Primary liver cancer

Wednesday 1 June, 2016

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On this page: Diagnosis | Staging | Prognosis | Treatment


This page explains how primary liver cancer is diagnosed, monitored and treated. For introductory information about primary liver cancer, including its symptoms and causes, see our key questions.

Diagnosis

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

Blood tests
Liver function tests

Several blood tests can check how well your liver is working. You may also have liver function tests done before, during and after treatment.

Blood clotting test

This checks if the liver is making proteins that help the blood to clot. Low levels increase your risk of bleeding.

Hepatitis

This checks for hepatitis B or C.

Tumour markers

Certain chemicals known as tumour markers are proteins produced by cancer cells. Tumour markers can help identify some types of cancer. The most commonly measured tumour marker for primary liver cancer is alpha-fetoprotein (AFP). Sometimes the AFP level is normal even when there is liver cancer. On the other hand, a raised AFP level does not always indicate cancer – conditions such as pregnancy, hepatitis and jaundice can also increase AFP levels without cancer being present.

Ultrasound

An ultrasound is the most common scan used to look for primary liver cancer. It’s often used to monitor people with cirrhosis.

This scan uses soundwaves to create a picture of your organs. It is used to show if cancer is present and how large it is.

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.

If a solid lump is found, the scan will help show whether it is cancer. Non-cancerous (benign) tumours in the liver can also be found during an ultrasound. These occur in about 4 out of 10 people.

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 your medical team beforehand. You should also let them know if you’re diabetic, have kidney disease or are pregnant.

CT scan

A CT (computerised tomography) scan uses x-ray beams to take many pictures of the inside of the body and 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.

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 inside 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, and you will usually be offered headphones or earplugs. The MRI scan may take between 30 and 90 minutes.

Endoscopic retrograde cholangiopancreatography (ERCP)

If bile duct cancer is suspected, an ERCP is used to look at the bile duct in more detail. This procedure may also be used to unblock the bile duct. You will be sedated and a thin, flexible tube with a light and camera on the end (endoscope) will be passed down your mouth and throat, through the stomach and into the small bowel. A dye is injected to show up any abnormal areas.

If there is a blockage, a small tube called a stent will be inserted to keep the bile duct open.

Biopsy

A biopsy is the removal of a tissue sample for examination under a microscope in a laboratory. This procedure is not always necessary for primary liver cancer, as diagnosis may be possible with scans and blood tests. If you are able to have surgery or a transplant, you will not need a biopsy. A biopsy may be used in the following circumstances:

  • for people without liver cirrhosis, or for people who have cirrhosis but who have other inconclusive or abnormal test results
  • before surgery or other treatment, if there is uncertainty about the diagnosis.

There is a small risk that the biopsy could spread the cancer along the path of the biopsy needle. 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 two ways.

Core biopsy

A needle is passed through the skin of the abdomen into the tumour to remove a sample. Local anaesthetic is used to numb the area. An ultrasound is used to guide the needle to the right spot. Afterwards, you may need to stay in hospital for a few hours, or overnight if there is a high risk of bleeding.

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.

ICG test

An indocyanine green (ICG) test may be done for people who have primary liver cancer and cirrhosis. The test helps surgeons assess how well the liver is working and determine if surgery is a treatment option.

During an ICG test, green dye is injected into the bloodstream. A probe is placed on a finger to measure how quickly the liver clears the dye from the bloodstream. This takes 15 minutes.

If the dye is cleared quickly, this shows that the liver is working well. However, if it is slow, it may be too risky to remove parts of the liver. In this case, the medical team will discuss other available treatment options.

Staging

The tests described above help the doctors decide how far the cancer has spread. This is called staging. Knowing the stage helps your health care team recommend the best treatment for you. They will also consider how well the liver is working. Several staging systems are used for liver cancer. The Barcelona Clinic Liver Cancer (BCLC) staging system is commonly used, and is described below. The categories are based on a combination of how well you can carry out daily tasks (performance status), tumour characteristics, and how well the liver is working (Child-Pugh score).

