure, which can be uncomfortable and make you feel breathless. A procedure called paracentesis or ascitic tap can provide relief. The skin on the abdomen is numbed with a local anaesthetic, and a thin needle is inserted into the abdomen and connected to a drainage bag outside your body. This fluid drains into the bag over a few hours. A water tablet (diuretic) is sometimes prescribed to slow down the build-up of fluid.

Pain

This can be managed with treatment and/or pain medicine. Treatment can include chemotherapy, radiotherapy or steroids.

Jaundice

This is caused when the cancer blocks the bile duct. Bile builds up, turning your skin and whites of the eyes yellow. Jaundice can be relieved by unblocking the bile duct with a tiny tube called a stent. See below for a description of the different types of stents.

Itchy skin

Jaundice can cause itching, which is often worse at night. The itching can be relieved by keeping your skin moisturised. Try to avoid alcohol, spicy food, hot baths and direct sunlight, which can make the itching worse. Medicine can be prescribed if the itching continues and is uncomfortable.

Bile duct obstruction

Sometimes secondary cancer in the liver can obstruct the bile ducts, particularly if it started in the ducts. Bile builds up in the liver and can cause symptoms of jaundice, such as yellowish skin, itchiness, pale stools or dark urine.

You may have a thin tube (stent) placed in your liver to drain the bile and ease your symptoms. The earlier the stent is inserted, the less severe the symptoms. This can be done in two ways.

Endoscopic stent placement

This is done as a day procedure. You will have a local anaesthetic and possibly a sedative to reduce discomfort.

A gastroenterologist or a surgeon inserts a long, flexible tube with a camera and light on the end (endoscope) through your mouth, stomach and small bowel into the bile duct. Pictures of the area show up on a screen so that the doctor can see where to place the stent. The stent is put in via the endoscope, which is then removed.

Recovery from an endoscopic stent placement is fairly fast. Your throat may feel slightly sore for a short time and you may need to stay in hospital overnight. After the procedure, there is a risk of the bile duct becoming infected and the pancreas becoming inflamed – your doctor will talk to you about what can be done.

Percutaneous stent placement

Sometimes a stent cannot be placed through an endoscope so it is placed through the skin in a procedure similar to a small operation. This may be done under general anaesthetic or heavy sedation, and usually requires an overnight stay in hospital.

Key points

  • Several different tests are used to diagnose secondary cancer in the liver.
  • Imaging tests such as CT, MRI and PET-CT scans may be used to create pictures of the inside of the body.
  • CT and MRI scans involve an injection of dye into the body, followed by a scan.
  • A biopsy is when tissue is removed for examination under a microscope. This is not done very often, but may be needed if other test results aren’t clear.
  • To work out where the primary cancer started, you may also have tests such as a colonoscopy, endoscopy or mammogram. Some people also have blood tests to look for tumour markers.
  • All of these tests will help your doctor work out the best treatment options for you and whether it may be possible to try to cure the cancer.
  • Your doctor may talk to you about your prognosis. This is the expected outcome of your illness, but no-one can predict exactly what will happen to you.
  • Most cancers are assigned a stage to describe how much cancer there is and whether it has spread. As secondary cancer in the liver has spread from a primary location, it is considered to be the most advanced stage.

Reviewed by: Graham Starkey, Liver Surgeon, Austin Hospital, VIC; Dr Ken Chan, Interventional Radiologist, Dr Jones & Partners Medical Imaging and Royal Adelaide Hospital, SA; David Fry, Consumer; Caitriona Nienaber, Oncology Nurse, Council Council WA, WA; A/Prof Monica Robotin, University of Sydney and Medical Director, Cancer Council NSW, NSW; and Dr Manfred Spanger, Interventional Radiologist, Eastern Health, Knox Private Hospital and Epworth Eastern, VIC.

Updated: 01 Jun, 2016