BCLC staging system for primary liver cancer
  • 0 (very early) - Single cancer less than 2 cm, Child-Pugh A
  • A (early) - Single cancer or up to 3 nodules less than 3 cm, Child-Pugh A–B
  • B (intermediate) - Many cancers in the liver, Child-Pugh A–B
  • C (advanced) - Cancer has grown into one of the main blood vessels of the liver, lymph nodes or other body organs; Child-Pugh A–B
  • D (end-stage) - Child-Pugh C
Child-Pugh score

A scoring system used in the BCLC staging system. It assesses how well the liver is working by measuring the level of damage caused by cirrhosis.

  • A - Liver is working well and cirrhosis is less advanced.
  • B - Liver is working moderately well.
  • C - Liver is not working well and cirrhosis is advanced.

Prognosis

Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis and treatment options with your doctor, but it is not possible for any doctor to predict the exact course of the disease. Liver cancer can often be effectively treated, especially if found before it spreads outside the liver.

To work out your prognosis, your doctor will consider:

  • test results
  • the type of liver cancer
  • 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.

Doctors often use numbers (statistics) when considering someone’s prognosis. Statistics reflect the typical outcome of disease in large numbers of people. While statistics give doctors a general idea about a disease, they won’t necessarily reflect your situation.

A liver transplant or surgical resection (removal of the diseased section of the liver) may be an option to treat some people with primary liver cancer. These procedures may offer the chance of a cure. Other treatments for primary liver cancer can relieve symptoms such as pain to improve quality of life.

"It helps to focus on what is happening now, what is actually known – not all the possibilities. One step at a time." - Sam

Treatment

The treatment for primary liver cancer depends on the size of the cancer, whether it is contained in one part of the liver and no major blood vessels are involved, and whether you have cirrhosis. The doctor will also consider your age and general health, as well as the options available at your hospital.

Treatment options by type of primary liver cancer
Hepatocellular carcinoma (HCC)

The main treatments for HCC use heat to destroy the tumour (thermal ablation) or deliver chemotherapy directly into the cancer (transarterial chemoembolisation or TACE). Surgery is used for about 5% of people.

  • Stage 0 (very early) – usually treated with surgery
  • Stage A (early) – usually treated with surgery, ablation, transplant or TACE
  • Stage B (intermediate) – TACE
  • Stage C (advanced) – targeted therapies or palliative treatment
  • Stage D (end-stage) – palliative treatment
Cholangiocarcinoma (bile duct cancer)

This is usually treated with surgery, chemotherapy, radiotherapy and stenting.

Angiosarcoma

This is usually treated with surgery and TACE.

Surgery

The aim of surgery (resection) is to remove the part of the liver that contains cancer.

Surgery is only suitable for a single tumour that has not grown into blood vessels. While surgery is the best option for treating primary liver cancer, the liver will need to be working well. People with early cirrhosis may be considered for surgery, but the liver of people with more advanced cirrhosis is probably not healthy enough for surgery.

The surgeon will consider surgery if liver cancer has not spread beyond the liver, and if you don’t have cirrhosis. The type of liver surgery you have 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
  • segmentectomy – removes a small section of the liver.

Surgery is done under general anaesthetic. The surgeon will remove the tumour and some tissue around the tumour. 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 return to normal size within a few months, although its shape may be slightly changed.

A lot of blood passes through the liver, and bleeding after surgery is a risk factor. Your medical team will monitor you for signs of bleeding and infection. 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 (see below).

Second stage – You will need to wait two months to allow your body time 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 primary liver cancer are done with a large cut in the upper abdomen. This is called open surgery.

It is now becoming more common for liver tumours to be removed with several smaller cuts (called keyhole or laparoscopic surgery).

The surgeon will insert a tiny telescope (laparoscope) into one of the cuts and will remove tissue with the tool at the end of the laparoscope.

People who have laparoscopic surgery usually have a shorter hospital stay, less pain and a faster recovery time.

However, laparoscopic surgery is not suitable for everyone and is not available in all hospitals. Talk to your surgeon about the best option for you.

Liver transplant

A transplant involves removing the whole liver and replacing it with a healthy liver from another person (a donor). This treatment can effectively treat HCC, but it is generally used only in people with a single tumour or several small tumours. It is not usually recommended for bile duct cancer.

To be considered for a liver transplant, you need to be in good health and not smoke or take illegal drugs, and you must have stopped drinking alcohol.

Donor livers are scarce, and waiting for a suitable liver may take many months or years. During this time, the cancer may continue to grow. As a result, most people have tumour ablation or TACE (see below) to control the cancer while they wait for a donor.

Recovering from a transplant

If you have a liver transplant, it may take 3–6 months to recover. You will probably find it takes a while to regain your energy. You will also be given drugs called immunosuppressants to prevent the body from rejecting the new liver. You will need to take immunosuppressants for the rest of your life. You will be given antibiotics to reduce the chance of infections. See after surgery for more details.

Currently, there is no cost for having a liver transplant in Australia when it is performed in a public hospital.

Tumour ablation

Tumour ablation destroys a tumour without removing it. It’s used to treat tumours smaller than 3 cm in size. It can be done in different ways, depending on the size, location and shape of the tumour.

 Thermal ablation

This uses heat to destroy a tumour. A CT or ultrasound scan guides a fine needle through the skin and into the tumour. Radio waves or microwaves are passed through the needle and into the tumour. This is done in the x-ray department or operating theatre while you are under local or general anaesthetic. Treatment takes 1–2 hours, and most people stay overnight in hospital. Side effects, which may include pain, nausea or fever, can be managed with medicines.

Alcohol injection

This involves injecting pure alcohol into the tumour. It isn’t available at all hospitals, but is used occasionally if other forms of ablation aren’t possible. Treatment is given through a needle that is passed into the tumour under local anaesthetic, using an ultrasound as a guide. You may be given more than one injection over several sessions. Side effects may include pain or fever, but these side effects can be managed with medicines.

Cryotherapy (or cryosurgery)

This treatment kills cancer cells by freezing them, but it is not widely available. You will be given a general anaesthetic for this procedure, then a cut will be made in your abdomen. The doctor will insert a probe through the cut into the tumour. The probe gets very cold, which freezes and kills the cancer cells. Cryotherapy takes about 60 minutes, and recovery is similar to recovery from surgery.

Transarterial chemoembolisation (TACE)

Chemoembolisation, or TACE, is a combination of chemotherapy (see below) and a procedure called embolisation. It involves injecting high doses of chemotherapy drugs directly into the liver to cut off the blood supply to a tumour. TACE is usually used for people who cannot have surgery. It is performed by an interventional radiologist.

Before TACE, you will be given a local anaesthetic and possibly medicine (a sedative) to help you relax. A small cut will be made in the groin, and a plastic tube called a catheter is passed through the cut and into a blood vessel called the hepatic artery. This artery takes blood to the liver.

The chemotherapy drugs are injected into the liver through the catheter. Tiny plastic beads or soft, gelatine sponges may also be injected to block the blood supply to the cancer. This makes the cancer shrink or stop growing. In some cases, beads that contain chemotherapy are given at the same time.

After TACE, you will need to remain lying down for about four hours. You may also need to stay in hospital overnight or for a few days. The treatment may be repeated, if needed. It is okay to be around children and pregnant women once you leave hospital.

Side effects of TACE

After TACE, it is common to develop a fever the next day, but this usually passes quickly. You may feel some pain, but this can be controlled with pain medicines.

Chemotherapy

Chemotherapy is the use of drugs to kill, shrink or slow the growth of tumours. It is used alone, or as part of TACE (see above).

With any type of liver cancer, you may have chemotherapy:

  • after other treatment, such as cryotherapy or surgery, to get rid of any remaining cancer cells (adjuvant chemotherapy)
  • to slow down cancer growth and control symptoms such as pain (palliative treatment).

Chemotherapy is not suitable for people with jaundice, as the liver may not cope with the drugs. People with advanced HCC are not usually offered chemotherapy, but it would depend on their overall health, liver function, and whether they have advanced cirrhosis.

You will have chemotherapy as a course of drugs over several weeks or months. It may be given into a vein, through a drip, or by mouth as tablets.

Side effects of chemotherapy

These will depend on the drugs used. They may include nausea; loss of appetite; tiredness; hair loss; skin changes; tingling or numbness in fingers and toes; mouth sores; and an increased risk of developing infections.

Most side effects are temporary, and there are ways to prevent or manage them. To find out more see Understanding Chemotherapy or call Cancer Council 13 11 20.

Targeted therapies

New drugs known as targeted therapies attack specific particles (molecules) in cancer cells to stop or slow their growth or reduce the size of the tumour. Targeted therapies may be recommended for people with advanced liver cancer or as part of a clinical trial.

The drug sorafenib (Nexavar®) is the first targeted therapy approved for treatment of advanced HCC. It is taken by mouth, usually as two tablets twice a day. Your doctor will give you more information about how to take it, and will adjust the dose if necessary.

Radiotherapy

Radiotherapy uses x-rays, gamma cells, electron beams or protons to kill cancer cells or injure them so they cannot multiply. It may be used to treat bile duct cancer.

During a radiotherapy session, you will lie on an examination table and a machine will direct the radiotherapy towards your body. The treatment is painless and can’t be seen or felt. Radiotherapy is usually given daily from Monday to Friday for several weeks.

Side effects of radiotherapy

People react to treatment differently; some have few side effects, while others have many. Most side effects are temporary and disappear a few weeks or months after treatment.

Common side effects include feeling tired; diarrhoea; needing to pass urine more often and burning when you pass urine (cystitis); and a slight reddening to the skin around the treatment site.

Radioembolisation (selective internal radiation therapy or SIRT)

Radioembolisation (also known as selective internal radiation therapy or SIRT) targets cancers in the liver with high doses of radiotherapy placed in tiny radioactive beads. It is performed by an interventional radiologist.

SIRT is used for HCC and bile duct cancer 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 to the tumour 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.

SIRT is not available in all hospitals. If you don’t have private health insurance that covers this treatment, you’ll need to pay for it yourself. Talk to your doctor about SIRT and the costs involved.

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.

Endoscopic stent placement

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

Your doctor may recommend that a thin tube (stent) is placed in the liver to drain the bile and ease your symptoms. The earlier the stent is inserted, the less severe the symptoms.

Endoscopic stent placement is done as a day procedure. You will have a local anaesthetic and possibly a sedative to reduce discomfort. A gastroenterologist or a surgeon will insert 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 inserted through the endoscope, which is then removed.

Recovery from endoscopic stent placement is fairly fast. Your throat may feel slightly sore for a short time and you may be kept in hospital overnight. Jaundice usually disappears over 2–3 weeks. There is a risk of infection of the bile duct and inflammation of the pancreas after stent placement – your doctor can give you more information.

Palliative treatment

Palliative treatment helps improve people’s quality of life by alleviating symptoms of cancer, when it’s not possible to cure

the disease. It is particularly important for people with advanced cancer, however, it can be used at any stage of cancer. It is not just for people who are about to die and does not mean giving up hope. Rather, it is about living for as long as possible in the most satisfying way you can.

As well as slowing the spread of cancer, palliative treatment can relieve pain and help manage other symptoms. Treatment may include chemotherapy, stent placement or 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 or call Cancer Council 13 11 20.

Key points

  • The most common treatments for primary liver cancer are tumour ablation and transarterial chemoembolisation (TACE).
  • Surgery is used to remove tumours that are small and easy to reach and haven’t spread widely throughout the liver.
  • Some people with primary liver cancer are able to have a transplant, but it can take many months before a donor becomes available.
  • After surgery, you will need several days in hospital to recover. You will be monitored closely during this time.
  • Tumour ablation destroys a tumour without removing it. It includes thermal ablation to heat the tumour (using radio waves or microwaves), cryotherapy to freeze the tumour, or alcohol injection.
  • Transarterial chemoembolisation or TACE is a combination of chemotherapy and a procedure called embolisation. It involves injecting high doses of chemotherapy directly into the tumour. This cuts off the blood supply to the tumour.
  • Chemotherapy uses drugs to kill or slow the growth of cancer cells. It is given into a vein or as tablets.
  • Other treatments for cancer in the liver include targeted therapies and selective internal radiation therapy (SIRT). These are also used when tumours can’t be surgically removed.
  • Palliative treatment helps improve quality of life by reducing symptoms. Chemotherapy drugs and stent placement may be used as palliative treatment.

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.